A Literature Review
Dr Ian Gawler OAM, BVSc, MCounsHS November 2020
What do mindfulness and meditation-based techniques have to offer people affected by dementia and their carers?
The world population is aging and the prevalence of dementia is increasing. By 2050, those aged 60 years and older are expected to make up a quarter of the population. With that, the number of people with dementia is increasing. Unfortunately, there is no current medical cure for dementia. The progression of symptoms with no hope of improvement is difficult to cope with, both for patients and their caregivers.
Mindfulness training has shown to improve psychological well-being in a variety of mental health conditions. Research has shown preliminary but promising results for mindfulness-based interventions to benefit people with dementia and their caregivers. In this extensive and well documented article, we examine
- Five recent, key research papers investigating the contribution mindfulness and meditation might make to those affected by dementia.
- What might be possible? Here we briefly examine the role of lifestyle and the mind in the prevention and treatment of dementia
- The role in dementia for a purpose-built app – Allevi8
- What is dementia and Alzheimer’s disease? Here we provide a detailed yet accessible summary of the many conditions collectively known as dementia
- Early signs of dementia
- The effectiveness of online mindfulness and meditation programs – what the research says
- Mindfulness, meditation and dementia – The research evidence base – key recent dementia research
- i) Review : Mindfulness, meditation, cognition and stress in people with Alzheimer’s disease (AD), dementia, mild cognitive impairment and subjective cognitive decline – 2018.
This meta-analysis investigated how the use of meditation as a behavioural intervention can reduce stress and enhance cognition, which in turn ameliorates some dementia symptoms. Ten papers were identified and reviewed.
There was a broad use of measures across all studies, with cognitive assessment, quality of life and perceived stress being the most common. Three studies used functional magnetic resonance imaging (fMRI) to measure functional changes to brain regions during meditation.
The interventions fell into the following three categories: mindfulness, most commonly mindfulness-based stress reduction(MBSR) (six studies); Kirtan Kriya meditation (three studies); and mindfulness-based Alzheimer’s stimulation (one study). Three of these studies were randomised controlled trials.
All studies reported significant findings or trends towards significance in a broad range of measures, including a reduction of cognitive decline, reduction in perceived stress, increase in quality of life, as well as increases in functional connectivity, percent volume brain change and cerebral blood flow in areas of the cortex.
Russell-Williams J, Jaroudi W, Perich T, Hoscheidt S, El Haj M, Moustafa AA. Mindfulness and meditation: treating cognitive impairment and reducing stress in dementia. Rev Neurosci. 2018;29(7):791-804.
- ii) Do adults with MCI have the capacity to learn mindfulness meditation? – 2019
High levels of chronic stress negatively impact the hippocampus and are associated with increased incidence of Mild Cognitive Impairment (MCI) and Alzheimer’s disease(AD). While mindfulness meditation may mitigate the effects of chronic stress, it is uncertain if adults with MCI have the capacity to learn mindfulness meditation.
Chronic stress negatively impacts the hippocampus, and high levels of chronic stress are associated with an increased incidence of MCI and AD. [6–8] Adults who are prone to high levels of psychological distress are more likely to develop dementia. Animal research demonstrates that high levels of cortisol (the “stress hormone”) can damage the hippocampus, a key structure involved in memory processing that atrophies with Alzheimer’s disease. Thus, other stress-reducing interventions, such as meditation and yoga, might be helpful for adults with MCI.
Previous studies have shown that the hippocampus is selectively activated during meditation,[15–17] and experienced meditators have larger volumes and gray matter concentration in their hippocampi compared to matched controls. In addition, research has shown that an eight-week MBSR class may increase gray matter density in the hippocampi of adults. MBSR is thus a stress-reducing intervention that impacts the hippocampus and could potentially interrupt the progression of MCI through these effects.
The period of time when an individual has MCI is transient and offers a rare window of opportunity prior to the development of dementia; finding an intervention that could help patients at this point of time could be invaluable. Since adults with MCI still have brain plasticity, we hypothesized that adults with MCI would be able to learn and benefit from mindfulness meditation and yoga.
