The population of individuals with Alzheimer's disease (AD) and related dementias is projected to expand from 5.5 to 13.8 million by 2050 (Alzheimer's Association, 2017), increasing the annual costs of dementia care from $259 billion to $1.1 trillion. The majority of care for individuals with AD is provided by approximately 15.9 million family caregivers, saving the U.S. health care system more than $230 billion annually (Alzheimer's Association, 2017).
The interest in and use of complementary and integrative health strategies continues to grow in the United States. In 2012, 34% of U.S. adults reported using at least one complementary modality for improved health (Clark, Black, Stussman, Barnes, & Nahin, 2015). Mind– body therapies, such as meditation, reflective exercise (e.g., yoga, tai chi, qigong), biofield therapies (e.g., Reiki, Therapeutic Touch, Healing Touch), and guided imagery, have increased in recent years in the United States, with approximately 20% of the population engaging in some form of mind–body practice (Clark et al., 2015). Records of these mind–body practices extend back to ancient times and are rooted in Eastern philosophy. Many of these therapies are currently practiced throughout the world and the evidence base to support the efficacy of these therapies continues to grow. Research findings suggest that the use of mind–body practices reduces stress, anxiety, and depression and improves associated health outcomes, including heart rate, blood pressure, and inflammatory markers (Ho et al., 2016). Thus, these therapies are potential targets for nonpharmacological treatment in the AD patient population.
Although the mechanisms underlying the putative physiological and psychological effects of mind–body therapies continue to be examined, the positive changes observed likely occur through a number of pathways, including modulation of the stress response. By reducing the activation and reactivity of the sympathoadrenal system and hypothalamic pituitary adrenal (HPA) axis, as well as promoting feelings of well-being, mind–body therapies may alleviate the effects of stress and foster multiple positive downstream effects by shifting the autonomic nervous system balance from primarily sympathetic to parasympathetic and leading to positive changes in cardiac-vagal function, mood, energy state, and related neuroendocrine, metabolic, and inflammatory responses (Taylor, Goehler, Galper, Innes, & Bourguignon, 2010). The autonomic nervous system, which is associated with emotion, and the HPA axis are expected to be positively affected by mind–body therapies, as evidenced by physiological measures such as improvements in heart rate variability (Kemper, Fletcher, Hamilton, & McLean, 2009), leading to a reduction in stress. Given that the HPA axis may be dysregulated in some individuals with dementia and may play a potential role in mediating behavioral and psychological symptoms of dementia (BPSD) (de Kloet, Joels, & Holsboer, 2005), these therapies may represent adjuncts to the conventional care and management of BPSD.
Health care providers are increasingly relying on the scientific literature and clinical practice guidelines, as well as patient preferences, to make decisions regarding the treatment of individuals with dementia (Cohen-Mansfield et al., 2014). Therefore, the current integrative review critically evaluates the literature examining the efficacy of selected mind–body therapies (i.e., reflective exercise [yoga and tai chi], meditation and mindfulness, biofield therapies [Reiki, Therapeutic Touch, and Healing Touch], and guided imagery) as supportive care modalities for patients with dementia.
Reflective Exercise (Evidence Grade A2)
Forms of reflective exercise, or meditative movement, are defined as a combination of meditation, deep breathing, and any form of movement (ranging from slow and gentle to fast and vigorous) to achieve a state of deep relaxation (Zheng et al., 2015). The most commonly practiced forms of reflective exercise are tai chi (sometimes referred to as taiji) and yoga; these therapies have demonstrated maintenance of or improvement in a range of health outcomes in healthy adults (Zheng et al., 2015). In the past decade, studies have explored the effects of reflective exercise on cognitive and physical function and psychological outcomes in individuals with dementia (Table A, available in the online version of this article), including various forms of tai chi (Burgener, Yang, Gilbert, & Marsh-Yant, 2008; Chang et al., 2011; Cheng et al., 2014; Cheng, Chow, Yu, & Chan, 2012; Lam et al., 2011; Lam et al., 2012; Li, Harmer, Liu, & Chou, 2014; Yao, Giordani, Algase, You, & Alexander, 2013) or yoga interventions (Eyre et al., 2017; Fan & Chen, 2011; Litchke, Hodges, & Reardon, 2012). In addition, studies have developed multicomponent interventions, such as the Preventing Loss of Independence through Exercise (PLIÉ) study, that have included body awareness, mindful rest, and progression of seated to standing exercises (Barnes et al., 2015). Sample sizes of reflective exercise studies have ranged from 11 to 329, and most participants were female. The settings for recruitment of participants included community living, adult day care, and long-term care.
