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Today, what works and what doesn’t. Over the past decade, the great majority of people who have reached out to me have been wives. The story is close to the same every time. Her husband has been told he has mild cognitive impairment (MCI). He came home with a prescription and a follow-up appointment in six months, and she came home with a stack of questions.

By the time she finds me, she has usually spent several late nights reading everything she can find, and she has a strong feeling that something important is being missed.

She’s right. If you’re in that position right now, the most useful thing I can tell you is to start now, and I want to explain why.

“Mild” is a misleading word

When MCI is caused by Alzheimer’s, the disease has typically been developing in the brain for 15 to 20 years before the first symptoms appear. Amyloid builds up, tau tangles spread, inflammation rises, and the brain loses connections between nerve cells, all while a person is still working, driving, and paying the bills.

The Alzheimer’s Association’s revised criteria now define Alzheimer’s by these biological changes. Under that definition, someone with MCI whose biomarkers show amyloid and tau already has Alzheimer’s disease. What he doesn’t have yet is an Alzheimer’s dementia diagnosis, because his symptoms haven’t become severe enough to interfere with daily life.

Not every case of MCI comes from Alzheimer’s dementia. Sleep apnea, nutrient deficiencies, an underactive thyroid, certain medications, and other conditions can cause the same symptoms and should not be left unchecked.

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What the standard visit covers

A typical investigation usually includes a short memory test, an MRI to rule out a stroke or tumor, and a few basic labs. Sometimes, an appointment with a neuropsychologist. Then comes a prescription, usually donepezil (Aricept), which can ease symptoms, modestly for a while in some people, but does nothing to change the disease process. In a three-year trial of people with MCI, it did not reduce the number who went on to develop Alzheimer’s dementia.

Most people in a twenty-minute appointment don’t have the time, or even think to ask what’s really driving the decline in this particular man, or if they do, the answer is often “we don’t know”. So the six-month follow-up becomes a wait to see how much worse things get.

Waiting to see if things get worse is pretty risky.

The new infusions, and why they fall short

The newer option many families hear about is an anti-amyloid infusion, Leqembi or Kisunla, given by IV every two to four weeks. Both carry the FDA’s strongest warning for brain swelling and bleeding, a risk that rises sharply for anyone with the APOE4 gene.

People on the drugs still declined, a few months more slowly than people on placebo, and when they stopped treatment, their decline returned to the untreated pace. Eisai’s computer model projects that staying on Leqembi could delay dementia by nearly three years, but so far, no one has been treated long enough to know.

The drugs rest on the idea that amyloid is the problem, yet autopsy studies have found that roughly a third of people who died with normal memory had enough plaques and tangles in their brains to meet the criteria for Alzheimer’s.

Newer drugs on the horizon may eventually be effective, affordable, and safe for APOE4 carriers, and one could become a real asset combined with a program that addresses the full picture. Today’s drugs are a long way from that, and waiting for them costs the time Alzheimer’s disease doesn’t allow.

What it really takes

Cognitive decline is a much wider process than amyloid, and much of what drives it starts elsewhere in the body: blood sugar problems, damaged blood vessels, chronic inflammation, infections, toxins, poor sleep, and the loss of hormones and nutrients the brain depends on. In 2024, the Lancet Commission on dementia estimated that 45% of dementia cases are linked to 14 risk factors we can change, most of them involving the whole body.

Their list leaves out a lot, including sleep, diet, chronic infections, gum disease, toxins, and hormones. Dr. Bredesen compares Alzheimer’s to “a roof with 36 holes.” Patch one hole, however well, and the rain still pours in through the other 35. Problem not solved.

Patch enough of them, and the results can be meaningful and lasting. Judy Benjamin watched her mother live with Alzheimer’s for 20 years, and in 2011, at 67, she was diagnosed herself. She became Dr. Bredesen’s first patient and followed his protocol closely.

Fast forward to 2025, at age 80, she walked nearly 2,800 miles from San Diego to St. Augustine to raise awareness that Alzheimer’s isn’t a one-way street. This September, at 82, she finished a 550-mile walk across England, from Land’s End to London.

Fifteen years after her diagnosis of Alzheimer’s, her cognition is normal, she works as a brain health coach and travels the world telling her story.

After a decade of working with people across every stage of this disease, I’ve seen five things make the difference.

Starting as early as you can. Before you have symptoms is the best time, but Alzheimer’s is still considered a disease of old age, so prevention seems unnecessary to most.

The signs of “senior moments” are a warning sign that the brain needs attention.

At the MCI diagnosis stage, the brain still has reserve to work with.

