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Mindfulness-based cognitive therapy for anxiety symptoms in older adults in residential care


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Objectives: Anxiety in older people is under-diagnosed and poorly treated despite significant impairments that arise from anxiety. Mindfulness-based cognitive therapy (MBCT) has been shown to be a promising treatment for anxiety. The aim of this study was to determine the effect of an MBCT program on anxiety symptoms in older people living in residential care. Method: Fifty-two participants (34 females) were randomly allocated into therapy and control groups using a 2 × 3 mixed design. The average age of participants was 83 years. Results: The group effect showed significant improvements on all measures at the end of the seven-week program in the therapy group, while the control group did not show significant changes. Conclusion: This study represents one of the first studies of the effectiveness of an MBCT program on anxiety symptoms for older people using a randomized controlled trial. The study has implications for future research that include the effectiveness of MBCT for the treatment of anxiety symptoms in older people, the utility of group therapy programs in residential care and the benefits of using specialized instruments for older populations.
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Aging & Mental Health
ISSN: 1360-7863 (Print) 1364-6915 (Online) Journal homepage:
Mindfulness-based cognitive therapy for anxiety
symptoms in older adults in residential care
Edward Helmes & Bradley G. Ward
To cite this article: Edward Helmes & Bradley G. Ward (2017) Mindfulness-based cognitive
therapy for anxiety symptoms in older adults in residential care, Aging & Mental Health, 21:3,
272-278, DOI: 10.1080/13607863.2015.1111862
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Published online: 13 Nov 2015.
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Mindfulness-based cognitive therapy for anxiety symptoms in older adults in
residential care
Edward Helmes and Bradley G. Ward
Department of Psychology, College of Healthcare Sciences, James Cook University, Townsville, Australia
Received 3 July 2015
Accepted 14 October 2015
Objectives: Anxiety in older people is under-diagnosed and poorly treated despite signicant
impairments that arise from anxiety. Mindfulness-based cognitive therapy (MBCT) has been shown to
be a promising treatment for anxiety. The aim of this study was to determine the effect of an MBCT
program on anxiety symptoms in older people living in residential care.
Method: Fifty-two participants (34 females) were randomly allocated into therapy and control groups
using a 2 £3 mixed design. The average age of participants was 83 years.
Results: The group effect showed signicant improvements on all measures at the end of the seven-
week program in the therapy group, while the control group did not show signicant changes.
Conclusion: This study represents one of the rst studies of the effectiveness of an MBCT program on
anxiety symptoms for older people using a randomized controlled trial. The study has implications for
future research that include the effectiveness of MBCT for the treatment of anxiety symptoms in older
people, the utility of group therapy programs in residential care and the benets of using specialized
instruments for older populations.
Anxiety; cognitive-behavioral
therapy; group treatment;
randomized controlled trial;
The practice of mindfulness goes back to Buddhist traditions
(Thera, 1992). Mindfulness also has a connection with a number
of Western psychological traditions and has become an integral
part of modern therapeutic approaches (Kang & Whittingham,
2010;Segal,Williams,&Teasdale,2013). Brown, Ryan, and Cress-
well (2007) reported a rapid increase in research into mindful-
ness and mindfulness-based cognitive therapy (MBCT) over the
preceding decade. The meta-analysis by Grossman, Niemann,
Schmidt, and Walach (2004) indicated the effectiveness of MBCT
for both everyday distress and more serious disorders, particu-
larly for depression (Metcalf & Dimidjian, 2014).
Mindfulness may have particular appeal to older adults
because of their increased likelihood of examining the mean-
ing of lifein the context of structured or spontaneous remi-
niscence (Rajeski, 2008). The encouragement to adopt a non-
judgmental approach (Kabat-Zinn, 1990) may also increase
the appeal to older adults who may nd the self-examination
of other therapeutic methods uncomfortable. Greeson (2008)
noted that the cultivation of equanimity and the ability to
observe thoughts and physical sensations without having to
change or act upon them may be an important therapeutic
tool for breaking the habitual behavior patterns that are chal-
lenged during therapy. Carmody, Baer, Lykins, and Olendzki
(2009) emphasize the roles of attention and consciousness.
Shapiro, Carlson, Astin, and Freedman (2006) suggested that
there were three elements of intention, attention and attitude
essential for mindfulness practice.
