Addressing issues related to geropsychiatry and the well-being of older adults
New research is providing health care professionals with evidence for the effectiveness of an intervention that is thousands of years old: meditation. Based on Buddhist principles, meditation can be taught through a variety of exercises, with the meditators often sitting quietly while focusing on their breathing, enhancing awareness of what is happening in the mind and body in what is often called a state of mindfulness (Hoppes, Bryce, Hellman, & Finlay, 2012). Mindfulness can be practiced through activities such as sitting, walking, eating, body scanning, and yoga. Ideally, lessons learned during mindfulness practice are brought to daily activities to enrich quality of life (Mackenzie & Poulin, 2006).
In a seminal paper on mindfulness meditation and pain, Kabat-Zinn (1982) described his concept of the Mindfulness-Based Stress Reduction (MBSR) program, which he introduced at the University of Massachusetts Medical Center. This program teaches mindfulness meditation in a small-group format. Participants learn to concentrate on the present moment in a receptive and nonjudgmental manner, thus integrating elements of awareness, experience of the present moment, and acceptance (Foulk, Ingersoll-Dayton, Kavanagh, Robinson, & Kales, 2014). Mindfulness is a way of shifting one’s perception from doing to being (Hoppes et al., 2012).
Since Kabat-Zinn’s (1982) introduction of the MBSR program, multiple studies have demonstrated the beneficial effects of mindfulness training (Black, O’Reilly, Olmstead, Breen, & Irwin, 2015; Foulk et al., 2014; Gallegos et al., 2013; Grossman, Niemann, Schmidt, & Walach, 2004). Proponents of meditation have asserted for many years that meditation practices produce beneficial cognitive and psychological changes that can persist over time, but evidence shows that individuals are not just feeling better because they are calm but that meditation results in observable changes in brain structure. Studies suggest that mindfulness meditation functions through arousal and neurocognitive processes that mediate the relationship between perception of stimuli and appraisal (Black et al., 2015).
Researchers at Massachusetts General Hospital demonstrated measurable changes over time in brain regions associated with memory, sense of self, empathy, and stress in 16 individuals who participated in an 8-week mindfulness meditation program (Holzel et al., 2011). The program consisted of weekly group meetings, each lasting 2.5 hours, with an additional 6.5-hour session during the sixth week of the course. Participants reported practicing mindfulness an average of 27 minutes per day during the 8 weeks. Magnetic resonance images taken 2 weeks after the program showed an increase in gray-matter density in the hippocampus, which is important for learning and memory, and in structures associated with self-awareness, compassion, and introspection. Participants’ reports of reduced stress were also correlated with decreased gray-matter density in the amygdala, which plays an important role in anxiety and stress. None of these changes were seen in 17 individuals who served as the control group.
Research with various populations has demonstrated that meditation can lead to significant improvements in problems such as anxiety, depression, substance abuse, hypertension, chronic pain, and loneliness (Creswell et al., 2012; Holzel et al., 2011; McGreevey, 2011). Because the aging process is often accompanied by many of these problems, it is important to consider the benefits of mindfulness meditation for older adults.
Depression and Anxiety
Mindfulness-based interventions have been shown to be helpful in treating depression and anxiety in older adults. Foulk et al. (2014) used a quasi-experimental pre–post design to measure changes in 50 older adults with depression, anxiety, or both, who participated in an 8-week mindfulness-based program. Data from the 37 participants who completed the program indicate significantly less anxiety, fewer ruminative thoughts, and fewer sleep problems. Data analysis showed a reduction in depressive symptoms, but the difference between before and after completion was not statistically significant.
Young and Baime (2010) retrospectively evaluated the impact of MBSR training on mood states in 141 adults older than 60. Mood changes were measured with the Profile of Mood States-Short Form (POMS-SF; McNair, Lorr, & Droppleman, 1971) before and after an 8-week program of mindfulness training. There was significant improvement in overall emotional distress and subscale mood measurements. For participants whose scores indicated the highest levels of depression and anxiety, more than 50% no longer reported clinically significant depression and anxiety.
Sleep problems are often related to symptoms of depression and anxiety. To address this problem, a recent study focused on the impact of mindfulness training on sleep (Black et al., 2015). Researchers recruited 40 older adults with “moderate” sleep problems as measured by their responses to the Pittsburgh Sleep Quality Index (PSQI; Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). Participants were randomly assigned to five weekly sessions, each 2 hours per week (plus homework), of either sleep hygiene education (n = 25) or mindfulness training (n = 24) (Black et al., 2015). Participants in the mindfulness group learned different meditation techniques, but did not specifically discuss sleep. At the end of the study, the mindfulness group showed significant improvement on the PSQI relative to those in the sleep education group. Mindfulness participants’ sleep-problem scale was lowered by an average of three points, as compared to an average of one point for the sleep education group. The mindfulness group also showed significant improvement relative to the education group on secondary health outcomes of depression symptoms and daytime fatigue. The authors noted that further research should determine the impact of mindfulness training on longer-term sleep effects.