What did the research find? Most adults with MCI were able to learn mindfulness meditation and had improved MCI acceptance, self-efficacy, and social engagement. So in summary, cognitive reserve may be enhanced through a mindfulness meditation program even in patients with MCI.
Wells RE, Kerr C, Dossett ML, et al. Can Adults with Mild Cognitive Impairment Build Cognitive Reserve and Learn Mindfulness Meditation? Qualitative Theme Analyses from a Small Pilot Study. J Alzheimers Dis. 2019;70(3):825-842.
iii) Review of already well researched mindfulness techniques – 2018
Although there is a wide variety of interventions that include components of mindfulness (e.g., Acceptance and Commitment Therapy), this review focuses on the two programs with the largest evidence base, the mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). These group-based programs have been studied in healthy populations and in those with mental or physical disorders, showing satisfactory to good efficacy (Chiesa and Serretti, 2009; Hofmann et al., 2010; Hempel et al., 2014).
Although current research supports the rationale for MBI with persons with dementia and their caregivers, only few RCTs have been conducted and more research is necessary
What can be said is participants receiving MBSR showed greater improvement in memory, but not cognitive control. Moreover, the MBSR group improved on measures of worry, depression, and anxiety, and decreased cortisol level for those with high baseline cortisol.
Studies with persons with Mild Cognitive Impairment (MCI) or Severe Cognitive Impairment (SCD) have looked at the effect of Mindfulness Based Interventions (MBI). This is informative for dementia research, since individuals with MCI have an increased annual conversion rate of 5–17% to Alzheimer’s disease (Cheng et al., 2017), and approximately 60% over a 15-year period of persons with SCD will continue to develop Alzheimer’s disease (Reisberg et al., 2008).
Studies with persons with MCI or subjective memory complaints have looked at the effect of MBI. One pilot study found a trend toward improvement of cognition, quality of life, and well-being for people in the mindfulness condition (Wells et al., 2013). A RCT showed that the participants in the MBI group showed less memory deterioration and greater decrease in depressive symptoms compared to the control group (Larouche et al., 2016).
Although these studies demonstrate feasibility of MBSR with older adults with SCD and MCI, and preliminary evidence for memory improvement, more research is necessary to investigate whether MBI can influence cognitive decline.
Berk L, Warmenhoven F, van Os J, van Boxtel M. Mindfulness Training for People With Dementia and Their Caregivers: Rationale, Current Research, and Future Directions. Front Psychol. 2018;9:982. Published 2018 Jun 13. doi:10.3389/fpsyg.2018.00982
- iv) Mindfulness practice can improve health outcomes of MCI – 2017.
Growing evidence has linked mindfulness to cognitive and psychological improvements that could be relevant for mild cognitive impairment (MCI). This Australian study reported long-term mindfulness practice may be associated with cognitive and functional improvements for older adults with MCI. The researchers concludedmindfulness training could be a potential efficacious non-pharmacological therapeutic intervention for MCI.
Wong WP, Coles J, Chambers R, Wu DB, Hassed C. The Effects of Mindfulness on Older Adults with Mild Cognitive Impairment. J Alzheimers Dis Rep. 2017;1(1):181-193. Published 2017 Dec 2.
- v) Support for dementia carers – a meta-analysis
Following analysis of five RCTs involving 201 carers that assessed the effectiveness of MBSR, the authors concluded low-quality evidence suggests MBSR may reduce carers’ depressive symptoms and anxiety, at least in the short term. “In conclusion, MBSR has the potential to meet some important needs of the carer, but more high-quality studies in this field are needed to confirm its efficacy.”
Liu Z, Sun YY, Zhong BL. Mindfulness-based stress reduction for family carers of people with dementia. Cochrane Database Syst Rev. 2018;8(8):CD012791. Published 2018 Aug 14.
Low level evidence in support of intervention with carers
- What might be possible?
Dementia is now well identified as another of the chronic degenerative diseases – like cancer, heart disease and MS. All these other known chronic degenerative diseases have been shown to be prevented by Lifestyle interventions. Once present, their symptoms have all been shown to be significantly lessened by Lifestyle interventions; and all have shown some signs – ranging up to major – of reversal through Lifestyle interventions. So why not dementia???