Smith (2004) argued that mindfulness training has equal
benets for older people to those for younger people. It
addresses matters more salient to older people, such as physi-
cal health and existential meaning. Smiths argument is thus
that mindfulness addresses issues that are more prevalent
with increasing age. In addition, the benet of focusing on an
individuals strengths may be particularly suited for older peo-
ple in residential care where weaknesses are more evident
(Smith, 2006). At the same time, the physiological changes
such as slowing of movements and lower energy that accom-
pany increasing age may mean that mindfulness programs
for older adults may be advantageous. This is particularly true
for residents of aged care facilities where psychological treat-
ments are often not readily available.
Cognitive behavioral therapy has been found to be effective
in treating generalized anxiety in younger adults (Borkovec &
Ruscio, 2001; Evans et al., 2008). Roemer and Orsillo (2002) have
suggested that the present moment focus of mindfulness in
MBCT may address the hallmark feature of generalized anxiety:
future-oriented worry. Expanding on this, Kim et al. (2010)sug-
gested that anxiety symptoms are exacerbated by components
such as lower self-efcacy and negative cognitive interpretation.
The prevalence of anxiety symptoms in older adults is not
clear from epidemiological research. Arbitrary age limits that
exclude anyone who is over 65 years, differences in the opera-
tionalization of anxiety, differing exclusion criteria and the use
of different cut-off scores are all relevant factors in the limita-
tions of current estimates. Given these factors, Wolitzky-
Taylor, Castriotta, Lenze, Tanley, and Craske (2010) reported
prevalence rates from 3.2% to 14.2%.
An additional factor is the comorbidity of anxiety with
depression, which is relatively common among older adults
(Flint, 1994) as is comorbid medical illness (Flint, 1999). The US
Center for Disease Control and Prevention (2003)estimated
that of people over the age of 65, 80% are living with one
chronic medical condition and 50% have two such conditions.
These gures suggest the need for effective interventions that
CONTACT Edward Helmes
© 2015 Taylor & Francis
VOL. 21, NO. 3, 272278
improve quality of life as well as provide relief from anxiety
symptoms (Sarma & Byrne, 2014;Scoginetal.,2007).
The above factors provide a rationale for investigation of
the effectiveness of an MBCT program for dealing with anxiety
symptoms in older adults living in residential care. Recently,
Meeks, Van Haitsma, Schoenbachler, and Looney (2015)
reported on the use of MBCT to treat depression in older adults
in residential care. Peterson and Plenh (1999) had investigated
the effects of MBCT on quality of life and anxiety sensitivity.
Measuring these latter factors appeared desirable for a study
aimed at reducing anxiety symptoms. Given the need for bet-
ter quality evidence for the efcacy of MBCT as a treatment,
the present study randomized participants into treatment and
active control groups and adopted instruments with good psy-
chometric properties that were developed for use with older
adults. It is also important to exclude those with relevant
comorbid conditions such as depression. Less relevant comor-
bid medical conditions, such as arthritis, need not lead to
exclusion. Because of the reports of benets of group pro-
grams for older adults (Agronin, 2009; Haslam et al., 2010), this
approach was adopted over individual treatment plans.
Another relevant factor for this study is the choice of
screening and outcome measures. Measures with docu-
mented reliability and validity in older adults were adopted
here in order to increase sensitivity to change.
It was hypothesized that individuals would show signi-
cant reductions in anxiety symptom scores over the three
time periods, and increasing dispositional mindfulness, signi-
cant reduction in anxiety sensitivity and greater quality of life.
The second major hypothesis was that the treatment group
would show greater differences from the control group on
the same measures.
Participants were recruited through a provider of aged care
services that included low and high permanent residential
care, day care centers and independent self-care units, with a
total of 370 beds. As residents of long-term care were sought,
an advertisement for a study of anxiety was placed in the
internal newsletter that was mailed to all individual residents
and also posted in communal areas. Managers also men-
tioned the research at residentsmeetings. Those expressing
an interest were contacted by the second author to arrange
for assessment and screening. The author met with each par-
ticipant individually to administer measures and explain the
structure of the program and provide an opportunity for
questions. The screening included an evaluation of the likeli-
hood of the resident to complete the eight weeks of the pro-
gram; residents often raised this concern themselves. The
project was approved by the Human Research Ethics Commit-
tee of James Cook University and the ethics committee of the
aged care service provider.
Mini-Mental State Examination (MMSE; Folstein, Folstein, &
McHugh, 1975)
The MMSE is a 30-item clinician-administered test that is argu-
ably the most widely used screening instrument for dementia
and cognitive impairment in older adults. It has good testretest
reliability (rD.89; Lezak, Howieson, & Loring, 2004)andgood
internal reliability (coefcient aD.83; Curtyo et al., 2001).