Chronic pain is a common problem for older adults. In addition to discomfort, it can lead to decreased appetite, impaired sleep, depression, and overall decreased quality of life. Approximately one fourth to one third of older adults suffer from low back pain (Morone, Greco, & Weiner, 2008). Morone, Greco, et al. (2008) implemented a study of 37 community-dwelling older adults (65 and older) with chronic low back pain. Participants were randomly assigned to an 8-week mindfulness-based meditation program or to a wait-list control group. Pain, physical function, and quality of life were assessed at baseline and at 8-week and 3-month follow-up intervals. The intervention group displayed significant improvement compared to the control group in measurements of pain acceptance and activities engagement. Data from the 3-month follow up suggested sustained benefits from the program as measured by continued meditation by program participants and sustained improvement in physical function and pain acceptance.
Morone, Lynch, Greco, Tindle, and Weiner (2008) noted that few first-person accounts exist in the literature that describe what an individual experiences while learning mindfulness meditation to alleviate pain and that no previous studies described these experiences of older adults. Therefore, to expand understanding of the quantitative findings described above, Morone, Lynch, et al. (2008) implemented a qualitative study to describe participants’ perceptions of using mindfulness to address their pain issues. The study included 27 older adults who had chronic low back pain of at least moderate severity for a minimum of 3 months. Participants kept diaries describing their experiences during participation in an 8-week mindfulness meditation program.
Themes that emerged through content analysis of diary entries reflected beneficial effects of mindfulness meditation on pain, attention, sleep, and a sense of well-being. Participants described increased body awareness that led to behavior change, improved coping with pain, and direct pain reduction through meditation. Participants also described improved attention skills, quality of sleep, and quality of life. Morone, Greco, et al. (2008) interpreted their findings within the framework of Kabat-Zinn (1982), in that pain reduction occurs through an attitude of detached observation of a sensation, uncoupling the physical sensation from the emotional and cognitive experience of pain. The authors believed that participants in their study used heightened awareness of pain sensation to uncouple the pain from emotion and cognition (Morone, Lynch, et al., 2008, p. 846).
Researchers have also investigated the impact of mindfulness meditation on other types of pain in older adults, including diabetic peripheral neuropathy (DPN). DPN is a common microvascular complication that affects approximately one half of patients with diabetes (Teixeira, 2010). The condition has potentially serious consequences, including infections and lower-limb amputations. The pain, often described as stabbing, burning, tingling, and deep aching, can be relentless (Teixeira, 2010). Teixeira (2010) used a pretest–posttest experimental design to explore the effect of a 4-week program of mindfulness meditation on pain, sleep, and quality of life of patients experiencing DPN. Participants were randomly assigned to either an intervention or control group. The intervention group received instruction in mindfulness meditation and was instructed to listen to a guided compact disc 5 days per week for 4 weeks. The control group received nutritional information and was instructed to maintain a food diary for 4 weeks. No statistically significant differences were found between the groups on outcome measures of pain, sleep, and quality of life, although the intervention group reported fewer painful symptoms. The author suggested that future studies include a longer intervention of 8 weeks and a larger sample in the hope of demonstrating efficacy of the mindfulness intervention for DPN.
Loneliness in older adults is an important risk factor for health problems. Increased expression of pro-inflammatory genes and increased risk for morbidity and mortality have been documented in lonely older adults; however, social networking programs (e.g., encouraging new relationships through community centers) have not been effective in decreasing loneliness (Creswell et al., 2012). To explore the effectiveness of mindfulness meditation for reducing loneliness and improving health of older adults, Creswell et al. (2012) implemented a study with 40 healthy adults ages 55 to 85. No enrollment criteria were used to recruit lonely participants, but the sample (recruited in Los Angeles) showed higher baseline levels of loneliness compared to a Midwestern older adult sample and an undergraduate student sample.
Participants were randomly assigned to an 8-week MBSR program or a wait-list control group, which received no intervention. Measurements included the composite UCLA-R Loneliness Scale (Russell, Peplau, & Cutrona, 1980) and blood samples obtained at baseline and after treatment. Participants in the mindfulness program attended weekly 2-hour meetings, in which they learned to pay attention to their body sensations, breathing, emotions, and daily activities. They were also asked to engage in 30-minute daily meditation exercises at home. Data analysis showed that after the 8 weeks of training, loneliness decreased significantly for participants in the intervention group, whereas loneliness increased slightly for the control group.
Blood samples in the mindfulness group showed reductions in the expression of inflammation-related genes, but the authors noted that further study was needed to understand the functional significance of these changes. The authors cited the study as the first to show that mindfulness meditation training reduces feelings of loneliness and recommended research to further explore the relationship.