Learning the sequential movements of reflective exercise provides motor training that is expected to improve cognition (Li et al., 2014). Additional contributions to cognitive stimulation include focused attention, postural control, verbal cues, and visual imagery. Reflective exercise interventions have shown maintenance of and improvements in cognitive function in individuals with dementia. A small study (N = 11) by Barnes et al. (2015) showed 18 weeks of the PLIÉ intervention improved global cognition scores whereas scores declined in the chair exercise control group. Other studies showed 40 weeks of combination taiji, 14 weeks of tai chi moving for better balance, and 20 weeks of tai chi adapted for individuals with osteoarthritis and cognitive decline compared with sedentary controls significantly improved global cognition (Burgener et al., 2008; Li et al., 2014; Tsai, Chang, Beck, Kuo, & Keefe, 2013). Chang et al. (2011) showed global cognition and working memory remained the same for participants who exercised regularly (n = 8) and a decline in scores for those (n = 3) who received a low-dose of tai chi. Eyre et al. (2017) reported improved memory and executive functioning following a 12-week Kundalini yoga intervention.
One large cluster randomized study (N = 110) showed global cognition and working memory scores significantly improved following 12 weeks of tai chi and Mahjong and declined for the control group (Cheng et al., 2014). Another large study (N = 329) reported significant improvements in global cognition and subjective cognition in tai chi and stretching and toning exercise control groups 2 months following a 12-week intervention class (Lam et al., 2011). At 1-year follow up of the same study, the cognitive function scores remained unchanged for both groups and the tai chi group showed a significantly lower risk of developing dementia than the toning and exercise control group (Lam et al., 2012). The tai chi group also showed greater improvement in delayed recall scores. Another small study of tai chi plus calligraphy and drawing observed improvements in cognitive scores following a 6-week intervention compared with usual care (Tai et al., 2016). One small study (N = 19) explored the effects of a 10-week chair yoga class on cognition in individuals with dementia in assisted living facilities. Cognition was unchanged for participants; however, caregivers reported participants slept better on days when they attended yoga (Litchke et al., 2012).
The use of large muscle groups and continuous flowing movements contribute to the improvements of physical function achieved as a result of reflective exercise. Eight studies explored the effects of different forms of reflective exercise on measures of physical function. One group tested the effect of an intervention developed for individuals in an adult day care for AD and dementia on performance, cognition, and quality of life. The intervention included body awareness, mindful resting, and exercises transitioning from a seated to standing position (Barnes et al., 2015; Wu et al., 2015). Analysis of field notes showed participants developed an awareness of bodily sensations, motor memory for movements practiced in class, and functional skills (Wu et al., 2015). Upper flexibility and balance scores improved at 18 weeks and balance continued to improve at 36 weeks (Barnes et al., 2015). Yao et al. (2013) showed a positive emotion tai chi practiced with caregivers improved balance scores by 2 seconds. Participants with mild cognitive impairment (MCI) showed greater improvement compared with those with moderate and severe cognitive impairment. Fan and Chen (2011) demonstrated 12 weeks of Silver Yoga designed for older adults significantly improved measures of flexibility, balance, strength, and cardiorespiratory fitness. The control group showed a significant decline in outcomes. Litchke et al. (2012) studied the effects of chair yoga on balance and the ability to perform activities of daily living (ADLs). The group with mild AD showed greater improvements in ADLs and a nonsignificant improvement in balance.
