Rejuvenation biotechnologies, tissue engineering, cellular restoration, ‘electronic medicine’, testosterone injections and stem-cell facelifts in your lunch hour – the battle against growing old, experts argue, is a war that’s already being won
Park Avenue, New York. I pass a striking couple on the sidewalk. They are clearly wealthy (tick), well-groomed (tick), expensively yet tastefully dressed (tick). But there is something else about them, too. Something that goes beyond money or good taste or a clever hairdresser. Something indefinable. It’s impossible to tell whether they are 50, 60, 70, or even older. They are ageless.
I’m standing at the centre of what is euphemistically known as “the age-management industry”. This is where the city’s most distinguished aesthetic surgeons run their discreet clinics. But, crucially, this couple don’t have the inflated, overstretched look of people who have had “work” done. I can’t keep my eyes off them, trying to work out why they look so … alive.
Age defiance is a staggeringly lucrative industry. Last year the global anti-ageing market generated more than £150 billion. By 2018 it will hit £216 billion. A new tribe is taking advantage of sophisticated scientific breakthroughs. They have learnt from the mistakes of the generation who sought to reverse old age and ended up with wind-tunnel facelifts and over-lasered skin.
The “Forever Youngs” are still having work done, make no mistake about that, but they are using cutting-edge techniques and harnessing new research into everything from exercise to diet to neuroscience.
And this appears to be only the beginning of the new age of ageing. It’s little wonder that the latest venture from Google, currently the most successful innovator on the planet, is ageing-related. Mere cosmetic enhancements are child’s play to Google, which is on an altogether more ambitious trajectory. In September 2013 its CEO, Larry Page, announced Calico – or California Life Company to give it its full name. This is Google’s mission to actually extend human life span.
According to Page, with some “moonshot thinking”, scientists will be able to harness advanced technologies that slow the ageing process and eliminate age-related diseases such as Alzheimer’s and cancer. Plans are in place to build a $1.5 billion life-extension research centre in San Francisco, run by Art Levinson, Steve Jobs’s successor as chairman of Apple and the former CEO of the biotechnology giant Genentech.
Google is not the only one to spot the potential of such a wildly growing market (by 2025, there will be 1.2 billion people over the age of 60. That’s more than double the number in 1995). The Age Reversal Fund is a venture-capital fund that links life scientists and researchers with wealthy investors. The world’s billionaires have a new obsession that goes beyond the merely material: they want what was previously tantalisingly out of reach – the ability to live longer. Much longer.
Thus Larry Ellison, CEO of the computer tech company Oracle and the fifth wealthiest man in the world according to Forbes magazine, is the money behind the Ellison Medical Foundation, an anti-ageing biomedical research centre. The Californian venture capitalist Paul F Glenn has endowed hundreds of millions to life-expansion research at Ivy League institutions such as Harvard, Princeton, MIT and Stanford. Peter Thiel, co-founder of PayPal and a Facebook board member, is a supporter of SENS, a research foundation specialising in rejuvenation treatments.
SENS is run by Aubrey de Grey, a Cambridge PhD graduate and gerontologist who believes that the first person to live to 150 is already alive today.
“Rejuvenation biotechnologies are, very simply, medicines that restore the structure of the body to how it was in early adulthood, and thereby restore it to maximum physical and mental performance,” explains de Grey, who also co-founded Methuselah – a foundation whose aim, through tissue engineering and regenerative medicine, is to create a world by 2030 in which 90-year-olds can be as healthy as 50-year-olds.
“By restoring the molecular and cellular structure of the body to that of a young adult, we will necessarily restore its function, too, which constitutes reversing ageing. Thus, people will remain truly healthy for longer, postponing the ill health that inescapably accompanies old age today.”
This notion that, like the painting in Dorian Gray’s attic, we can reverse ageing, has become an obsession for scientists. So much so that Dr David Sinclair, a professor of genetics at Harvard Medical School, has taken matters into his own hands. Every day he swallows capsules that he believes trick cells into thinking they are young again. “We’re talking not just slowing down ageing, but reversing it,” he says.
In research published last year in the journal Cell, Sinclair described how mice were given a naturally occurring molecule called nicotinamide adenine dinucleotide, or NAD, which reduces in the body as we age and makes cells less efficient. By increasing the amount of NAD, in just one week of treatment, two-year-old mice tissue resembled that of six-month-old mice. In human years, that is akin to a 60-year-old’s cells becoming more like a 20-year-old’s.