The published cases of people who improved their scores, some of them back into the normal range, were intentionally people who started at MCI. The lower the cognitive score when someone begins, the harder the climb, and past a certain point the realistic goals shift.

A thorough investigation. Two people can walk into a doctor’s office with the same memory score for very different reasons. One may have insulin resistance and oxygen dropping every night from untreated sleep apnea. Another may have mold toxins from a slow leak behind a bathroom wall and a reactivated herpes virus.

Each needs something the other doesn’t, and the only way to know which “holes are in the roof” is to test for them. I organize these hidden contributors by systems and test accordingly: Immune, Gut, Metabolic, Detoxification, Nutrients, Neuro, Cardio. Each category has specific tests, most are not standard. Dr. Bredesen calls this comprehensive evaluation a cognoscopy.

A comprehensive program. Social media is full of lifestyle advice for brain health, and much of it is sound. For someone who has already progressed to MCI, though, those pieces have to come together in a comprehensive plan built around what the right testing shows. Dr. Bredesen’s group has built the evidence for this approach since 2014, most recently in a randomized control trial with people who have MCI or early dementia.

After nine months on a personalized program, participants’ overall cognitive scores rose from about the 30th percentile for their age to about the 65th, while the group receiving standard neurology care slipped downward.

Their spouses noticed it too: partners in the personalized group reported improvement, and partners in the standard care group reported decline. The paper is still in peer review, and the trial was funded by a nonprofit foundation, because there’s no drug to sell at the end of it.

Community. In that randomized trial, participants worked with coaches and were expected to exercise six days a week. Exercise is just one several lifestyle aspects. Coaching was not a side detail.

The core of this program is lifestyle change, and anyone who has made a New Year’s resolution knows how it tends to look by February.

There are thousands of excellent books on diet, exercise, sleep, and stress. Many of us have read a few of them, closed the cover, and found ourselves facing the same problem the next morning, because the change has to happen in the kitchen at 9 p.m. and in the decision to put on walking shoes at 7 a.m., long after the reading is done.

Age adds challenge. A 70-year-old man who has eaten the same breakfast for forty years and has a bad knee faces a steeper climb than a 55-year-old who already walks every morning.

For wives, there’s another layer. You’re often making these changes for two people, one of whom may not remember the plan, may not believe anything is wrong, or may push back on dietary changes. And you’re doing it surrounded by people who still see Alzheimer’s as a one-way street.

When the general belief is that nothing can be done, anything outside the standard prescription can look like snake oil to the friends and family offering opinions. Food is where this shows up most. “Oh, just let him eat what he wants” comes from love, from people who have no idea how much blood sugar, inflammation, and nutrition have to do with his brain.

Then there’s dinner out with friends, when suddenly the two of you are ordering differently from everyone else at the table.

I’ve heard more than one story from wives about the pressure that follows: the dessert passed his way, the teasing, the “one won’t hurt.”

The research on behavior change explains why this matters so much. It’s been documented that people who join a lifestyle program with like-minded peers and receive added educational support are far more likely to stick with it.

I see sustainable long-term lifestyle changes in my Direct Access members all the time.

Community is important. A place where people know your name. A place where you learn what you’re doing and why, so you can hold your ground without offending anyone at the dinner table or restaurant if needed. And when to let it go.

Where the constant questions you have in the beginning get answered by a certified practitioner, quickly and without scheduling an appointment or driving across town.

Where you can talk with and ask questions of others who have already been through what you’re just learning. And where you can get live, face-to-face connection with those same people, who understand, because all of us need that.

The wife of one of my first clients was instrumental in guiding the creation of my Direct Access community years ago. I have no idea how many questions she asked me as she began her journey, but it was clear that she literally needed direct access! : )

And so have all those since.

It truly would have been helpful in my own life when I realized my mom was on the same path as other female relatives. Any info would have been helpful back then, before we had all that has been building since 2016.

Staying with it. The people who wrote their stories in The First Survivors of Alzheimer’s, like Judy, have held their improvement for years by staying with the program. What they continue is a way of living that corrects many of the causes of their decline and improves their heart, blood sugar, sleep, and energy along the way, combined with tracking their data to eliminate the guesswork.

Here’s the good news

MCI is the stage where the most can still change. The contributors driving decline can be found with the right testing. Many of them can be corrected, and the research shows people improving rather than just declining more slowly. You don’t need to wait for a new drug or a worse score to begin. You can start now, with a personalized plan and people around you who understand what you’re doing and why.

It all starts in the Direct Access community, send an email to info@angelachapman.net requesting a link to more information.

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