Hindawi Publishing Corporation
Evidence-Based Complementary and Alternative Medicine
Volume 2012, Article ID 927509, 9 pages
TheEffectsof Meditation on PerceivedStress andRelated
Indicesof Psychological Status andSympatheticActivation
K. E.Innes,1,2T. K. Selfe,1,2C.J. Brown,2K. M.Rose,2,3andA.Thompson-Heisterman3
1Department of Community Medicine, West Virginia University School of Medicine, P.O. Box 9190, Morgantown,
WV 26506-9190, USA
2Center for the Study of Complementary and Alternative Therapies, University of Virginia Health System, P.O. Box 800782,
McLeod Hall, Charlottesville, VA 22908-0782, USA
3Department: Family, Community & Mental Health Systems, School of Nursing, University of Virginia Health System,
Charlottesville, VA 22908-0782, USA
Correspondence should be addressed to K. E. Innes, firstname.lastname@example.org
Received 8 November 2011; Revised 5 December 2011; Accepted 5 December 2011
Academic Editor: David Mischoulon
Copyright © 2012 K. E. Innes et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Objective. To investigate the effects of an 8-week meditation program on perceived stress, sleep, mood, and related outcomes in
adults with cognitive impairment and their caregivers. Methods. Community-dwelling adults with a diagnosis of mild cognitive
impairment or early-stage Alzheimer’s disease, together with their live-in caregivers, were enrolled in the study. After a brief
training, participants were asked to meditate for 11 minutes, twice daily for 8 weeks. Major outcomes included measures of
perceived stress (Perceived Stress Scale), sleep (General Sleep Disturbance Scale), mood (Profile of Mood States), memory
functioning (Memory Functioning Questionnaire), and blood pressure. Participants were assessed pre- and post-intervention.
Results.Ten participants (5 of 6 dyads) completed the study. Treatment effects did not vary by participant status; analyses were thus
pooled across participants. Adherence was good (meditation sessions completed/week: X = 11.4±1.1). Participants demonstrated
improvement in all major outcomes, including perceived stress (P < 0.001), mood (overall, P = 0.07; depression, P = 0.01), sleep
(P < 0.04), retrospective memory function (P = 0.04), and blood pressure (systolic, P = 0.004; diastolic, P = 0.065). Conclusions.
Findings of this exploratory trial suggest that an 8-week meditation program may offer an acceptable and effective intervention for
reducing perceived stress and improving certain domains of sleep, mood, and memory in adults with cognitive impairment and
tia, is a chronic, progressive brain disorder resulting in a loss
of memory, reasoning, language skills, and the ability to care
for one’s self . AD is the seventh leading cause of death in
the US , affecting 5.3 million Americans at an estimated
cost of $148 billion, figures that are expected to increase dra-
matically in the coming years [3, 4]. AD affects quality of life
for both the patient and the caregiver in profound ways.
Many individuals with cognitive impairment become unable
to engage in once loved activities that gave them a sense of
purpose or pleasure . Behavioral and social skills may also
deteriorate, resulting in feelings of social isolation, anxiety,
and depression, which, in turn, further increase risk for poor
mental and physical health outcomes [6, 7]. For example,
neuropsychiatric symptoms are common in adults with AD,
as well as in those with mild cognitive impairment (MCI)
[8, 9]. Up to 64% of AD patients  and 59% of those with
mild cognitive impairment  suffer from sleep disrup-
MCI sufferers, affecting up to 87% and 83% of these popu-
lations, respectively [12, 13].
2Evidence-Based Complementary and Alternative Medicine
Caregivers are also at elevated risk for distressful symp-
toms, including increases in sleep disturbances, depressive
symptoms, and burden, as well as cognitive decline relative
to age and gender-controlled noncaregivers [14, 15]. For ex-
ample, studies in community-dwelling caregivers of persons
with dementia have prevalence rates of self-reported sleep
disturbances and depression of up to 68% and 55%, respec-
tively [16, 17], as well as a six-fold increased risk of dementia
compared to noncaregivers . Likewise, recent research
has shown caregivers of MCI patients to suffer significantly
a need for increased support services that is comparable to
those caring for dementia patients . Distressful feelings,
impaired sleep, and subsequent maladaptive behaviors in
caregivers have been associated with further deterioration of
the care recipient’s functional and psychological status, cul-
minating in further distress in the caregiver [17, 22, 23]. Di-
stressful sleep and mood responses of both members of the
caregiving dyad can thus contribute to a vicious cycle that
may lead to deleterious health effects for both, and, ultimate-
ly, to institutionalization of the care recipient [6, 17, 24, 25].