And what are Lifestyle interventions? The things you can do for yourself – like what you eat and drink, your exercise levels, relaxation, mindfulness and meditation. Many believe the mind-based interventions are key, both due to their direct effects and because the mind decides what we do with our lifestyle. Get the mind into a good state and everything else follows – we eat better, drink more wisely, are more inclined to exercise and so on.
- Purpose built app – Allevi8
The free mindfulness and meditation-based App – Allevi8 – has been specifically designed to assist people affected by chronic degenerative disease. Allevi8 targets 5 main issues – stress and mental health, emotional health, pain management, healing and finding meaning amidst adversity.
Allevi8 is available via a simple search in your App store. There is a free, meditation session via Zoom – Allevi8@8 – that goes out live each Monday. This session is well attended and many report how helpful it is to receive practice tips and meditate in a like-minded community each week. To join, simply download Allevi8 and the link will be sent by email. All of this is free, however, you might like to consider paying it forward – there is a secure donation facility on the App under “Gift”.
- What is dementia and Alzheimer’s disease?
A simple guide to the facts about dementia and Alzheimer’s disease
What follows is a compilation of information from sources such as dementia and Alzheimer’s websites, scientific references and Wikipedia. This information has been compiled in good faith and is intended to be accurate, succinct and easy to understand. It is not a short read as dementia represents a range of conditions, each of which are explained in turn.
- i) Dementia
Dementia, also known as senility,is a broad category of brain diseases that cause a long term and often gradual decrease in the ability to think and remember that is great enough to affect a person’s daily functioning. Other common symptoms include problems with emotional expression, language,and a decrease in motivation.
The most common type of dementia is Alzheimer’s disease which makes up 50% to 70% of cases. Other common types include vascular dementia (25%), dementia associated with Lewy bodies (15%), alcohol related dementia (unclear), fronto-temporal dementia (rare) and mixed dementia (10%).
- ii) Alzheimer’s disease
First be clear, Alzheimer’s disease is not a normal part of aging. Alzheimer’s disease is an acquired, progressive, degenerative disorder that attacks the brain’s nerve cells, or neurons, resulting in loss of memory, thinking and language skills, and behavioural changes.
Alzheimer’s disease is associated with 2 types of abnormal lesions – plaques and tangles.
Plaques or to be more specific, Beta-amyloid plaques, are sticky clumps of protein fragments and cellular material that form outside and around neurons.
Tangles, or neurofibrillary tangles, are insoluble twisted fibers composed largely of the protein that builds up inside nerve cells.
Although these 2 lesions are hallmarks of the disease, scientists are unclear whether they cause it or a by-product of it.
The most common symptoms are short-term memory loss and word-finding difficulties. People with Alzheimer’s disease also have trouble with visual-spatial areas (for example, they may begin to get lost often), reasoning, judgment, and insight. Insight refers to whether or not the person realizes they have memory problems.
Common early symptoms include repetition, getting lost, difficulties keeping track of bills, problems with cooking, forgetting to take medication, and word-finding problems.
The part of the brain most affected by Alzheimer’s is the hippocampus. Other parts of the brain that show shrinking (atrophy) include the temporal and parietal lobes. However, the brain shrinkage in Alzheimer’s disease is very variable, and a brain scan cannot actually make the diagnosis (but may eliminate other causes). The relationship between undergoing anaesthesia and Alzheimer’s disease is unclear.
It is often said that the seriousness of, and difference between, AD and other dementias, is seen in the response to the question: “Did you turn the computer off?”
Those with dementia respond: “I can’t remember”. Those with AD respond: “ What’s a computer?”.
iii) Vascular dementia
This type of dementia is caused by disease or injury affecting the blood supply to the brain, typically involving a series of minor strokes. Symptoms will depend upon where the strokes have occurred and whether the vessels involved are large or small.Multiple injuries can cause progressive dementia over time, while a single injury located in a critical area critical (i.e. hippocampus, thalamus) can lead to sudden cognitive decline.
