The current post originated from two questions by my Twitter follower @juliagapowell:
- What is the evidence for mindfulness improving wellbeing of people living with dementia?
- What stage of dementia can be best supported by mindfulness?
Great questions. Thank you.
Non-pharmacological interventions, those that do not rely on medication, have become increasingly popular in dementia over the last decade. Not only are most of them effective, but are also very cost-efficient and can be used with little or no support once learnt. Mindfulness-based interventions have become of particular recent interest in dementia, as it has been shown that in healthy older people mindfulness-based intervention can improve their wellbeing and even potentially slow down cognitive decline.
But what is mindfulness and how does it work?
Mindfulness focuses our mind being aware of our physical, emotional, and mental state in the present moment. In essence, mindfulness focuses our mind on the ‘here and now’ in a non-judgmental way. The key concept behind mindfulness is of course not new, but millennia-old as it is based on Buddhist philosophy and meditation practice.
We have been all there, lying awake in the middle of the night worrying or ruminating about some issue which goes round and round in our head, stopping us from falling asleep again. Not only can have we such perseverative thoughts in the middle of the night but if faced with stressful life situations they can dominate our thinking the whole day and can increase our stress levels significantly.
To break this vicious cycle of continued rumination on our thoughts and worries, mindfulness focuses us on the here and now without judgement. Instead, of worrying about what might happen in the future, let’s focus on how we are feeling and what the issues are in the present. There are several techniques available for mindfulness, ranging from meditation to physical activity but they all have the same goal of living in the present and stop worrying about the future. Many research studies have shown that people who regularly practice mindfulness are less anxious and stressed throughout their life.
What’s not to like about that?
It is therefore not surprising that mindfulness has also been increasingly explored in dementia. It is commonly known that dementia is a highly stressful condition. Not only is dementia stressful for the people affected by the disease but also their carers and families. High stress and burden are known to be a common feature in carers of people with dementia, leading in the worst cases to carer burnout syndrome.
One aspect why dementia is so stressful is the uncertainty of how the condition will develop over the next few months, weeks or days. This uncertainty increases our stress levels, as we constantly worry about ‘what might happen in the future’. Since we already know that mindfulness therapy deals exactly with those worries, it would make therefore sense that mindfulness therapy should improve wellbeing in people with dementia and their carers.
But what is the scientific evidence that mindfulness therapy actually works in people with dementia and their carers?
The scientific evidence to date has been mixed on this question. There are several potential reasons why this might be. For one, mindfulness has not been long tried in dementia and therefore the evidence relies on only a few studies conducted so far. The other aspects relate to the fact that there is no specific mindfulness therapy approach, instead of different ways to administer mindfulness are used which might have varying effects in dementia. Finally, the outcome of the mindfulness is often differently measured, which makes it difficult to come to some definite scientific conclusion as to what mindfulness specifically improved.
However, a recent systematic review* tried to tackle this question by reviewing all existing intervention studies using mindfulness in people with dementia and their carers. The researchers identified 11 intervention studies in total – showing again that not many scientific studies to date have been conducted using this technique in dementia.
The results of the review demonstrate that for people with dementia, the effects of mindfulness therapy were indeed very variable across studies. Some studies showed very positive effects, while other studies showed no or little effect. The most consistent evidence for mindfulness was to improve psychosocial factors, such as stress and anxiety in people with dementia. However, the effects were far from robust as the researchers point out, mainly because of the variability of the different mindfulness therapy approaches used across studies.
Even more variable were the results for mindfulness to improve cognitive function in people with dementia and the research caution therefore that the evidence, so far, is weak to use mindfulness to improve cognitive function in people with dementia.
What about different stages of dementia? Is mindfulness more useful in certain stages of the disease than others?
The scientific evidence to date is only available for people with mild dementia or prodromal forms, such as Mild Cognitive Impairment. To my knowledge, no study to date has investigated whether mindfulness can help people with dementia in more moderate stages of the disease.
There might be several reasons for this, including the fact that memory problems become more severe in the moderate stages of the disease, which might preclude people with dementia to remember or use mindfulness on a regular basis. In addition, behavioural and language problems often emerge in the more moderate stages of the disease, which makes any intervention or therapy difficult to administer or to learn. Still, future studies might be able to adapt existing mindfulness interventions to the more moderate stages of dementia.
Is it all bad news then for mindfulness as therapy for dementia?
The systematic review also showed that mindfulness has strong and reliable positive effects on the stress and burden levels of the carers of the people with dementia. Virtually all studies showed that mindfulness reduced stress and burden in dementia carers to a significant degree.
In summary, the scientific evidence to date shows that mindfulness has variable outcomes for people with dementia. The tailoring of specific mindfulness therapies for dementia might overcome this variability in the future but so far it is difficult to recommend any particular kind of mindfulness therapy for people with dementia, even in the early disease stages.
The picture is completely different for dementia carers. For carers, the scientific evidence is strong, showing that mindfulness brings a significant reduction of stress and burden. Mindfulness should be therefore considered for dementia carers, as it provides a cost-effective but powerful way to improve the dementia care experience.
*Shim M, Tilley JL, Im S, Price K, Gonzalez A. A Systematic Review of Mindfulness-Based Interventions for Patients with Mild Cognitive Impairment or Dementia and Caregivers. J Geriatr Psychiatry Neurol. 2020 Sep 16:891988720957104. doi: 10.1177/0891988720957104. Epub ahead of print. PMID: 32935611.