agement strategies that target the complex effects of chronic
stress and address the associated multiple, interrelated men-
tal, and physical health challenges affecting these vulnerable
caregiver dyads. Of particular promise in this regard is med-
itation, an ancient psychophysical discipline that is gaining
increasing favor throughout the western industrialized world
as a means of reducing stress and improving mental and
physical well-being .
As indicated in recent systematic reviews by our group
and other investigators, and by the growing body of original
research on the health effects of meditation, there is mount-
ing evidence that even brief (5 days −8 weeks) meditation
programs may improve neuropsychological, metabolic, and
clinical profiles in a range of populations [26–30]. For exam-
ple, studies have shown meditation to reduce perceived stress
[28, 31–33], anxiety [28, 31, 33], and depressive symptoms
[33–35], enhance quality of life [30, 34], decrease sleep dis-
turbance , improve several domains of cognition ,
reduce sympathetic activation, and enhance cardiovagal tone
both acutely and long term in clinical as well as nonclinical
populations [27, 36].
While research in Alzheimer’s patients and their care-
givers remains limited, findings from previous observational
studies and a recent small clinical trial suggest that medita-
tion practice may reduce stress, anxiety, and depression and
improve health and cognitive outcomes in both adults with
cognitive impairment and their caregivers [31, 37–39]. How-
ever, no studies to date have examined the effects of a struc-
tured meditation program in caregiver dyads. To our knowl-
edge, the current pilot study is the first trial to investigate the
effects of meditation on perceived stress and related indices
of psychological morbidity and sympathetic activation in
caregiver dyads, and among the first to investigate the effects
of meditation in caregivers or AD patients.
2.1. Study Participants. Community-dwelling caregiving
dyads were recruited using newspaper ads, flyers, and bro-
chures placed in medical offices (e.g., the UVA Memory Dis-
orders Clinic) and other public places in Charlottesville, VA,
USA. Study advertisements detailed the study and eligibility
requirements and provided study contact information for
those interested in participating. Eligible participants were
caregiving dyads composed of: (1) an adult with a physician-
confirmed diagnosis of MCI or early stage AD of at least 6-
week duration, and current examination within the last 12
months with a score of 20 or higher on the Mini Mental State
Exam (MMSE); and (2) a live-in caregiving relative (both
members of the caregiving dyad were required to enroll in
and able to complete paper-and-pencil questionnaires and
late stage dementia; history of schizophrenia or psychosis;
pregnant or caring for an infant; primary caregiver for a sec-
ond person not in this study; began or stopped taking a cho-
linesterase inhibitor (e.g., donepezil (Aricept)) or psychotro-
pic medication (e.g., antipsychotic and antianxiety agents)
within the previous 6 weeks; serious physicaltrauma or diag-
nosis of serious chronic health condition requiring medical
treatment and monitoring within the previous 3 months
(e.g., diabetes, serious renal disease, and cancer); acute coro-
nary syndrome or cerebrovascular event within the past 6
months (e.g., myocardial infarction, and coronary artery
bypass); and meditation practice within the past 12 months.
All participants provided informed consent, and the study
was approved by the University of Virginia Institutional
2.2. Outcome Measures. Assessment of perceived stress and
related physiologic and psychological profiles was performed
twice during the study: at baseline and following the 8-week
treatment period. The baseline assessment was performed
immediately following provision by the participant of writ-
ten informed consent to participate in the study. The follow-
up assessment was performed upon each participant dyad’s
completion of the 8-week meditation program. At each visit,
heart rate and blood pressure, measures of sympathetic
activation, were measured three times, and the average
was recorded using an automated blood pressure monitor
(Omron Model HEM-780) following a 5-minute seated rest
period. Each participant also completed a short battery of
established, well-validated, and self-report instruments to
assess perceived stress (Perceived Stress Scale [PSS]) ,
mood and affect (Profile of Mood States [POMS]) ,
Positive and Negative Affect Scale [PANAS]) , stress
hardiness (Dispositional Resilience Scale [DRS]) , sleep
quality (General Sleep Disturbance Scale [GSDS]) , self-
compassion (Self-Compassion Scale [SCS]) , and cog-
nitive status (Memory Functioning Questionnaire [MFQ])
. In addition, participants were administered a brief
treatment expectancy questionnaire, as well as a short exit
regarding the effects of yoga on gait in the elderly 
Evidence-Based Complementary and Alternative Medicine3
and cardiovascular disease (CVD) risk in older adults. This
survey includes both structured and open-ended questions
regarding the participants’ experience with the study staff,
perceived benefits and problems with the meditation inter-
vention, reasons for leaving the study early or not adhering
to the study protocol, and other concerns. Specific questions
regarding perceived measurement burden were included.