A non-randomized controlled study reported tai chi significantly improved balance, endurance, and confidence in the ability to avoid falling as compared with controls (Li et al., 2014). One study showed 20 weeks of tai chi combined with cognitive–behavioral therapy and a support group improved balance, whereas the control group declined (Burgener et al., 2008). In a cluster randomization study of older adults with cognitive impairment and osteoarthritis, individuals who participated in 20 weeks of tai chi compared with those in an attention control group had significantly improved symptoms of arthritic pain, joint stiffness, physical function, balance, and strength (Tsai et al., 2013). Tai chi compared with stretching and toning significantly improved balance at 5 months and the effects were sustained at 1 year (Lam et al., 2011; Lam et al., 2012).
The relaxation response engendered by reflective exercise is believed to affect psychological outcomes. Wu et al. (2015) conducted qualitative interviews following 18 weeks of the PLIÉ intervention delivered to individuals with dementia attending an adult day care. Emotional changes included acceptance of resting in the moment, sharing personal stories with emotion, and attitudes toward the PLIÉ program and exercise. Social changes (i.e., interpersonal relationships) shifted from feelings of anxiety to ease and coherence in interactions, making friends, and caring for others. Kundalini yoga improved levels of resilience among participants with MCI (Eyre et al., 2017), whereas tai chi plus calligraphy and drawing compared with usual care significantly improved quality of life among individuals with dementia (Tai et al., 2016).
Depression was the most often examined outcome among studies of reflective exercise interventions. One study showed a significant improvement following 12 weeks of Silver Yoga compared with usual activity (Fan & Chen, 2011). Depressive symptoms also improved following a 12-week Kundalini yoga intervention (Eyre et al., 2017). Another study showed 3 months of Mahjong significantly improved depression compared with tai chi and a handicraft in older adults with moderate depressive symptoms living in long-term care (Cheng et al., 2012). However, the depression scores returned to baseline at 6 months. Depression remained unchanged in other studies including individuals with dementia living in community settings and long-term care (Burgener et al., 2008; Lam et al., 2011; Lam et al., 2012), although participant baseline depression scores were reported within the normal range (Burgener et al., 2008; Lam et al., 2012).
Self-esteem improved significantly following 40 weeks of a multicomponent taiji intervention compared with a sedentary control group (Burgener et al., 2008). Fan and Chen (2011) showed a significant improvement in problem behaviors following 12 weeks of Silver Yoga compared with usual activity. Another study reported a significant improvement in BPSD as rated by caregivers, as well as caregiver distress and burden, following the 18-week PLIÉ intervention (Barnes et al., 2015).
Given the consistent, positive results from a number of RCTs examining the effects of reflective exercise interventions, including improvements in cognitive and physiological measures, as well as BPSD, reflective exercise interventions (specifically tai chi and yoga) warrant an evidence grade of A2.
Meditation and Mindfulness (Evidence Grade A2)
Meditative and mindfulness techniques are based on age-old practices, derived mainly from Eastern Buddhist traditions. Researchers disagree on the specific definition of meditation; however, the concept commonly consists of behavioral and mental techniques focusing on controlled mental activity. In Western terms, these modalities are more broadly described as mindfulness-based interventions (MBI) and focus on self-regulatory techniques to maintain one's attention and awareness (Marciniak et al., 2014). An example is mindfulness-based stress reduction (MBSR), a prescribed program of moment-to-moment awareness of sensations (breath), emotions (mood), and thoughts (anxiety), and may include individual or combined reflective exercises, transcendental meditation (TM), or other stress reduction techniques (Wells et al., 2013). Other examples of MBIs are Vipassana (insight) meditation (Lazar et al., 2005), Zen meditation (breathing focused mindfulness) (Pagnoni & Cekic, 2007), any mantra-based mindfulness (e.g., TM, Kirtan Kirya, Vihangam yoga) (Innes, Selfe, Brown, Rose, & Thompson-Heisterman, 2012), or body scanning (i.e., progressive focused awareness of the body) (Clark et al., 2015).