Geriatric Anxiety Inventory (GAI; Pachana et al., 2007)
The GAI can be administered either by the clinician or by self-
report. This is one of the few measures of anxiety developed
specically for older people, with good internal reliability
(coefcient aD0.91), with specicity (84%) and sensitivity
(75%) for GAD.
Montgomery and Asberg Depression Rating Scale (MADRS;
Montgomery & Asberg, 1979)
The 10 items can be self-reported or administered by a clini-
cian. The MADRS has good predictive value as a measure of
depression specically developed for use with older people. It
has good inter-rater reliability (Morris et al., 2005) and good
internal reliability (coefcient aD.82; Mundt et al., 2006).
World Health Organization to Quality of Life Scale for
Older People (WHOQOL-OLD; Power, Quinn, Schmidt, &
WHOQOL-OLD Group, 2005)
The 24 items of the WHOQOL-OLD have undergone extensive
development for use with older populations. It has good
face validity and internal reliability (alpha D.85; Bowling &
Stenner, 2011) and subscale reliability ranging from .72 to .91
(Power et al., 2005).
Mindfulness Attention and Awareness Scale (MAAS; Brown
& Ryan, 2003)
The 15 items of the MAAS indirectly assess the cognitive,
emotional, physical, interpersonal and general domains of
mindfulness. It has been validated in college, working adult
and cancer patient samples. It has good internal reliability
(alpha D.89; Mackillop & Anderson, 2007).
Anxiety Sensitivity Index (ASI; Peterson & Reiss, 1993)
The 16 items of the ASI measure the concerns about the cata-
strophic or negative consequences of anxiety symptoms. It
has good internal consistency (alpha D.82; Telch, Shermis, &
Lucas, 1989) with good testretest reliabilities ranging from
.65 to .75 (Peterson & Plenh, 1999).
The interview and screening battery were designed around
the following inclusion criteria: scores at or above 26/30 on
the MMSE; scores above 10/20 on the GAI; scores on the
MADRS below 19. Further exclusion criteria were subject to
an order under the Ofce of the Public Guardian or Ofce of
the Protective Commissioner; subject to an order under the
local State Mental Health Act, a pre-existing mental illness
(other than anxiety) or acute crisis; diagnosed substance
abuse; personality traits making them possibly disruptive to
group processes; active psychosis, including mania; express-
ing suicidal ideation; not competent in English. A total of 40
individuals were screened and either declined to participate
(nD11), had other psychiatric disorders (nD9), met exclu-
sion criteria (nD15), or declined for other reasons (nD5).
Possible participants excluded from the study were referred
to appropriate services through the facility for treatment.
Figure 1 provides a ow chart of participant selection.
Calculation of statistical power
The G
Power program (Erdfelder, Faul, & Buchner, 1996) esti-
mated that 52 participants would be needed for a medium to
large treatment effect (CohensdD.7) with an 80% chance of
detecting the treatment effect with alpha D.05.
The study was a randomized controlled trial using a 2 £3
mixed repeated measures design contrasting the intervention
comprising seven sessions of MBCT with the activity-based
control treatment. The within-subjects factor was measured
at three time points, with measures administered at the end
of session 1, the end of session 8 and at one month follow-up.
The primary dependent variables were the scores on the GAI,
Participants were randomly assigned to either control or ther-
apy group using a random number table by an independent
researcher with 26 participants per group (see Figure 1). The
implementation of an MBCT program was based upon that
delivered by Segal et al. (2002) that in turn was built upon ear-
lier such programs pioneered by Kabat-Zinn (1982). The MBCT
program was largely based on that described by Segal et al.