Participants completed the exit questionnaire at the follow-
up assessment or (for those not completing the study), at
another time of the participant’s choosing. In addition, par-
ticipants recorded the number of minutes of meditation
practiced each day for the 8 weeks of the study using a daily
2.3. Intervention. Immediately following baseline assess-
itation training. Participants were taught the Kirtan Kriya,
a basic, easy-to-learn form of yogic meditation that incorpo-
rates both a mental component (repetition of the Sa-Ta-Na-
Ma mantra) and a physical/motor component (touching the
thumb to each fingertip in sequence with the mantra). For
this study, we used the 11-minute version of the practice (re-
peating the mantra for: 2 minutes aloud, followed by 2 min-
utes whispering, 3 minutes silently, 2 minutes whispering
again, and ending with 2 minutes aloud). Participants were
given a meditation CD and an illustrated instruction sheet
for home use. The meditation CD contained four tracks: the
first track comprised an 11-minute guided meditation ses-
sion which participants were instructed to follow at least
once a week to reinforce the in-person training; the second
track was identical to track one but accompanied by ocean
sounds; the third track provided only the timing cues need-
ed for the participants to conduct the meditation session
without guidance; track four also provided only timing cues,
but coupled with ocean sounds. Participants were instructed
to meditate for 11 minutes twice a day, every day for 8 weeks
(for a total of 112 sessions) and to record each practice ses-
sion on the daily meditation log.
2.4. Statistical Analysis. Descriptive statistics were generated
for the baseline characteristics of each group: cognitively im-
paired patients and caregivers. Potential differences between
characteristics of caregivers and cognitively impaired partic-
ipants were evaluated using chi square (for categorical var-
iables), independent student’s t-tests (for continuous vari-
ables with a normal distribution), or Wilcoxon signed rank
with evidence of skewing). We used separate repeated mea-
sures ANOVA models (multivariate tests) to assess the effects
of meditation on change over time (baseline to 8 weeks) in
perceived stress and in related indices of psychological and
physiological health. Because this was a small exploratory
pilot study, and we were looking for trends as well as signi-
ficant differences, all statistical tests were evaluated using an
alpha of 0.05 (two-tailed test).
Twelve adults (6 dyads), ranging in age from 48 to 85 years
(X = 73.3 ±3.9 years), enrolled in the study (Table 1). Seven
participants were female (3 caregivers and 4 cognitively im-
paired), and 5 were male (3 caregivers and 2 cognitively im-
paired). All participants were married; five of the six care-
givers were spouses. One participant with cognitive impair-
ment was cared for by her daughter. Ten participants were
retired, one (caregiver) was a homemaker, and one (care-
giver) was employed full time. Ninety-two percent of partici-
pants were college educated, with 58% reporting a Bachelor’s
degree or higher level of education. All participants were
non-Hispanic white. Poor sleep quality and/or daytime
sleepiness/fatigue at least 2 times per week was reported by
more than 90% of participants. Caregivers reported signif-
icantly poorer sleep (P < 0.01) and demonstrated signifi-
cantly higher memory function (P = 0.01) at baseline than
did participants with cognitive impairment but were similar
in other baseline characteristics (Table 1).