“We’re doing animal studies now to make sure that is it safe and to understand what the doses are, but I don’t see any barriers to starting human studies next year,” says Sinclair, who has teamed up with colleagues at the University of New South Wales in Australia.
“Right now, I’m taking the molecule in capsules as a little experiment on myself, and so far I’ve seen nothing negative. I wouldn’t like to say I look younger; I don’t expect that. But I certainly find that I am able to do more work and that I have more energy.”
What about the future? “In ten years, there will be medicines available that you will start taking when you’re 30 and will prevent diseases of ageing,” he predicts. He wields terms like “reprogramming” as though reading the script for the latest sci-fi movie. He even talks about body-part replacement – the idea that we will be able to grow our own skin, even our own livers.
“We will be able to live not just a little bit longer, but a lot longer, and to look younger as well. We are on the verge of a number of separate medical breakthroughs that together will allow us to live to 150. These technologies will definitely be available.”
Time, surely, for a reality check. Would he honestly want to live to 150? “Absolutely,” he replies swiftly. “The world will be a place where we don’t have to worry about getting cancer in our fifties and sixties or getting Alzheimer’s in our seventies and eighties.
“We’ll be able to play tennis with our great-grandkids. People won’t spend the last years of their lives in nursing homes; they’ll be able to be productive members of society right up to the very end.”
Sinclair isn’t alone in his fascination with a life span almost twice what we expect now. He receives 20 emails a day from people asking to join the forthcoming human trials on his age-delaying drug.
On a Saturday night in west London, a Notting Hill banker’s wife recalls going out to dinner and spotting a well-known celebrity from the Nineties walking in. “It was so obvious she’d had work done,” she says. “That isn’t what you want at all.”
She describes the new aesthetic – and I realise that she’s describing the New York couple that had recently entranced me. “The best treatments are the ones that no one knows about. What you don’t want is people knowing definitively that you have had something done. The best compliment a woman like me can get is my husband saying, ‘You look well rested,’ or a friend saying, ‘Have you just got back from holiday?’ You don’t want to look like you’ve had work done. Anyone can do that.”
She talks about wives who grew up being stared at in the street and don’t want that male gaze to stop; men who have been invited to ten-year college reunions and need their peers to tell them how great they look. “It’s all part of the package.”
The idea that someone can see the kind of life you’ve lived by the lines on your face is an anathema. In this super-rich set, the men and women want a plumped-up, dewy glow. The irony is that it’s fiercely competitive, yet no one can reveal the amount of effort that’s gone into achieving it. “It’s all about perfection,” she explains. “The perfect house, the perfect face, the perfect body.”
Two years ago, at the age of 43, American attorney Segal Magori looked in the mirror and didn’t like what she saw. Despite a regular regime of Botox and other fillers, she was losing plumpness in her face. “My face was gaunt and the fillers looked fake,” she says. Her aesthetic surgeon. Scott Wells, suggested a stem-cell facelift (a misnomer: no surgery is involved, although the treatment can be done in conjunction with a facelift), using her own body’s tissue to turn back the clock.
Fat is harvested by liposuction from a patient’s abdomen, hips or thighs and is processed, cleansed and injected into cheeks, temples, brows or wherever there is volume loss. Practitioners believe that this fat contains stem cells, which can help to rejuvenate the skin and boost healing.
After the solution is injected, a laser is used to activate the stem cells. Unlike with fillers, patients do not see the results immediately, because it takes time for the stem cells to do their work and form fat in the patient’s face.
“It’s kind of like gardening. We’re planting seeds and then waiting for the harvest,” says Wells. Again, it is a new treatment and, intriguingly, he notes: “Although we don’t know as yet how all this works at the basic science level, those of us performing stem-cell procedures are overwhelmingly convinced of their benefits. It’s like the Wright brothers, who knew they were flying before the exact principles of aeronautical engineering had been perfected.”
None of this seems to worry Magori, who is engaged to the American politician Bruce Blakeman, once married to Nancy Shevell, Paul McCartney’s wife. She is thrilled with the result. Her procedure cost around $20,000 and she hopes it will last ten years. “I’m sold on it. The result has been phenomenal.”
“She’s been frozen in time and she loves it,” her doctor tells me.
