Mindfulness, Depression, Anxiety, and Spiritual Well-Being in Elder Care

Reference

Hsiung Y, Chen YH, Lin LC, Wang YH. Effects of Mindfulness-Based Elder Care (MBEC) on symptoms of depression and anxiety and spiritual well-being of institutionalized seniors with disabilities: a randomized controlled trial. BMC Geriatr. 2023;23(1):497. 

Study Objective

To evaluate changes in mental health and spiritual well-being using mindfulness-based elder care (MBEC) among seniors with disabilities in a long-term-care (LTC) residential settings

Key Takeaway

The practice of MBEC in a group setting, conducted over an 8-week period, leads to changes in depression, anxiety, and spiritual well-being with significant improvements in trait-based anxiety and in religious and existential spiritual well-being during and at least up to 4 weeks post the intervention period. 

Design

A randomized, single-blind, controlled trial

Participants

Investigators recruited qualified senior residents (aged 65 years or more) in LTC facilities. They found 77 eligible participants and randomized them to 38 individuals in the intervention group (IG) and 39 in the control group (CG). At study completion, there were 37 participants in the IG and 28 in the CG (total N=65).

When comparing IG vs CG participants, both groups were predominantly female (60.5%/59.0%), widowed (55.3%/51.3%), and Buddhist/Taoist (60.5/59.0%) and had an education level of primary school (41.1%/28.2%) in the IG/CG groups, respectively. No significant differences were found between the 2 groups regarding their demographic characteristics.

Inclusion criteria were as follows:

1.  the individual lived in a residential LTC institution for at least 3 months; 
2. their score for activities of daily living (ADL), according to the Barthel Index, was under 100; and 
3. they were able to communicate in Mandarin or Taiwanese.

Those who could not participate in the study included those who met any of these exclusion criteria: 

1. senior residents with a history of severe sensory and/or major cognitive impairment; 
2. residents with a history of major depression, or 
3. those who were unable to follow instructions during the program as determined by physicians and nurses in respective institutions. 

Intervention

The MBEC intervention: 8 weekly group sessions consisting of a 50-minute MBEC session including lecture/presentation followed by progressive activities each week, including but not limited to: increasing awareness by practicing mindful seeing and mindful eating, walking and sitting meditations, and using related loving-kindness meditations. 

Each session: The breakdown of the sessions followed the pattern of an initial 10 minutes of activity that covered the essential principles and practices from the previous session(s), followed by 30 minutes of mindfulness exercises, 10 to 20 minutes of discussion, and final closing of the session. 

Control group: Those in the control group (CG) received usual care alone as provided by the LTC centers and additionally received a weekly visit from the research team. These conversations included 10 to 15 minutes of conversations that were unrelated to mindfulness intervention. In this way, commitment and control-group single-blinding were maintained.

Study Parameters Assessed

Investigators collected parameters assessing primary outcomes and secondary outcomes from all participants at 4 time points: baseline, mid-intervention, postintervention, and a 4-week follow-up (T0, T1, T2, and T3 respectively). 

Primary outcomes of depression and anxiety levels were assessed using the Geriatric Depression Scale Short Form (GDS-SF) and the State-Trait Anxiety Inventory (STAI) Y forms. For the secondary outcome of spiritual well-being, investigators used the Spiritual Well-Being Scale (SWBS). 

The STAI uses 2 subscales measuring 20 items for each category of state and trait anxiety on a 4-point scale from “not at all” to “very much so” in both present moment and in general. 

The SWBS is a 20-item scale that measures an individual’s well-being and overall life satisfaction.¹ It measures both religious and existential well-being. The measures based on religious well-being relate to spiritual life in relation to belief in God, and the measures on existential well-being relate to perceptions of life’s meaning and satisfaction in how well adjusted the individual is to self, community, and surroundings. The items are rated from “1–Always Disagreed” to “6–Always Agreed,” and total values are related to low, moderate, and high spiritual well-being.   

Other information collected include demographic information, length of stay in the institution, and religious beliefs at baseline. This study used the Chinese version for all tests. 

Every MBEC program was led by a primary investigator and research assistants (RA) who were community nurses specialized in LTC practice and trained and certified with an MBEC certification from the Taiwanese Mindfulness Association. The program was held in a 10-person consultation room; 1 trained RA led the program, and the respective participants were then closely monitored by the same RA via telephone interviews conducted twice a week to evaluate participant practice of diaphragmatic breathing. The RA prepared booklets and mindfulness information, written reminders from session highlights, and encouraging messages to be shared with families and friends if needed. Evaluations during biweekly sessions were gathered, and progress and feedback were monitored during sessions and encouraged. 

