"How did you recover so well?"

"It's hard to believe you ever had a stroke!"

After almost every performance, an audience member asks a variant of that question.

And yes, I am very lucky in how dramatic my recovery has been, though I have residual defects, discussed in my shout out of 3/4/18 (see my Blog page if you missed it).

Luck, hard work, abundant rehab resources, and many helping hands are in large part responsible.

But studies of cognitive decline with aging are worth revewing. Factors that reduce the risk of cognitive decline may also be implicated in the ability to recover cognitive skills as well, and most worked in my favor.

First, absence of cardiovascular or other chronic disease; I had none, took no meds other than vitamins and the occasional ibuprophen for aches and pains. (If you do have medical issues, optimal control is crucial.)

Second, favorable socioeconomic status. That's a complex one, no doubt affecting diet, stress and resources. But it has been studied intensely in populations of nuns living together, where, for most of their adult lives, they have had similar lives and resources. It was found that the richer the vocabulary in early life, the less cognitive decline with age. Meaning mental agility is tied to early in life enrichment. I lived in a family that believed most strongly in education. We had no television for most of my years growning up, because it wasn't "educational." Our family beliefs: Bored? Go read the dictionary. Finished Webster's, read Oxford's. Finished that? There's the Encyclopedia Brittanica. Finished that? You'd better go to the library and find something else. Boredom is a lack of curiousity and effort to be engaged. No intelligent person should ever be bored. With that background, being articulate, aceing verbal tasks and tests and cognitive enrichment was almost a given.

The third predictor of reduced risk of cognitive decline is involvement in complex and intellectually stimulating environment. Novel stimuli are important. So doing crossword puzzles is good, but after a while, no added benefit. You need to do something else, like Sudoko. Learning an instrument, learning a new language, all those things help. During my rehab, I had coloring books of tesselations (an arrangement of shapes closely fitted together, especially of polygons in a repeated pattern without gaps or overlapping) where I had to create or replicate patterns or shapes, packs of picture cards depicting a story which I had to put in chronologic order, fill in the blank word games. At the computer remediation lab, I had a Sim City like game where I had to build buildings and blocks, then recognize them from different angles to help with spatial awareness. I had music games, riddles, word puzzles, number games, math games, sequencing games, some untimed, but many timed to speed my processing times. In addition, when I was able, I was encouraged to return to my hobby of silversmithing. Through the various aspects of jewelry design and fabrication - cutting, sawing, soldering, polishing, beading, cutting and polishing stones, I could practice a lot of hand eye coordination, timing, design, conceptual and sequencing skills while also learning my limits and abilities. I was much slower that I'd been, and struggled with some of the hand eye coordination and spacial perception than before, but I had a point of reference in my former skills to work towards.

The fourth predictor: flexible personality style at midlife. Before my stroke, I was not what anyone would have called flexible. But the tree that won't bow will break. And something in the Alice in Wonderland world I lived in after my stroke created a spaciousness, an unknowing, a beginner's mind quality that left me wide open to a rebirth of sorts. Newly chafing at medicine, I discovered first Jerry Jampolsky's Attitudinal Healing (loosly based on secularized concepts from A Course in Miracles) then improvisation, both of which supported fundamental life view changes, giving me many more ways to see, and many more ways to be.

The fifth predictor, high cognitive status of spouse (!) did not come into play. But those studies are fascinating (just saying)!

The final predictor is maintenance of high levels of perceptual processing speed. After my stroke, slowed processing speed was probably my weakest area from day one. Six months after my stroke, I was pouring hot water for tea. I became aware of a sensation of heat. But the time I realized I was pouring it on my arm rather than the cup in my hand, I already had second degree burns. Then I just stood there, not knowing what to do. Eventually, I remembered, "Oh, yes, cold water." I ran cold water over my arm, but the scars remain today. So, processing speed was something I concentrated on. Specific cognitive training can increase the efficiency of processing speed . Improving my processing speed was the true marathon of my rehabilitation. I continued to work on it for 7-8 years with specific computer games.

So, I had many factors going for me that would prevent cognitive decline that probably helped in terms of cognitive rehabilitation.

When I became involved enough in the world of improv, acting, writing and performing, I felt that my daily life included enought challenge and stimulation that I no longer needed to do specific rehabilitation. And I still continued to improve. I haven't noticed a lot of change in the last few years, but then, I'm also getting older, and haven't noticed a decline either!!! Others with brain injuries, however, may have to maintain a schedule of rehabilitation over the long haul to avoid backsliding.

Thankfully, most of you will never be in a position to need cognitive rehab.

But God willing and the Creek don't rise, most of you will get older. And normal aging brings cognitive changes, many of which fall into the decline column.

So what can you can do to minimize those changes and optimize your brain health?

1- Good control of medical risk factors, especially cardiovascular disease (including atrial fibrillation), high blood pressure, high cholesterol, diabetes and obesity). DO NOT SMOKE! Limit your alchohol intake. Even moderate drinking increases your risk. Heavy drinking is the strongest modifiable risk factor. (Some studies suggest moderate drinking can be healthful, but they looked at limited populations, and remain controversial.)

2- Be physically active - as little as 20-30 minutes of brisk walking makes a difference, but high levels of fitness can reduce dementia risk by 90%. (CNN version of article.)

3- Follow a healthy diet- The MIND Diet (Mediterranean-DASH Intervention for Neurodegenerative delay, DASH is Dietary Approaches to Stop Hypertension), emphasizing leafy greens, other vegetables, berries, poultry, fish, olive oil, beans,nuts, whole grains and yes, wine, is associated with lower rates of Alzheimer's . Diet may be especially important for those with brain injuries, who have an increased risk of dementia.

4- Challenge your brain- with varied and novel activities- learn a new instrument, a new language, etc

5-Enjoy social acivity and social interactions. Isolation and lonliness are associated with cognitive decline.

But, if I had to pinpoint the single factor most important factor (over which I might have had some control) in my successful rehabilitation, I'd say motivation. My overarching motivation: to see my boys educated and launched. Motherhood is powerful!

As for how else I've changed, my residual deficits, more thoughts on optimal post discharge service integration and shout outs to those in the rehab community to whom I am most graterful- that's for another time.