MBI practices are distinct from psychological or behavioral therapies in that these practices are based on the concept of self-awareness (Marciniak et al., 2014). MBIs share a common goal of expanding one's facility for mindfulness, or a sense of “being in the moment” without judgment. These practices generally have a prescribed amount of training and practice, with daily or weekly short periods of mindfulness sessions. For example, MBSR is typically an 8-week program of instruction with daily sessions of approximately 12 minutes, whereas Kirtan Kyra is a meditative practice in which one chants along with synchronized, repetitive finger movements (Innes et al., 2012). Practitioners of MBIs generally have experience with or combine one or more of these modalities; therefore, research is often limited to a general definition of MBI activities (Fox et al., 2014).
MBIs have been shown to have benefits on mental and physical health, as well as neural morphology, and many individuals have adopted these practices as a part of health maintenance (Fox et al., 2014). Effects include reductions in depression and anxiety, as well as improvement in mood, sleep indices, cognition, memory, well-being, and quality of life (Newberg, Wintering, Khalsa, Roggenkamp, & Waldman, 2010). Many of the studies of MBIs involving individuals with dementia (Table B, available in the online version of this article) have shown an impact on cognition including improvements in logical memory (Innes et al., 2012; Moss et al., 2012; Newberg et al., 2010; Paller et al., 2015), working memory, verbal fluency, and attention (Moss et al., 2012; Newberg et al., 2010; Paller et al., 2015). MBIs have also been shown to improve sleep (Innes et al., 2012; Paller et al., 2015), increase cerebral blood flow (CBF) (Moss et al., 2012; Newberg et al., 2010), and improve mood (Innes et al., 2012; Moss et al., 2012).
Meditation and mindfulness intervention studies.
In a randomized controlled pilot trial using MBSR as an intervention and functional magnetic resonance imaging (MRI) and neurocognitive testing to evaluate brain activity, Wells et al. (2013) demonstrated that MBSR was a feasible intervention for individuals with MCI and was associated with changes in spontaneous brain activity in the hippocampus and putamen/inferior frontal gyrus. Hippocampal volume and other brain regions associated with dementia showed trends toward improvement (p = 0.07). In addition, a trend for change from baseline was observed for the MBSR group versus controls in terms of scores on the Alzheimer's Disease Assessment Scale cognitive subscale and the Perceived Stress Scale at 8 weeks (Wells et al., 2013). A second study of MBSR found similar findings, including increased quality of life, fewer depressive symptoms, and better subjective sleep quality (Paller et al., 2015).
Three studies used the Kirtan Kyra meditative intervention (Innes et al., 2012; Moss et al., 2012; Newberg et al., 2010). Innes et al. (2012) conducted a study in community-dwelling individuals with dementia and their family caregivers and reported significant improvements in perceived stress, mood, depression, sleep, retrospective memory function, and blood pressure. Moss et al. (2012) reported positive changes in mood, anxiety, and other neuropsychological parameters, which correlated with changes in CBF. Another study with a similar cohort recruited from a memory clinic with a control group listening to music found increased neuropsychological memory test scores and CBF via SPECT scan (Newberg et al., 2010).
Cognition is affected by MBIs in direct and indirect ways. Neurological correlates of meditation during practice have shown increases in CBF and activation of networks in brain regions that regulate attentional control, such as the frontal lobes and anterior cingulate cortex, through neuroimaging studies (Marciniak et al., 2014; Moss et al., 2012; Newberg et al., 2010; Wells et al., 2013). MBIs also influence risk factors for AD, including hyper-cholesterolemia, hypertension, and depression, and have a neuroprotective effect by increasing cortical thickness (Marciniak et al., 2014). The observed reductions in inflammatory markers, stress, and anxiety, and increases in telomere length evidenced by MBIs may lead to better cognitive functioning and, thus, improved quality of life. As described in a previous review of the mechanisms of action of nonpharmacological therapies in dementia (Burgener et al., 2015), including MBIs, physiological measures including MRI, electroencephalogram, and serum levels of melatonin, serotonin, and cortisol have been explored to elucidate the physiological effects of MBIs. Given the consistent improvements in cognitive measures and BPSD outcomes reported by several RCTs of MBIs, these interventions warrant an evidence grade of A2.