Key Findings

Compared to baseline, the intervention group had changes in mental health—depression and state- and trait-anxiety—from pretest and in each subsequent 3 post-testing time points (T1, T2, and T3). Existential spiritual well-being also improved after completing the program (T2 and T3 with a P<0.001), and significant augmentation of religious spiritual well-being was noted postintervention (T2 vs T0 with a P<0.05). 

Interestingly, the control group showed significant improvement, too, with regards to mental health. Researchers noted improvements in depression at the 4-week follow-up along with state- and trait-anxiety benefits in the 2 postintervention time points compared to baseline (T2 vs T0 and T3 vs T0). What was not significant were any changes in spiritual well-being, which was significantly worse posintervention compared to baseline (T2 vs T0 with a P<0.001). 

When comparing differences between groups (IG vs CG), the IG group showed significantly greater reductions in state-anxiety at T2 (effect size 0.27) and trait-anxiety at both T2 (effect size 0.14) and T3 (effect size 0.11) when compared to the CG.

Where spiritual well-being was concerned, significant improvements occurred both during the intervention period and post-treatment in the IG vs the CG. The improvements were significant at the postintervention and 4-week follow-up (periods T2 [effect size=1.05] and T3 [effect size=0.40]) and demonstrated significant improvements in both subscales of religious (T2 effect size=1.05, and T3 effect size=0.40) and existential well-being (T2 and T3 effect sizes=0.23).

Transparency

This study was funded by the Ministry of Science and Technology and MacKay Medical College. The authors declared no competing interests. ClinicalTrials.gov ID: NCT05123261.

Practice Implications & Limitations

Science is a funny thing. We perform experiments to test the things we know but want to see in a different light. There develops a need and a desire to give weight to the things that we feel from the inside but want to view as separate from us—distant, so that we may give space to explore what we may have missed and what we may be able to refine and define next time. 

Medicine is a practice. Each patient gives us the opportunity to do the very same in an intimate, personal manner, often informed by that scientific inquiry and clarified by us as doctors. We integrate and translate the information we read and learn into personalized treatments for our patients. In those very moments, we are both scientists and healers; hence, we are asked to step back and allow ourselves to view the results from an unbiased vantage point, free of the confinement of what should or should not be.

Every time we learn something new, we open the door to viewing our patients, our future patients, and our own story with just a little more clarity. In doing so, we get to allow space for the plot of their story and ours to develop, modify, and move us forward with grace, forgiveness, and kindness. And hence here, we open the door of scientific inquiry into mindfulness and its impacts on anxiety, depression, and spiritual well-being.

Thus, it is important to note that even the control group, who had frequent check-ins, had improvement for all markers save spiritual well-being. This suggests frequent contact in and of itself can begin to address the loneliness factor that exists in many elderly populations.

Mindfulness-based medicine used for the purpose of addressing mental and spiritual well-being is necessary in medicine in every age group, and even more so when those individuals live with disabilities. The main study reviewed here focused on a distinct population—elders living with disabilities within institutional care settings. The results of this study provide insight about the spiritual and existential questions that continue into later years and how applications like MBEC practices can make a positive impact.

When investigators are considering spiritual health, if they are using the SWBS, as this study did, whether participants have a belief in God will affect the results, and while in this study population, participants had a religious belief, as practitioners, this should be considered and respected when talking with patients about their relationship to health, disease, and spiritual health, and modifications or result interpretation should be made in an undiscriminating manner, when necessary. 

This study highlighted that MBEC made significant changes that lasted 4 weeks beyond the intervention period in both trait anxiety and in the enhancement of religious and existential well-being. 

However, there were no improvements in geriatric depression or state anxiety.

The authors point out that 1 reason for this may be the necessity for ongoing mindfulness-based care in this age group, in order to maintain a constant sense of awareness to improve mental health. Another factor involved could be the low level of depression at the initiation of treatment (less than 5 points out of 15 points), and though improvement did occur, it could not be considered significant. 

This study illustrates another reason why we, in naturopathic, homeopathic, and integrated medical practices, must work toward the inclusion of mindfulness-based treatments in all age groups—especially in the often-overlooked 65-year-plus demographic. 