For those in the know, these procedures are increasingly available in the UK. Dr Aamer Khan works from his clinic in Harley Street in London. In between surgery appointments in the operating theatre, Khan describes to me a cohort of patients who end up looking younger, as though they have been subtly photoshopped in real life. He uses words such as “spectacular” and “revolutionary”.
Like Scott Wells, he is fond of a simile to explain how the science works – he compares stem cells to “generals who direct the soldiers to do the job”. He describes vividly a patient who was showing acute signs of ageing through a lifetime of smoking, sunbathing and sugar (the three enemies of youthful-looking skin) and who ended up looking dramatically younger after stem-cell treatment.
“The thing about this kind of regenerative work is that while you would have no idea that they have had surgery, the skin carries on improving, up to two years later.”
Khan goes on to explain how more knowledge about the way telomeres work – the bits at the end of genes, like the plastic tips of a shoelace, that get shorter every time a cell generates – means that a longer life span is all too easily within reach. “If we have been programmed to live 90 years, we may be able to live until we’re 120.”
In another clinic near by on Wimpole Street, Dr Marion Gluck has another approach to ageing that is fast gaining popularity through word of mouth recommendation, but sounds less like the plot of a Hollywood movie. She believes that replenishing the body’s hormones is the key. “Hormones,” she says, “are the missing link to anti-ageing. They complete the picture. They are the foundation.”
What is striking about her clinic – which has recently expanded to another floor, such is the increase in demand – is how well her patients, both men and women, look. “They are here to maintain their health,” she says. “Maintain their vitality, their joy of life, their looks.” She talks about slowing down ageing “considerably” and an exclusive band of high-achievers who want to “take control of something that is inevitable”.
How does she do it? Gluck and her team analyse a patient’s hormone levels. As women go into the menopause, their levels of hormones such as progesterone begin to drop. Something similar happens to men’s testosterone in the andropause, when they may display telltale signs such as erectile dysfunction, decreased energy and reduced muscle mass.
Gluck prescribes bi-identical hormones that, unlike in hormone-replacement therapy, are sourced naturally (some of the men who see her have been offered under-the-counter testosterone substitutes at their gyms).
Many of her patients come from referrals from gynaecologists and psychiatrists. Intriguingly, Gluck maintains that the emotional fallout of ageing – anxiety, panic attacks, depression – can be alleviated by the rebalancing of hormones and, as a consequence, within weeks, patients not only feel better, they look younger, too.
She sees “women who are the main breadwinners. They earn the money. They need to be fit and keep going for at least another 15 years.”
One of Gluck’s most popular treatments is a face cream she has made up specially at the pharmacy. It contains the hormone estradiol, which helps to hydrate the skin and plumps up – there’s that word again – the face without needing to resort to fillers. Does she use it? “I’ve used nothing else on my skin for the past seven years.”
Back in New York, on Park Avenue, Dr Harry Fisch runs a testosterone clinic. Every day Fisch sees tired, moody middle-aged men unable to perform in bed or the boardroom, and offers them testosterone gels that can be applied onto the upper body like antiperspirant.
“Imagine a man of 50,” he says. “Overweight, ponytail at the back, and he buys a Porsche, right? You know what I call that? Meno-porsche. They are feeling they don’t have the oomph, they are feeling that car will bring them the sex appeal and the sexuality that they need. They need to check their testosterone first.”
Thousands of men now swear by it, applying the gel after they shower. The latest innovation is a testosterone injection called Nebido – injected into the muscle in the buttock, it lasts longer than the gel.
It’s these easy-application versions of the treatment that are largely responsible for the industry’s boom over the last decade. Global sales of testosterone rose from $150 million in 2000 to $1.8 billion in 2011, and now 300,000 NHS prescriptions for testosterone – five times the number two decades ago – are issued each year.
On the other side of America, in Las Vegas, the aptly named Dr Jeffry Life – a body-builder in his mid-seventies – runs an extended lifespan facility for men. He claims that, along with a healthy lifestyle plan, HGH injections (a cocktail of three hormones, including testosterone), can help men to beat the middle-age slump.
“A typical patient of mine is in his late forties, early fifties, has poor blood sugar, drags himself out of bed every morning, feels horrible, works all day, can’t wait to get home and take a nap, has zero libido,” says Life. His patients pay $6,000 (£3,650) for a day-long assessment, and then $900-$1,050 a month, adding up to tens of thousands of dollars over decades.