Biofield Therapies (Evidence Grade A2)
Historical accounts of energy-based interventions have been found in cultures globally (Anderson & Taylor, 2011). More recently termed biofield therapies, these interventions involve the modification of the human energy field by directing healing energy through the hands and include Healing Touch, Therapeutic Touch, and Reiki, among others (Anderson & Taylor, 2011). These therapies most likely mediate effects through a psychoneuroimmunological framework by reducing stress and anxiety and promoting relaxation, outcomes that have been reported in various chronic disease populations (Anderson & Taylor, 2011). Biofield therapy studies involving individuals with dementia have used quasi-experimental and RCT designs (Table C, available in the online version of this article). Healing Touch over the course of 5 days decreased agitation (Hawranik, Johnston, & Deatrich, 2008), similar to findings reported by Wang and Hermann (2006). Using a RCT design, a Healing Touch intervention combined with Body Talk Cortices significantly improved cognitive decline and mood in individuals with dementia compared with usual care controls (Lu, Hart, Lutgendorf, Oh, & Schilling, 2013). Therapeutic Touch was found to improve levels of agitation and decrease levels of salivary cortisol in three studies using a RCT design of individuals with dementia living in skilled nursing facilities (Woods, Beck, & Sinha, 2009; Woods, Craven, & Whitney, 2005; Woods & Dimond, 2002). Reiki improved measures of cognitive function and BPSD in individuals with dementia and MCI compared with usual care (Crawford, Leaver, & Mahoney, 2006). Although biofield therapy interventions may be more amenable to individuals with dementia or MCI given that no cognitive or physical engagement is required on the part of the recipient, a limitation of these interventions is the availability of trained practitioners of the therapies. The positive results observed in the reviewed studies required multiple sessions with trained providers over a period of days (Woods et al., 2005; Woods et al., 2009), weeks (Wang & Hermann, 2006), or months (Lu et al., 2013). However, given the significant improvements in BPSD, specifically agitation, reported following biofield therapy interventions using RCT designs and quasi-experimental studies, these therapies, including Healing Touch, Reiki, and Therapeutic Touch, warrant an evidence grade of A2.
Biofield therapy and guided imagery intervention studies.
Guided Imagery (Evidence Grade C1)
Guided imagery involves developing mental pictures of persons, objects, or feelings, and stimulates various senses and triggers psychological processes (Heyn, 2003). Guided imagery has shown benefits in cognitively intact individuals; however, few studies have examined whether individuals with dementia can benefit in the same way through more stability in emotion and increased focus (Table C). A small study (Heyn, 2003) (n = 13) showed an improvement in heart rate, overall mood, and engagement in physical exercise using a multisensory intervention involving storytelling and imagery combined with a warm-up session of seated exercise as one of four components. In addition, cognitive scores remained stable over the 6 months following the intervention. However, it should be noted that participants in this study displayed moderate to severe cognitive impairment. Hussey, Smolinsky, Piryatinsky, Budson, and Ally (2012) found results suggesting that individuals with mild AD can perform basic visual imagery, but not on a complex level aiming at improving verbal recognition, which was the aim of the study. However, the authors suggest that mental imagery may help individuals with mild AD overcome apathy and poor attention, and may provide meaningful strategies for improving memory functioning. Given the small number of studies exploring guided imagery interventions for individuals with dementia, this modality warrants an evidence grade of C1.