On scans of the brain, a person with vascular dementia may show evidence of multiple strokes of different sizes in various locations.
So what actually is a stroke?
A stroke happens when blood supply to the brain via an artery is interrupted. This occurs most commonly when the artery is blocked (ischaemic stroke) or much less commonly bursts (haemorrhagic stroke). The resulting area of brain damage is called a cerebral infarct, or more simply, just an infarct.
A major stroke occurs when the blood flow in a large vessel in the brain is suddenly and permanently cut off. Most often this happens when the vessel has become narrower and then is blocked by a clot. Much less often it is because the vessel bursts and bleeds into the brain. Minor strokes are when the same processes occur on a smaller scale.
Types of vascular dementia
Vascular dementia can differ according to the cause of the damage, the type of stroke involved and the part of the brain that is affected. The different types of vascular dementia have some symptoms in common and some symptoms that differ. Their symptoms tend to progress in different ways.
- a) Post-stroke dementia
After a major stroke, the sudden interruption in the blood supply starves the brain of oxygen and leads to the death of a large volume of brain tissue. However, not everyone who has a stroke will develop vascular dementia, but about 20% of people who have a stroke do develop post-stroke dementia within the following 6 months. A person who has one major stroke is then at increased risk of having further strokes. If this happens, the risk of developing dementia is higher.
b)Single-infarct dementiaand Multi-infarct dementia
This type of vascular dementia is caused by smaller strokes that commonly cause damage to the cortex of the brain, the area associated with learning, memory and language.
These types of stroke may be so small that the person does not notice any symptoms when they occur. Alternatively, the symptoms may only be temporary – lasting perhaps a few minutes – because the blockage clears itself. If symptoms last for less than 24 hours, it is called a ‘mini-stroke’ or transient ischaemic attack (TIA). A TIA may mistakenly be dismissed as a ‘funny turn’.
If such a stroke interrupts the blood supply for more than a few minutes, an infarct will result. Sometimes just one infarct forms in an important part of the brain and this causes dementia (known as single-infarct dementia). Much more often, a series of small strokes over a period of weeks or months lead to a number of infarcts spread around the brain. Dementia in this case (known as multi-infarct dementia) is caused by the total damage from all the infarcts together.
A person with Multi-infarct dementia is likely to have better insight in the early stages than people with Alzheimer’s disease, and parts of their personality may remain relatively intact for longer. Symptoms may include severe depression, mood swings and epilepsy.
c) Subcortical dementia or Binswanger’s disease
This was thought to be rare, but is now being reassessed, and may in fact be relatively common. Once considered rare, is now thought to be the most common type of vascular dementia.
Subcortical vascular dementia is caused by diseases of the very small blood vessels that causes infarcts to tissue that lies deep in the brain – the “white matter”. These small vessels develop thick walls and become stiff and twisted, meaning that blood flow through them is reduced. It is caused by high blood pressure, thickening of the arteries and inadequate blood flow.
Small vessel disease often damages the bundles of nerve fibres that carry signals around the brain, known as white matter. It can also cause small infarcts near the base of the brain. Small vessel disease develops much deeper in the brain than the damage caused by many strokes. This means many of the symptoms of subcortical vascular dementia are different from those of stroke-related dementia.
Common symptoms include slowness and lethargy, difficulty walking, emotional ups and downs and lack of bladder control early in the course of the disease.
- iv) Lewy Body disease
Lewy body disease is caused by the degeneration and death of nerve cells in the brain. The name comes from the presence of abnormal spherical structures, called Lewy bodies, which develop inside nerve cells. It is thought that these may contribute to the death of the brain cells.
Lewy body disease is similar to Alzheimer’s disease in many ways, and in the past it has sometimes been difficult to distinguish the two. It has only recently been accepted as a disease in its own right. It can occur by itself or together with Alzheimer’s disease and/or Vascular dementia. It may be hard to distinguish Lewy body disease from Parkinson’s disease, and some people with Parkinson’s disease develop a dementia that is similar to that seen in Lewy body disease.
The symptoms of dementia with Lewy body disease include difficulty with concentration and attention, extreme confusionand difficulties judging distances, often resulting in falls.
