By Russell H. Greenfield, MD, Medical Director, Integrative Oncology Services, Carolinas Medical Center, Charlotte; Clinical Assistant Professor, School of Medicine, University of North Carolina, Chapel Hill; Visiting Assistant Professor, University of Arizona College of Medicine, Tucson, Arizona. Dr. Greenfield reports no financial relationships relevant to this field of study.
Synopsis: Elderly patients with mild-to-moderate depressive symptoms may experience improvement in affect with the practice of mindfulness-based stress reduction.
Source: Gallegos AM, et al. Emotional benefits of mindfulness-based stress reduction in older adults: The moderating roles of age and depressive symptom severity. Aging Ment Health 2013; May 22 [Epub ahead of print].
Regular practice of mindfulness-based stress reduction (MBSR) benefits a wide variety of patients in disparate health circumstances, yet one patient population where the impact of MBSR training has yet to be explored indepth is the elderly. Old age is often accompanied by harsh realities that may include a decline in physical health as well as emotional stressors. While many weather these developments, they are nonetheless challenging for even the most optimistic and resilient of elderly patients, in large part because of a perceived, and, often real, sudden and increasing lack of control. The authors of the current study previously explored this realm and developed what they call the Motivational Theory of Life-Span Development.1 Using this theory as a framework, they sought to examine the effects of age and depressive symptom severity on changes in positive affect among older (≥65 years), community-dwelling adults (n = 200) randomized to either an 8-week MBSR program or a waitlist control group.
The theory developed by the investigators suggests that all people, especially the elderly, best maintain control and adapt to changing opportunities by developing strategies for replacing unattainable goals with more appropriate ones. Primary control is important to everyone and can be thought of as directed at changing the environment to bring it in line with an achievable desired outcome. Adults lose much of their capacity for primary control with increasing age, and depression worsens this circumstance; but older adults might compensate by employing secondary control processes, defined as changing oneself so as to be better aligned with environmental forces, even when those forces restrict available options.2 Interventions that augment secondary control provide emotional benefits in uncontrollable circumstances and are important for promoting optimal emotional aging. In this context, MBSR helps teach participants to increase nonjudgmental awareness of their momentary emotional and physical experiences and improve regulation of affect by increasing attention, awareness, and acceptance of emotions as they arise moment-to-moment.
Subjects were recruited through newspaper advertisements and flyers posted at primary care offices. Exclusion criteria included potential cognitive or uncorrected sensory impairment, major depression with psychotic features, bipolar disorder, and substance abuse within the past year. Once enrolled, subjects were randomized to active (MBSR) and control (waitlist) groups. The eight-week MBSR program consisted of nine group sessions (15-20 members), seven of which were 2 hours in duration and one, at mid-treatment, that was 7 hours long. Practices emphasized during these meetings included yoga (mindful movement), sitting meditation (mindful awareness of one's experience while sitting), informal meditation (while walking or engaged in other activities), and the body scan (serial attention to the sensations of different regions of the body). Activities were adapted on an individual basis to accommodate the presence of limitations, including physical and sensory impairments (the authors give the example of sitting yoga for those using wheelchairs).
Participants were administered the Center for Epidemiologic Studies Depression Scale, Revised (CESD-R), the Hamilton Rating Scale for Depression (HAM-D), and the Positive Affect (PA) scale of the Positive and Negative Affect Schedule (PANAS) at baseline, at the end of treatment (8 weeks), and 6 months thereafter by one of three masters-level research assistants. Potential confounders including gender, comorbidity, and level of education were controlled for, and subjects 70 years or older were compared to younger participants. Regression was used to determine whether age, depressive symptom severity, or their interaction over time were associated with changes in the positive affect.
The groups were similar at baseline save for slightly greater depressive symptom severity in those receiving MBSR. After 8 weeks, 54% of participants in the MBSR group experienced improvements in positive affect (average d = 0.12) compared to 46% in the waitlist control group (average d = 0.00). Analysis of positive affect outcomes at the 6-month follow-up revealed significant group by baseline depressive symptom severity (ß = -0.17, P = 0.02) and group by baseline depressive symptom severity by age (ß = -0.14, P = 0.05) interactions; as a result, analyses examining the contributions of age and baseline depressive symptom severity to changes in positive affect were conducted separately for both the MBSR and waitlist control groups. The findings are noteworthy: Older MBSR group members who had more severe baseline depressive symptoms experienced less improvement in positive affect at treatment completion (ß = -0.21, P = 0.02) and at 6-month follow up (ß = -0.30, P = 0.003) than age-matched subjects who were happier at baseline. Effects related to age (ß = 0.05, P = 0.66) and the depressive symptom severity by age interaction (ß = -0.03, P = 0.75) were not significant. MBSR group members ≥ 70 years with low baseline depressive symptom severity had the greatest improvement in positive affect at the 6-month follow-up, whereas those ≥ 70 years with worse baseline depression had the poorest outcomes (ß = -0.25, P = 0.01). Age and depressive symptom severity were not associated with changes in affect in the waitlist control group. The authors conclude that MBSR improves positive affect for older adults in the absence of severe depression.
MBSR helps cultivate nonjudgmental acceptance of one's circumstances. Based on this study's findings, by extension it also enhances secondary control provided that severe depression is not present, where MBSR has the potential to worsen affect.
The authors frequently promote their previously published Motivational Theory of Life-Span Development, but it seems appropriate as the theory is convincing and functions well as a backdrop to help explain the potential advantages of MBSR for older adults. Limitations of the trial are few and include potential for bias (voluntary sign-ups), unequal randomization (slightly worse baseline depression in the MBSR group), and limited ethnic diversity, but overall the study was well done.
Practitioners in the trenches know that some elderly patients manage the situational changes associated with aging better than others. Those who by nature are more optimistic may not need any specific interventions to gird their inner resilience, but for those for whom the burdens of life have become increasingly challenging MBSR may prove a valuable tool. Old dogs can learn new "tricks" — MBSR seems a good one to consider sharing with select elderly patients.