Although the majority of AD- and dementia-related research continues to focus on disease etiology and pathology, as well as efficacious and effective pharmaceutical treatment, individuals with dementia and their caregivers continue to seek interventions to assist in managing the disease process. Mind–body therapies may help fill this niche by providing personalized, low-cost, efficacious strategies with no documented side effects. In the current review, reflective exercises (e.g., yoga, tai chi), biofield therapies (including Therapeutic Touch and Healing Touch), and mindfulness and meditation-based interventions ranked highest in level of evidence to support the use of these approaches in individuals with dementia (evidence grade A2), whereas guided imagery obtained a grade of C1. Given these moderate to high rankings and a continued focus on the examination of these therapies, mind–body approaches for symptom management in individuals with dementia represent effective avenues for caregivers and health care providers to explore.
As research continues, several areas of importance related to research design and methodology should be considered. Mind–body therapies do not fit the mold of a typical RCT design. Oftentimes, these approaches involve multicomponent interventions that may increase variation beyond that of a typical RCT. Thus, replication of study findings, valid evaluation of study outcomes, and ensuring treatment fidelity may be more challenging. Creating an equivalent control comparison group can be difficult given the characteristics of the mind–body therapy under study. Given that mind–body therapies are easily identifiable by study participants and observers by virtue of the nature of the therapy itself, non-blind study designs should be considered (Cohen-Mansfield et al., 2014). Research designs that are relevant to clinical practice and provide results that are informative to health care professionals, as well as patients and their families, are needed to support evidence-based practice, such as sequential multiple randomization trial experimental designs (Song, DeVito Dabbs, & Ward, 2016). In addition, the inclusion of qualitative data and the perceptions of caregivers of individuals with dementia are key outcomes in this area of research to gauge the efficacy and effectiveness of these interventions.
Regardless of study design, a consistent weakness of several of the studies reviewed was a lack of detailed methodology, particularly with regard to descriptions of the mind– body therapies used. These methods are key in evaluating the results of studies, grading and comparing evidence related to mind–body therapies, and replicating research findings. An extension of the CONSORT requirements as applied to studies of nonpharmacological interventions (Boutron, Moher, Altman, Schulz, & Ravaud, 2008) provides guidance that applies not only to the reporting of the results of studies examining mind–body therapies, but also points of consideration in the design of these studies. Recently, more specific recommendations have been put forward in terms of particular interventions, such as the Delphi consensus recommendations related to the reporting of yoga studies (Fischer-White, Anderson, & Taylor, 2016).
The physiological mechanisms of mind–body therapies continue to be explored. This information is useful in providing objective results to support the exploration of such interventions. The majority of mechanistic studies have focused on stress pathways, which play a role in AD and dementia. New studies, such as those related to biofield therapies, point to other cellular pathways that may have direct effects on the pathophysiology of the disease, such as insulin-like growth factor-1 and amyloid beta (Yan et al., 2004). The literature concerning studies examining possible mechanisms of action of mind–body therapies continues to grow. Although several studies have focused on caregivers of individuals with dementia (Ho et al., 2016) or older adults at risk for MCI or dementia (Ashton et al., 2017), there remains a lack of studies exploring physiological measures and biomarkers in individuals who already have a diagnosis of dementia or MCI. The inclusion and exploration of these physiological pathways may potentially provide information allowing for personalization of therapeutic approaches to managing symptoms among individuals with dementia, as well as possible preventive mechanisms. The influence of mind–body interventions on epigenetic mechanisms relevant to early stage dementia warrant further study, particularly with regard to stress pathways. The addition of bio-imaging outcomes to this area of research would also help elucidate mechanisms and regions of the brain specifically affected by mind–body interventions.
Given the level of evidence for the mind–body therapies reviewed, particularly reflective exercises and biofield therapies, health care practitioners can provide recommendations to patients and their families regarding the efficacy of these therapies. The practices reviewed represent strategies that are efficacious and relatively low cost, with no documented side effects or contraindications. For individuals with dementia and their families, these supportive strategies may provide additional tools for managing the disease process by helping alleviate symptoms of dementia and promoting well-being. Gerontological nurses can aid patients by providing information regarding mind–body interventions and practices.