There are also three cardinal symptoms, two of which must be present in order to make the diagnosis:
- Visual hallucinations
- Parkinsonism (tremors and stiffness similar to that seen in Parkinson’s disease)
- Fluctuation in mental state so that the person may be lucid and clear at one time and confused, disoriented and bewildered at other times. Typically this fluctuation occurs over a period of hours or even minutes and is not due to any underlying acute physical illness.
Some people who have Lewy body disease may also experience delusions and/or depression.
- v) Alcohol related dementia
Alcohol related dementia can affect men and women of any age. It is currently unclear as to whether alcohol has a direct toxic effect on the brain cells (neurotoxicity hypothesis), or whether the damage is due to lack of thiamine (or vitamin B1). Nutritional problems, which often accompany consistent or episodic heavy use of alcohol, are thought to be contributing factors.
- Impaired ability to learn things
- Personality changes
- Problems with memory
- Difficulty with clear and logical thinking on tasks which require planning, organising, common sense judgement and social skills
- Problems with balance
- Decreased initiative and spontaneity.
Generally skills learned earlier in life and old habits such as language and gestures tend to be relatively unaffected.
Who gets alcohol related dementia?
Anyone who drinks excessive amounts of alcohol over a period of years may get alcohol related dementia. Males who drink more than six standard alcoholic drinks a day, and women who drink more than four, seem to be at increased risk of developing alcohol related dementia. The risk clearly increases for people who drink high levels of alcohol on a regular basis.
The National Health & Medical Research Council of Australia recommends that for health reasons related to the prevention of brain and liver damage adult males should drink no more than four standard drinks per day and adult females should drink no more than two standard drinks per day. NOTE : For cancer, there is no really safe limit.
Some people who drink at high levels do not develop alcohol related dementia, but it is not currently possible to understand and predict who will and who will not develop alcohol related dementia.
Some people who develop alcohol related dementia might also show some degree of recovery over time if they reduce alcohol intake to safe levels or abstain from alcohol and maintain good health.
- vi) Fronto-temporal dementia or Pick’s disease
Fronto-temporal dementia (FTD) is one of the less common types of dementia. The term covers a wide range of different conditions. FTD occurs when nerve cells in the frontal and/or temporal lobes of the brain die, and the pathways that connect the lobes change. Some of the chemical messengers that transmit signals between nerve cells are also lost. Over time, as more and more nerve cells die, the brain tissue in the frontal and temporal lobes shrinks.
The frontal lobes of the brain, found behind the forehead, deal with behaviour, problem solving, planning, speech and the control of emotions.
Symptoms of FTD include changes in personality and behaviour, and difficulties with language. These symptoms are different from the memory loss often associated with more common types of dementia, such as Alzheimer’s disease. As FTD is a less common form of dementia, many people (including some health professionals) may not have heard of it.
vii) Mixed dementia
At least 10 per cent of people with dementia are diagnosed with mixed dementia. This generally means that both Alzheimer’s disease and vascular disease are thought to have caused the dementia. The symptoms of mixed dementia may be similar to those of either Alzheimer’s disease or vascular dementia, or they may be a combination of the two.
5. Early signs of dementia
The early signs of dementia are very subtle and vague and may not be immediately obvious. Some common symptoms may include:
- Progressive and frequent memory loss
- Personality change
- Apathy and withdrawal
- Loss of ability to perform everyday tasks.
- The effectiveness of online mindfulness and meditation programs – increasingly well proven
- i) Online programs and their benefits – a meta-analysis
The aim of this meta-analysis of 15 randomised controlled studies was to estimate the overall effects of online MBIs on mental health. Results showed that online MBIs have a small but significant beneficial impact on depression, anxiety, well-being and mindfulness. The largest effect was found for stress, with a moderate effect size.
For stress and mindfulness, analysis demonstrated significantly higher effect sizes for guided online MBIs than for unguided online MBIs. In addition, effect sizes for stress were significantly moderated by the number of intervention sessions.
The researchers concluded their findings indicate online MBIs have potential to contribute to improving mental health outcomes.