According to the 2021 Centers for Disease Control and Prevention reports, life expectancy of those at age 65 was an average of 18.4 years. In 2022, it was reported that 23.5% of those—noninstitutionalized and aged 65 years or more—were in fair or poor health; 12.3% of the people in that category reported taking prescription medications for feelings of depression, 4% of whom reported regular feelings of depression, and with 13.3% taking prescription medications for feelings of worry, nervousness, or anxiety and 8.1% regularly having feelings of worry, nervousness, or anxiety. Additionally, 1.2% reported not getting mental health care due to cost, and 8.7% of this population reported smoking.² In 2020, 16.8% (or 1 in 6) of the US population was aged 65 years or more, with the largest cohort lying between the ages of 65 to 74 (“Boomers”) and a cohort growth rate that was the highest since 1880 to 1890.³ In Canada in 2020, 19% of the population was aged 65 or more, whilst in Mexico in 2022, this age group comprised 8.32% of the population.^4,5

When we practice medicine, we listen to the stories of our patients and address the concerns presented to us and begin the process of engaging in care of an individual who needs and seeks help in what for them is most urgent, and what holds them back from moving forward in their journey.

Depression—or any variation on what entails depression—is not always addressed in patient visits, as it is not always the primary concern that a patient may present with, but it is important for clinicians to inquire with compassion and prudence when necessary, even when it may be “managed” in some other way. 

Using the Geriatric Depression Score questionnaire during patient interviews or through intake forms may be 1 nonintrusive manner of doing so, but only when assessed through the lens of nonjudgment and used as a guide as opposed to a confining definition. This may also open the door to what may be a missing factor in the care they need. Using a complement of nutrition and mindfulness may be 1 avenue that leads to change with impact. 

When considering a multimodal approach, this following study reflects the very nature of complementary medical care when approached from many angles, using collaborative medicine including mindfulness practices in a holistic care approach. 

Using neurodegenerative disease as their basis for treatment care, authors Sandison et al used this multimodal approach in a population with established cognitive decline.⁶ Alzheimer's disease is prevalent today, affecting 6 million in the US.⁷ Sandison and colleagues used a protocol-driven, uncontrolled, pragmatic trial to “test feasibility and estimate effects in a real-world clinical setting,” in which lifestyle, diet, and individualized treatments can play a role in the improvements in cognition in those with cognitive decline. Treatments were individualized based on the following results and tested at baseline: environmental exposure, gastrointestinal health, systemic inflammation, traumatic brain injury, hormone levels, chronic infection, and sleep factors. 

For the lifestyle treatments, investigators included exercises, such as aerobic and strength training, and they encouraged and supported personalized social interaction when feasible during Covid-19 pandemic measures. Investigators also encouraged mindfulness, using either mindfulness practices such as daily meditation or prayer dependent on participant preference, and they recommended 12 minutes of daily Kirtan Kriya meditation to all participants with alternatives of mindful acts of kindness and/or daily prayer practice when, for religious reasons, the alternate meditation practice was undesired. 

Dietary measures consisted of an organic ketogenic diet, which was encouraged and supported and measured by diet diaries, blood ketone measurements at clinical visits, and weekly follow-up phone calls from certified health coaches to support and discuss treatment plans and improve patient adherence. All participants also received a nootropic blend, including nutrients, omega-3s, and vitamin D. This study showed improvements in Montreal Cognitive Assessment (MoCA) scores (19.6±3.1 to 21.7±6.2 [P=0.013]), improvements in mean scores in the Cambridge Brain Sciences (CBS) memory domain (25.2 [SD 23.3] to 35.8 [SD 26.9]; P<0.01), and CBS overall composite cognition score, with all CBS domains improved after this 6-month intervention. 

In conclusion, the study under review here shows us that mindfulness-based elder care is beneficial in those experiencing anxiety and depression and improves religious and existential spiritual well-being. The study specifically found that mindfulness alone can make the biggest impact and can continue to have longer-lasting effects in the areas of spiritual well-being and trait anxiety. It is important to note that even the control group, all markers save spiritual well-being had improvements. This highlights the value of frequent contact and connection during treatments, and it can begin to address the loneliness factor that exists in many elderly populations. 

For the areas where mindfulness may not make as significant gains, we as practitioners have other avenues to consider, especially when those changes may be basic and noninvasive, like dietary modifications that are based on doing no harm. If we, as practitioners, can begin to inquire about spiritual well-being—even through using the SWBS—we can begin to have impact by having conversations with our patients, and in particular with our aging patients. When matters of life, death, purpose, and questions of an existential nature begin to arise, they are not always shared nor are they addressed in healthcare routinely. If these matters are addressed when time permits, the physician who does so with sincerity and attention may open the door to healing for both doctor and patient.