A flaw, of course, in this brave new world of non-ageing is that it is an arena available only to the wealthy: the elite who have the time, money and lifestyle that allows them to look ahead. Are the rest of us destined to wake up on our 50th birthdays with cadaverous cheekbones and dodgy knees?
It does not seem so. While the masses may not – yet – be booking in for lunchtime stem-cell treatments, we already take some anti-ageing treatments for granted. Few women – unless they’re making a deliberate statement – don’t get their grey hair coloured. Few of us are looking forward to an old age with a set of false teeth on the bedside table.
Part of the mass appeal of the 5:2 diet – apart from the dramatic weight loss – was the idea that it promised compelling anti-ageing health benefits. Research conducted over the past six decades has shown that decreasing the number of calories eaten by mice, monkeys, fish and fruit flies by 30 per cent increases their life span by about 30 per cent.
Not only that, but this extra life is healthier. Their hearts are stronger, they are more resistant to cancers and their brains are sharper. Even their fur greys more slowly.
Researchers are still investigating whether a diet with drastically reduced calories slows the ageing process in humans as it does in animals, but it has already been shown to reduce the risk of heart attacks, strokes and diabetes, which doctors say in itself will increase people’s life expectancies.
Dr Michael Mosley is the medically trained broadcaster who helped to popularise intermittent fasting – the less extreme version of calorie restriction – with his Horizon programme, which resulted in the 5:2 diet.
“We live in a snacking culture,” he says, “and it’s one of the things I bang on about because it is profoundly bad for you, filling yourself up between meals. There is quite compelling evidence that the old idea that you should eat lots of small meals a day is a bad one.”
He says that it may be better to consume two large meals a day rather than dividing the same amount of food into six smaller ones. “It’s about satiation. Eating foods that will keep you full and therefore eating less.”
So when teatime does eventually roll around, what should we be eating to live for longer? Well, if you guessed “vegetables”, congratulations, although Mosley says this may be because of their fibre content – fibre being something everyone who wants to live for longer should absolutely eat – rather than because they are vegetables and therefore intrinsically healthy. “We still don’t know what it is about vegetables that’s meant to be so good for us. The old idea was that it was antioxidants, but that’s not so clear now.”
How about stocking up on superfoods? Kale? Spirulina? Swiss chard?
“Well, I don’t believe there are such things as ‘superfoods’.” What about stuff like a “Mediterranean diet”? All those olive-oil adverts make out it’ll keep you alive for ever. “There is good evidence that a diet rich in legumes and with a dash of olive oil and a little red wine can be very good for you. But if you smoke, everything else is just small print.”
Mosley says that if you want to live longer, but also look younger while you’re doing it, you should keep down your blood-glucose levels, because that can be just as bad for your complexion as cigarettes. And the way you keep your blood-glucose levels down is, again, by not eating too much. Mosley believes that most people over the age of 40 should try to have their levels tested regularly. “Because there are an awful lot of people who are diabetic or pre-diabetic and don’t even know it.”
If workouts were once about extolling youth, now they are about preserving it. Gone are the chiselled, overworked midlife bodies that we saw a decade ago, replaced by more delicate muscle definition and limbs that are less scrawny, but leaner than they appeared even in their twenties.
A dramatic development in fitness expectations means that in the past few years, despite being plagued by a slowing metabolism, pre-menopausal women can aim for a flat stomach and sculpted arms. And men faced with a diminishing muscle mass can prevent a thickening waistband and still hope to achieve a ripped core. From Gwen Stefani and Cameron Diaz to Hugh Jackman and Gerard Butler, a new breed of forty and fiftysomethings is redefining not just what an ageless body looks like, but what’s entailed in achieving it.
Throwing yourself into marathon running and triathlons is now considered the ageing equivalent of sunbathing. Hugely effective in terms of fat loss, these long, pounding activities can leave you drawn and haggard. Dalton Wong, personal trainer to Jennifer Lawrence, says too much endurance slogging at a certain age just stresses the skin, “in a way that causes wear and tear and leads to a drop in its youthful plumpness”.
You still need it – but in shorter bursts. Wong recommends no more than 45 minutes of aerobic activity a few times a week when you hit your forties. More than that might raise levels of the stress hormone cortisol, which exacerbates ageing, he says.