6 women and 4 men; one dyad withdrew in the first 2 weeks
due to scheduling conflicts. Compliance was very good over-
all, with participants completing an average of 11.4 ± 1.1
meditation sessions per week (out of 14 possible). Because
treatment effects did not vary by participant status (cogni-
for the purposes of analysis. As illustrated in Table 2, partic-
ipants demonstrated statistically significant improvement in
the primary outcome measure, perceived stress (P = 0.03)
as well as in sleep quality (P = 0.02), retrospective memory
function (P = 0.04), and systolic blood pressure (P = 0.004)
following the 8-week intervention. Participants also demon-
stolic blood pressure (P = 0.065) and mood impairment
as measured by the POMS (overall, P = 0.07; depression,
P = 0.01; anger/hostility, P = 0.09). Adjustment for treat-
ment expectancy did not alter these findings. Reduction in
perceived stress was correlated with positive changes in total
mood (r = 0.83 and P = 0.003) and sleep scores (r = 0.57
and P = 0.08). Similarly, improvement in sleep was strongly
correlated with improvements in mood (r = 0.71 and P =
0.03), again suggesting strong inter-relationships among
these factors. No statistically significant improvements in
positive or negative affect (as measured by the PANAS) were
noted (Table 2). In addition, participants did not show sig-
suggesting that the observed improvements in stress, sleep,
and mood were not mediated by these factors.
Participant feedback regarding the study and the medi-
tation program was positive overall. Responses to structured
and open-ended questions on exit questionnaires and com-
ments on meditation logs indicated generally high satisfac-
tion with the program, with 9 of the 10 participants who
the meditation and the quiet time to relax and/or reflect.
Concerns regarding the program included scheduling the
time to meditate, with nine participants commenting that
they had some difficulty with the time factor. One caregiver
4 Evidence-Based Complementary and Alternative Medicine
Table 1: Baseline characteristics of participants with MCI/early stage Alzheimer’s disease and their caregivers (N = 6 dyads).
Cognitively impaired (N = 6)
Age (mean ± SE in years)
At least 4 years of college
Less than 4 years of college
Mood, stress, and sleep quality
Perceived stress scale
Profile of mood states (POMS)
Positive-negative affect scale
General sleep disturbance scale (Total)
Memory functioning scale (Total)
Measures related to sympathetic activation
Heart rate (average)
Systolic blood pressure (average)
Diastolic blood pressure (average)
Caregivers (N = 6)
NS: P > 0.10.
reported difficulty concentrating (but appreciated his wife’s
dedication and the obvious help it has been to her),
and another caregiver stated that the cognitively impaired
member of the dyad found the practice challenging.
Findings of this preliminary pilot study suggest that a medi-
tation program is feasible to implement in adults with cogni-
tive impairment and their caregivers, and may offer a cost-
effective intervention for improving perceived stress, mood,
sleep, and blood pressure in this population. To our know-
ledge this is the first study to assess the effects of a mind-
body program in caregiver-cognitively impaired dyads, and
among the first to evaluate the effects of a simple medita-
tion program in community-dwelling adults with cognitive
impairment. Our findings are consistent with those of a
recent study in 14 adults with memory loss that showed im-
proved well-being and neuropsychological function over
time, along with increased cerebral blood flow after a similar,
8-week, 12-minute/day Kirtan Kriya meditation program
of mindfulness meditation in caregivers of dementia patients
did not show significant improvements over time in care-
giver-perceived stress, mood, or sleep , possibly in part
due to reduced compliance . Studies regarding the effects
caregivers have also shown significant attenuation of most
benefits over time [50, 51], perhaps in part due to the higher
Evidence-Based Complementary and Alternative Medicine5
Table 2: Change over time in indices of psychosocial status, sleep, memory functioning, and sympathetic activation in adults with cognitive
impairment and their caregivers (N = 10 participants).
(Mean ± SE)
Mood, stress and sleep quality
Perceived stress scale
General sleep disturbance scale
Profile of mood states
Memory functioning scale
Seriousness of forgetting
Retrospective memory functioning
Measures related to sympathetic activation
Heart rate (average)
Systolic blood pressure (average)
Diastolic blood pressure (average)
∗Repeated measures ANOVA.
NS: P ≥ 0.10.
(Mean ± SE)
gram such as that implemented in this study may carry ad-
vantages in terms of sustainability, especially in already heav-
ily burdened populations such as caregivers. While it is un-
known if the benefits observed in our study persisted, the
high compliance and generally high satisfaction expressed by
participants are encouraging. Based on participant com-
ments, compliance and continued practice might be further
improved by emphasizing flexible practice times to accom-
modate different or changing schedules.