(2002) with eight weekly sessions of 1.5 hours each. This is 30
min less than the session length in the Segal method. Shorter
sessions (approximately 1 hour) in contrast to time-limited
groups have been found to be benecial for older adults. A
focus on group discussions and mutual support can help
adaptation to increase control and reduce dependency
(McBee, 2009). Participants were given printed handouts
based on Kabat-Zinn (1990) and Segal et al. (2002) each week
that summarized the session content with homework tasks
and a diary for daily recording practice. Homework tasks were
emphasized during sessions and daily records of homework
that were reviewed weekly. Participants were also given CDs
with tracks for body scan, mindfulness of breath and mindful-
ness of sound and thoughts. Sessions were run within two
facilities, with two study groups at one home with roughly
equal numbers for each therapy group and fewer than 10 par-
ticipants per therapy group. The MBCT group was run by the
second author who has training in MBCT and 15 yearsexperi-
ence in providing MBCT. The control group participated in a
structured activity program that was facilitated by two nurs-
ing assistants experienced with this approach. Content of the
control group sessions was taken from standard activity pro-
grams (Butler, 2005) and included changes in forms of enter-
tainment, travel in the Australian outback, role of weddings,
nautical life, air travel, shopping and past residences. The
focus was on personal experiences and reminiscing. These
sessions ran for the same length of time, on the same day
and time of day as the MBCT program. Participants in both
Assessed for eligibility (n = 92)
Excluded (n = 40)
Not meeting inclusion criteria (n = 15)
Other diagnoses (n = 9)
Declined to participate (n = 11)
Other reasons (n = 5)
Analysed (n = 26)
Missing follow up data was imputed using
appropriate statistical methods (see Results)
Lost to follow-up (give reasons) (n = 2)
Allocated to intervention (n = 26)
Received allocated intervention (n = 26)
Did not receive allocated intervention
Lost to follow-up (give reasons) (n = 2)
Allocated to intervention (n = 26)
Received allocated intervention (n = 26)
Did not receive allocated intervention (n = 0)
Analysed (n = 26)
Missing follow up data was imputed using
appropriate statistical methods (see Results)
Randomized (n = 52)
Total number of residents (n = 370)
Figure 1. CONSORT ow chart of study recruitment.
study groups were also explicitly encouraged to complete
their homework assignments.
Two sessions of each program were videotaped and
reviewed by a senior psychologist to ensure treatment integ-
rity. Taped sessions were checked for consistency of program
delivery and the presence of key concepts to ensure that
expectations of the group with regard to work between ses-
sions were delivered uniformly.
Analysis revealed that 7.7% of participants did not provide
one month follow-up measures. This is well within the sug-
gested 20% acceptable limit to allow for the use of missing
data imputation methods. No missing data were present at
other time points. Littles missing completely at random
(MCAR) test was conducted to assess for non-random pat-
terns of missing data. No identiable patterns were identied
(15 df)D17.8, pD.27). The missing values for the four par-
ticipants were imputed using the estimation maximization
(EM) method provided in SPSS. This allowed all analyses to be
conducted with the full sample. No univariate outliers were
identied using the cut-off of 3.3 standard deviations from
the mean. The assumptions of homogeneity of variance and
covariance matrices and multivariate normality were satised.
More than 80% of all participants missed fewer than two
sessions, with more than 92% attending ve or more sessions
for the therapy group and 88% for the control group.
Table 1 below outlines scores obtained on the GAI, MAAS,
ASI and WHOQOL-OLD for both control and therapy groups
with mean scores and standard deviations.
A2£3 mixed multivariate analysis of varience (MANOVA)
using all 52 participants was conducted to investigate differ-
ences between therapy and control groups across all depen-
dent variables (DVs) at all three time points. Using a
combined model of all DVs, Wilks criterion indicated there
was a signicant difference between the therapy and control
groups (F(12, 39) D10.458, p<.001, Wilks Lambda D.237,
partial h
D.763). Follow-up one-way repeated measures
analyses of variance (ANOVAs) were conducted for each of
the four dependent variables, GAI, MAAS, ASI and WHOQOL-
OLD, across T1, T2 and T3. To control for Type I error, a Bonfer-
roni adjustment was applied to these analyses and an
adjusted alpha level of pD.006 was used. No further alpha
adjustment was used in follow-up tests in order to preserve
power for these analyses. Mixed univariate 2 £3 repeated
measures ANOVA statistics show that signicant group by
time interaction effects occurred for the therapy group across
time for each of the DVs (GAI:F(1.7, 86.6 df)D31.6, p<.001;
MAAS:F(1.5, 75.7 df)D22.6, p<.001; ASI:F(2, 100 df)D15.7,
p<.001; WHOQOL:F(1.4, 68.6 df) D14.2, p <.001).
Tables 2 and 3report repeated measures t-tests for both
the control group and the therapy group respectively for all
DVs at all three time comparison points.