Up to half an hour of jogging, cycling or fast walking three times a week – and not hell for leather, but at around 65 per cent of your maximum pace – could be enough. Earlier this year, scientists at McMaster University in Canada reported that this kind of approach was enough to boost skin plumpness in the outer and inner layers of a group of volunteers aged 65 and older.
After three months, the complexion of the exercisers resembled what the scientists said they’d typically expect to find in healthy 20 to to 40-year-olds.
What about strength training? There’s little doubt we need it post 35, when muscle begins diminishing at a rate of 1lb a year, leaving you with sag and sinew unless you address it. But heavy weights are out, unless you are looking for the overworked Madonna look of the past decade.
In America, the trend is very much for medium to light weights lifted slowly, which increases the intensity of the workout without adding bulk. Adam Zickerman, trainer to Sharon Stone and Uma Thurman, suggests aiming for a metronomic lift of ten seconds up with the weight and ten seconds down, which ensures that the muscles “don’t rely on momentum to propel movement”.
While everyone agrees that weights are a good thing, there’s some disparity on how heavy they should be. Zickerman says they should be heavy enough to leave you feeling tired after 50 seconds and unable to perform more repetitions after 90 seconds.
The likes of Tracy Anderson, guru to Gwyneth Paltrow, and Simone De La Rue, trainer to Sandra Bullock, 50, eschew that approach, believing that dumbbells should never be heavier than 3lb and that endless fast repetitions are the route to an exquisite mature body, be it male or female.
Beyond that, lengthening is key. Stretch out that body so that it looks as lithe as it did a decade ago. And for that, the current thinking is that nothing surpasses ballet barre workouts. Not even yoga comes close – it can overstretch the muscles, reducing their ability to gain tone.
Mick Jagger puts his extraordinary suppleness at 70 down to ballet. Niki Rein of Barrecore, in London, says middle-aged men are among her fastest-growing group of clients. “Barre work involves high repetitions of movements, holding contractions and working to exhaustion,” she says. “The movements bring the muscle closer to the bone, to give you an ultralean and long appearance as you get older.”
The overriding message? Keep moving – fast and with focus – to keep the years at bay.
It is not only in the body where advances in turning the clock back are being made. In the new edition of her book Mindfulness, Ellen Langer, professor of psychology at Harvard University, discusses her research into how positive mental attitudes can reverse some of the decline of advancing years. She conducted a landmark experiment that involved elderly men spending a week in a retreat that had been retrofitted to look 20 years older, with radio and television tuned to that era and photographs of the men’s younger selves on display.
The men were instructed “to be who you were in 1959”. During the week the men became more independent, motivated and energetic. At the end, each man had gained an average of three pounds, their hearing and memory had improved and even the strength of their hand grips increased. They had literally, says Langer, become “younger”.
She took a group of hotel chambermaids and pointed out to them that their highly physical jobs – making beds, cleaning rooms and vacuuming – was beneficial exercise. The women’s mental attitudes changed and they lost weight and even lowered their blood pressure.
Similarly, Langer’s research assistants interviewed 47 women ranging in age from 27 to 83 just before they were due to have their hair cut. Their blood pressure was measured. After their hair appointments, women who thought they looked younger had lower blood pressure.
“The mindsets we form when we are younger lock us into our health when we get older. If you believe you can’t control your life and health, then you can’t,” she says. “But if we didn’t make those assumptions in the first place, we wouldn’t have to live with them.”
Langer adds that children should not infantilise their elderly parents but help them to stay engaged and challenged by life. By unquestionably assuming that old age means frailty and weakness, we expect too little of elderly people.
“We don’t know how many more serene and exciting options for living one’s later life might be conjured up if our minds were open to them,” the cognitive psychologist says. “We should see a world of possibilities in our current lives rather than seeing ageing only as a time of loss.”
There are today more people living with Alzheimer’s in the UK than there are people living in the city of Liverpool. By next year, this figure will reach 850,000; by 2025, the number of people in this country with some form of dementia will top 1 million.
Alzheimer’s is incurable, but not untreatable, and there are things that we can do to try to avoid or delay its onset as we get older. Often as not, these are the same things we would do to try to keep our hearts healthy, given that a weak cardiovascular system limits the amount of oxygen reaching the brain.