Spijkerman MPJ et al. Effectiveness of online mindfulness-based interventions in improving mental health: A review and meta-analysis of randomised controlled trials. Clinical Psychology Review Vol 45, 2016, 102-114
- ii) How do online programs compare to face to face?
Mindfulness-based interventions are shown to be effective in reducing psychological distress in people affected by cancer. However, these interventions lack availability and flexibility, which may compromise participation in the intervention, especially for people experiencing symptoms like fatigue or pain. Therefore, mindfulness-based interventions are increasingly offered via the internet. Here are 5 research reports demonstrating online programs have similar outcomes to in person programs…
This first study examined a randomised group of 245 heterogeneous patients with cancer affected by psychological distress. Compared with Treatment as Usual (TAU), MBCT and eMBCT were similarly effective in reducing that psychological distress. Also, both interventions reduced fear of cancer recurrence and rumination, and increased mental health-related quality of life, mindfulness skills, and positive mental health compared with TAU.
Compen F, Bisseling E, Schellekens M, et al. Face‐to‐face and internet‐based mindfulness‐based cognitive therapy compared with treatment as usual in reducing psychological distress in patients with cancer: A multicenter randomized controlled trial. J Clin Oncol. 2018;36(23):2413‐2421.
This second study provides further evidence for the feasibility and efficacy of an online adaptation of a mindfulness-based program as it reported usage was associated with the reduction of mood disturbance and stress symptoms, as well as an increase in spirituality and mindfully acting with awareness compared with a treatment-as-usual waitlist.
Zernicke KA, Campbell TS, Speca M, McCabe‐Ruff K, Flowers S, Carlson LE. A randomized wait‐list controlled trial of feasibility and efficacy of an online mindfulness‐based cancer recovery program: The eTherapy for cancer applying mindfulness trial. Psychosom Med. 2014;76(4):257‐267.
This third study found nonusers had more fear of cancer recurrence at baseline than users. Regular users reported a larger reduction in psychological distress and more improvement of positive mental health (ie, emotional, psychological, and social well-being) after the intervention than other participants. The study showed that adherence was related to improved patient outcomes. The researchers recommended patients with strong fear of recurrence or low levels of conscientiousness should receive extra attention, as they are less likely to respectively start or complete eMBCT. Future research may focus on the development of flexible and adaptive eMBCT programs to fit individual needs.
Cillesen L; et al. Predictors and Effects of Usage of an Online Mindfulness Intervention for Distressed Cancer Patients: Usability Study; J Med Internet Res 2020;22(10):e17526)
Fourthly, this trial compared an online 6 week program to Treatment As Usual. It concluded online mindfulness instruction represents a widely accessible intervention for reducing psychological distress and its behavioural manifestations in cancer survivors, especially those who are unable to participate in in-person training. Effect sizes were all medium to large as well.
Messer D, Horan JJ, Larkey LK, Shanholtz CE. Effects of internet training in mindfulness meditation on variables related to cancer recovery. Mindfulness. 2019;10:2143–2151.
Finally, this study focused on the long-term effects of a RCT during the nine-month follow-up period. The study compared a mindfulness-based program delivered online with the same program delivered in person. Analyses revealed long-term reductions in psychological distress and rumination, and long-term increases in positive mental health and mental health-related quality of life in both interventions over the course of the nine-month follow-up. Furthermore, patients seemed to benefit more from the online program based on psychological distress levels, especially those patients with low levels of mindfulness skills and conscientiousness.
Cillessen L, et al, Consolidation and prediction of long-term treatment effect of group and online mindfulness-based cognitive therapy for distressed cancer patients.Acta Oncol. 2018 Oct; 57(10):1293-1302.
There is now a solid evidence base for mindfulness and meditation being used to help people affected by dementia (including their carers) to overcome the associated symptoms of dementia such as stress, anxiety, depression and loss of cognition and memory.
Also, there is good evidence online mindfulness – based programs like our own Allevi8 App have positive benefits and that these benefits are increased with the support of an on-line guide or mentor. Further, the evidence concludes that increasing the number of guided sessions increases the measured benefits.
Literature reviews are available for:-