Optimize medical issues treatment:Diabetes is a common disease that when treated properly has lower rates of depression and cognitive issues.Diabetes has twice the rate of depression than that of nondiabetic comparison groupsWhen Type 2 Diabetes was brought under better control through medications, working memory significantly improvedHypertensive patients without vascular complications had deficits with speed of cognition, episodic and working memory, and executive function.  Treat depression and mental health issuesTreat seizure disordersTreat OSAMedications:Reduce polypharmacy (for example when baclofen and gabapentin were taken together they had cognitive effects but when taken alone did not in one studyTake off or minimize anticholinergic medicationsMost commonly used: Hydroxyzine, Amitriptyline, Benztropine, Clozapine, Diphenhydramine, Doxepin, Imipramine, Methocarbamol, Nortriptyline, Olanzapine, Paroxetine, Quetiapine (see full list here)Take off or minimize dose of antihistamine medicationsTaper off benzodiazepines because of issues with psychomotor speed, memory, processing speed, attention, verbal memory, general intelligence, working memory, verbal reasoning (mean effect size -0.74) (xanax, klonopin, ativan, ect). Of note, after tapering off patients from chronic benzodiazepine use, there was significant improvement in sensorium. However compared to controls or normative data, there was an incomplete restoration of function at 6 months. Of note this could be because people who are on benzodiazepines often have multiple other stressors and things going on which could factor into this discrepancy.  Of note, temazepam for sleep might be of less concern. Tapering off of these meds can be dangerous if done too fast; specifically there can be issues like having a seizure. Please work with a physician to slowly decrease these medications.  Zolpidem if taken 8 hours prior to driving or cognitive tests, it does not cause impairment, whereas if taken 4 hours prior does. At 2 hours after ingestion it causes cognitive issues and balance issues.Minimize or take off opioids (vicodin, oxycodone)In one animal study, opioids reduced neurogenesis by 42% in the hippocampal granule cell layerReduce or eliminate topiramate and valproate (of note, sometimes valproate has been helpful in hyperactive delirium with improvement in aggression)Consider alternatives to carbamazepine or zonisomideMedications with mild sensorium issues: gabapentin does not cause cognitive changes but does sometimes have occasional sedation issues at higher doses, oxcarbazepine (slight alpha wave slowing and some some issues with sedation), trazodone (mild issues with short-term memory, verbal learning, body sway, muscle endurance)Medications without cognitive effects: Lamotrigine, Keppra (although 20% had complaints of somnolence), propranolol.Sleep issues:Poor sleep leads to decreased memory encoding, mood issues, worse concentration, driving accidentsSleep counteracts the effects of chronic stress and allows the body’s immune system to “regenerate”Set up patterns of rest (limiting caffeine and electronics at night before bed, consistent bed and wake times, and eliminating napping)Diagnose and treat Obstructive Sleep Apnea and treat with CPAP and weight loss.  Uses in CPAP will improve short term memory, episodic memory, processing speed and mental flexibilityAnother study showed that CPAP improved depression scoresDrug and Alcohol issues:Get off THCPersistent cannabis use showed greater IQ decline (6 points) and worse on neuropsychological tests with greater impairment of executive functioning and processing speed. There were also problems in attention, memory, learning, verbal IQ cited in other studies. Effects were worse when frequent cannabis use was used prior to age 18.Use alcohol in moderation1-6 drinks per week was shown to reduce risk of dementia whereas >14 drinks per week increased risk in a prospective cohort studyReco