Caregivers of Older Adults
More than 15 million Americans provide care for individuals with Alzheimer’s or other dementias, which resulted in 17.7 billion unpaid hours in 2013 (Alzheimer’s Association, 2014). Studies have shown that caregivers receive rewards of joy and satisfying new relationships from their caregiving experiences, but these are interwoven with stressors that often jeopardize well-being (Hoppes et al., 2012; Sorrell, 2005). In 2013, caregivers of individuals with Alzheimer’s and other dementias incurred $9.3 billion in additional health care costs of their own that were attributed to the physical and emotional burden of caregiving (Alzheimer’s Association, 2014). Approximately 60% of these caregivers rate their emotional stress as high or very high, and more than one third report symptoms of depression. The relationships among caregiver burden, loneliness, anxiety, and depression have been well established (Hoppes et al., 2012). It is clear that interventions are needed to reduce caregiver burden.
Despite increasing evidence of effectiveness of mindfulness-based interventions, until recently, applicability of this approach for caregivers has received little attention in the psychological research literature (Mackenzie & Poulin, 2006). New evidence suggests that mindfulness meditation can be useful for caregivers of older adults (Hoppes, et al., 2012; Hurley, Patterson, & Cooley, 2014). Because of the chronic and progressive nature of dementia, caregivers face the risk of developing unhelpful automatic and habitual ways of interacting with recipients of their care (Mackenzie & Poulin, 2006). Mindfulness training provides an opportunity for caregivers to disengage from these habitual and automatic ways of reacting to adopt a new awareness of important factors in the caretaking experience or in themselves that serve to increase stress.
Hurley et al. (2014) reviewed the literature to critically evaluate studies that focused on meditation-based interventions to reduce symptoms of depression among caregivers of individuals with dementia and/or reduce subjective burden. The authors reviewed eight studies that met their inclusion criteria. Seven studies focused on mindfulness interventions for symptoms of depression. Five of these studies reported significant reductions in depression scores from before and after intervention and two found a trend for reduced depression scores, but the difference was not statistically significant. Five studies assessed participants’ levels of burden before and after intervention. Three of these studies reported a significant reduction before and after intervention. One of the remaining two studies showed a nonsignificant trend for reduced levels of burden among participants and the other did not find any significant pre–post changes. The authors concluded that the results showed tentative evidence that meditation-based interventions could be an effective intervention for decreasing depression or burden in caregivers, stressing the need for more research with larger samples to provide further evidence.
Hoppes et al. (2012) implemented a study with 11 participants to explore the effects of 4 hours of mindfulness training over 4 weeks on the well-being of caregivers of individuals with dementia. Researchers used a mixed methods design, collecting survey data that assessed participants’ perceptions of burden, hope, optimism, and mindfulness at baseline, the end of the program, and 1 month after the program. Qualitative interviews with eight participants were conducted 1 month after intervention. Analysis of quantitative data demonstrated a statistically significant decreased sense of burden coupled with increased hope after mindfulness training. After intervention, differences for optimism and mindfulness were not statistically significant. Themes of increased acceptance, increased awareness, increased peace, and decreased reactivity to difficult behaviors emerged from qualitative interviews. The authors suggested that evidence from the study supported brief training in mindfulness for caregivers of family members with dementia.
Mindfulness training may help older adults successfully manage physical and psychological challenges of aging in a manner that reduces distress and promotes vitality (Young & Baime, 2010). An important benefit of this intervention is the possibility of helping avoid or reduce the number of medications, which is often a problem with this population (Foulk et al., 2014). Health care professionals working with older adults and their caregivers should consider the possibilities of referrals for mindfulness training for their clients. Many communities offer classes in mindfulness meditation; books and online classes are also helpful resources. Some group interventions for mindfulness meditation are eligible for insurance coverage (Foulk et al., 2014). It is important that any intervention for mindfulness is based on a structured program led by an experienced and certified instructor (Black et al., 2015).
In contrast to typical Western goal-oriented approaches focused on fixing a problem, mindfulness training can enhance one’s ability to be in the moment and experience what is happening without judgment (Mackenzie & Poulin, 2006). Mindfulness meditation appears to have a protective effect of decreasing harmful effects of life stress on mental health (de Frias & Whyne, 2015). In fact, de Frias and Whyne (2015) suggest that older adults experiencing high levels of stress would receive the most benefit from mindfulness meditation and that targeting especially vulnerable older adults, such as those grieving the loss of a loved one, would be an important step in helping maintain a healthy mental status. More research is needed to identify effective mindfulness-based interventions for older adults and their caregivers. However, increasing evidence shows that mindfulness meditation is an intervention that can be helpful for problems such as depression, anxiety, chronic pain, loneliness, and caregiver burden.
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