The problem is that, as we age, we cannot rely solely on a healthy heart as our only means of defence against dementia. We need to be able to call upon the brain to defend itself, which, again, is easier said than done, given that our brains age and fail in the same way our hearts do, entering into a shallow dive of falling function from our late forties onwards.
The solution? To try to somehow halt that decline. And one way of getting the elderly to do this could be through the unlikely avenue of playing video games, albeit ones specially designed with the retention of brain function in mind.
In the US, the start-up company Akili Interactive Labs has been developing something called Project: EVO, an iPad game that its creators believe is capable not only of diagnosing mental-health issues, but also treating them. They have even trademarked the term “Electronic Medicine”, which they use to describe the way in which they believe their software will “improve neural functioning and cognitive symptoms”, which is just another way of saying that it has the potential to reverse some of the effects of ageing and combat some of the side effects of dementia.
These are big claims, but Akili is already conducting clinical trials in partnership with the pharmaceutical giant Pfizer and is currently seeking approval from the US Food and Drug Administration for the game. If successful, this would make Project: EVO something a doctor could actually prescribe a patient in the same way as they would drugs.
But what is Project: EVO, and how can it help in the fight against Alzheimer’s? In it, you steer a rocket-powered surfboard down a winding river while, at the same time, completing other tasks and demands that pop up on the screen as you play, from tapping the screen whenever certain shapes appear to shooting down road signs along the way. The idea is that the game requires the player’s brain to be doing several things at once – for different parts of the brain to be working in concert.
This is called “coherence” and is something our brains struggle to achieve as they age – ie, co-ordinating different parts to focus on a particular mental task. So an older person may still be very good at doing sudoku puzzles, because that requires only one part of their brain to be used, but would struggle to do sudoku puzzles and, at the same time, be required to navigate a maze or remember a certain sequence, because that requires several parts of their brain to work in concert. That, effectively, is what playing Project: EVO encourages.
And there is strong evidence this can not only improve the sharpness and brain function of the elderly when playing the game, but that these improvements also transfer into their real lives. Players notice new stimuli and are able to shift their attention from one thing to another with more ease.
This shouldn’t really be a surprise. Just as playing computer games is increasingly recognised as a means of increasing cognitive function in children – from working memory to their ability to notice fine detail – the same basic principles have been witnessed in tests carried out by the Project: EVO creators with an earlier prototype game.
Elderly people who played the game on its hardest setting regularly were shown via EEG (electroencephalography) scans to have the same electrical patterns as 20-year-olds playing the game for the first time.
Tests are continuing, but if there is even the slightest chance that such games can turn back the clock on ageing brains, then perhaps it won’t be long until we’re all playing for our lives.
Alzheimer’s early warning signs
• Struggle to remember recent events, although you can easily recall things that happened in the past?
• Find it hard to follow conversations or programmes on TV?
• Forget the names of friends or everyday objects?
• Find it hard to recall things that you have heard, seen or read?
• Lose the thread of what you are saying?
• Have problems thinking and reasoning?
• Feel anxious, depressed or angry?
• Feel confused even when in a familiar environment, or get lost on familiar journeys?
• Find that other people start to notice or comment on your memory loss?
Alzheimer’s can be treated effectively, but early diagnosis is essential. The Alzheimer’s Society has devised this questionnaire to look for the early warning signs. Diagnosing Alzheimer’s is difficult and requires careful medical evaluation. If you answer yes to any of these symptoms you should seek medical advice. For more information go to alzheimers.org.uk
Normal memory or dementia?
Normal age-related memory changes
• Able to function independently and pursue normal activities, despite occasional memory lapses.
• Able to recall and describe incidents of forgetfulness.
• May pause to remember directions, but doesn’t get lost in familiar places.
• Occasional difficulty finding the right word, but no trouble holding a conversation.
• Judgment and decision-making ability the same as always.
Symptoms that may indicate dementia
• Difficulty performing simple tasks (paying bills, dressing appropriately, washing up); forgetting how to do things you’ve done many times.
• Unable to recall or describe specific instances where memory loss caused problems.
• Gets lost or disorientated, even in a familiar place; unable to follow directions.
• Words are frequently forgotten, misused or garbled; repeats phrases and stories in same conversation.
• Trouble making choices; may show poor judgment or behave in socially inappropriate ways.