Identifying feasible, cost-effective interventions for re-
ducingstressand forimproving sleep andmood in both cog-
nic stress, sleep disturbance, and mood impairment in these
cterizes the lives of family caregivers has been linked to
adverse changes in sleep , mood [52, 53], and immuno-
logical function [52, 54] and elevated risk for metabolic
syndrome, CVD, and mortality [55, 56] in this population.
Chronic psychological stress can have profound effects on
memory and behaviors in persons both with and without
cognitive impairment and has been prospectively linked to
increased risk for dementia in older adults . Eleva-
tions in hypothalamic pituitary adrenal (HPA) axis activity,
manifested by elevated cortisol levels, are associated with
hippocampal volume loss and memory impairment in non-
demented, elderly persons [58, 59]. Further, in mouse mod-
els for Alzheimer’s disease, studies show elevated production
of β-amyloid under stressful conditions, suggesting that
stress may contribute to an increase in plaque deposits and
progression in AD .
Similarly, prevalence of mood disorders is high in both
AD patients and their caregivers. For example, depressive
tively, of these populations [12, 16]. Depressive symptoms
and other distressful states have, in turn, been linked to
significantly increased risk for diabetes, CVD, stroke ,
and other components of the metabolic syndrome [62, 63]
and are a significant contributor to the profound reductions
6 Evidence-Based Complementary and Alternative Medicine
and their family caregivers [12, 64]. In addition, mood dis-
turbance can contribute to impairment of both sleep and
memory, as well as to HPA axis dysregulation and autonomic
dysfunction and related proinflammatory changes; in this
way, poor emotional health may promote a vicious cycle of
and related chronic conditions [59, 65, 66].
Sleep disruption, also common in cognitively impaired
adults and their caregivers, likewise has negative effects on
health, functioning, and quality of life in both patients and
their carers and is a major reason for institutionalization
[11, 24, 25]. Sleep disturbances have been strongly associat-
ed, in a bidirectional manner, with depression and other di-
promote glucose intolerance, proinflammatory changes, dy-
slipidemia, obesity, and hypertension [68, 70, 71]. Sleep dis-
turbances have likewise been linked with increased risk for
bothforincident type2diabetes andforCVDmorbidity and
mortality [59, 70–72]. The association of sleep to chronic ill-
ness and related risk factors appears strongly reciprocal [70,
The reductions in blood pressure observed in this study
are consistent with previous research regarding the effects of
simple meditation programs in older adults with hyperten-
sion, coronary artery disease, and related chronic conditions
[36, 74, 75]. Caregivers are at greater risk for hypertension
, and recent research has suggested that elevated blood
pressure may largely explain the increased coronary heart
disease risk observed in this population . Elevated blood
pressure has also been linked to subsequent cognitive decline
and implicated in the initiation and progression of AD [78–
Thus, if our findings are confirmed in larger randomized
controlled trials, a simple and inexpensive intervention,
meditation, may offer psychological, cognitive, and physio-
logical benefits to both cognitively impaired adults and their
caregivers, which in turn could have important implications
for physical and mental health, emotional well-being, and
cognitive function in both populations.
Strengths of the study include the community-based de-
sign, the inclusion of both cognitively impaired patients and
their caregivers, and the high retention and compliance of
participants. However, limitations of this pilot study are sev-
eral. The sample size was small, limiting power and general-
izability. The study lacked a control group, raising the
possibility that our findings could be in part explained by
a placebo effect. However, adjustment for treatment expect-
ancy did not attenuate the observed improvements, suggest-
ing that expectation of benefit did not account for the ob-
served improvements. Participants were relatively well edu-
cated, most were retired, and all were non-Hispanic white,
again limiting generalizability to other ethnic and socioe-
conomic groups. Our study sample comprised community-
living dyads who were willing and able to participate in a
meditation trial and thus are likely not representative of all
cognitively impaired adults and their caregivers. The study
was relatively short term and did not include a follow-up
component, so persistence of benefits is unknown.
4.1. Conclusions. Findings of this exploratory trial suggest
that a simple meditation program may offer an acceptable
and effective intervention for reducing perceived stress and
blood pressure, and improving certain domains of sleep,
mood, and memory in adults with mild cognitive impair-
ment or early stage Alzheimer’s disease and their caregivers.
These preliminary findings warrant confirmation in larger,
controlled trials and in ethnically and socioeconomically di-
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