It is clear that the effect sizes reported in Table 3 for the
therapy group all show signicant changes in the predicted
direction for all DVs at almost all time points. The exceptions
to this are for the GAI from T2 to T3 (pD.553) and the
WHOQOL-OLD at the same time points (pD.153). All other
changes in DVs for the therapy group were signicant across
time points. With the exception of the GAI, the strongest
effect sizes were observed for changes from T1 to T3. For the
GAI, the largest effect size was observed in the change from
T1 to T2, with a non-signicant change from T2 to T3. The sig-
nicant changes all reected effect sizes in the very large
range (Rosenthal, 1996).
The control group reported in Table 2 did not show any
signicant change in scores obtained for any of the DVs at
any time point. It is noted that some of the effect sizes
reported for the control group were in the small range (MAAS
means for T1:T2, T1:T3; ASI means for T2:T3 and WHOQOL-
OLD means for all reported effect sizes), with one score
approaching a moderate effect size (ASI mean for T1:T3). To
better understand these ndings, it is noted that some of the
mean differences indicated a worsening of scores over time
(e.g. some of the MAAS effect sizes reported means scores
that showed a decrease in dispositional mindfulness). For
scores that showed small to approaching moderate effect
sizes, the actual mean score movements revealed scores that
lack adequate ecological validity to be meaningful in a practi-
cal sense. An example here is the almost moderate effect size
(dD.42) observed for the ASI for T1:T3. This represents a
movement on the ASI of less than one point in a possible
64-point scale, compared with the very large effect size noted
in the therapy group where an almost six-point movement is
Table 1. Comparison of session one (T1), session eight (T2) and one month (T3) follow-up measures for control and therapy groups.
Control group Therapy group
T1 T2 T3 T1 T2 T3
GAI 11.69 1.69 11.77 1.82 11.55 1.81 11.65 1.09 8.69 1.29 8.54 1.79
MAAS 65.88 12.89 64.88 13.56 65.17 12.31 56.88 13.73 63.42 11.64 67.18 10.91
ASI 22.46 8.07 22.12 8.83 21.73 8.64 26.54 7.38 23.54 6.26 20.66 6.88
WHOQOL 88.96 10.36 87.54 11.32 88.10 10.80 86.85 11.76 92.04 11.44 92.91 11.78
Note: GAI Geriatric Anxiety Inventory; MAAS Mindfulness Attention and Awareness Scale; ASI Anxiety Sensitivity Index; WHOQOL World Health
Organization Quality of Life.
Table 2. Repeated measures t-tests for control group across time for all DVs.
Measure Comparison times Mean differences t
T1:T2 ¡.08 .25 .81 .07
GAI T2:T3 .22 .70 .49 .19
T1:T3 .14 .38 .70 .11
T1:T2 1.00 1.11 .28 .31
MAAS T2:T3 ¡.28 .47 .64 .14
T1:T3 .72 .90 .38 .25
T1:T2 .35 .67 .51 .19
ASI T2:T3 .39 1.01 .32 .28
T1:T3 .75 1.48 .15 .42
T1:T2 1.42 1.17 .25 .33
WHOQOL T2:T3 ¡.56 .93 .36 .26
T1:T3 .87 .76 .46 .21
df D25.
Adjusted alpha level, pD
noted. Examination of the mean differences for the control
group reveals mean scores that either did not move in the
desired direction, or moved in a manner that was not clinically
Follow-up univariate t-tests were conducted for each of
the four DVs, GAI, MAAS, ASI and WHOQOL-OLD, across T1, T2
and T3 (Table 4). A Bonferroni adjustment was used to control
for inated Type I error rate (adjusted signicance level,
Follow-up univariate t-tests analyses indicated that partici-
pants in the therapy group had signicantly lower GAI scores
than people in the control group at T2 (MD8.7, SD D1.29
and MD11.8, SD D1.82, respectively), t(51) D7.04, p<.001,
CohensdD1.95, representing a very large effect size. Univar-
iate t-tests also indicated that people in the therapy group
had signicantly lower GAI scores than people in the control
group at T3 (MD8.5, SD D1.79 and MD11.6, SD D1.81,
respectively), t(51) D6.02, p<.001, CohensdD1.67, simi-
larly indicating a very large effect size.
No other signicant differences between therapy and con-
trol groups were detected using univariate t-tests with the
Bonferroni adjusted alpha level across all time points. How-
ever, for the MAAS at T1 the control group had higher scores,
on average, compared with the therapy group (MD65.7, SD
D12.89 and MD56.9, SD D13.73 respectively), t(51) D2.44,
pD.018, CohensdD.68 representing a moderate effect size.
If a less stringent alpha adjustment had been used, this mean
difference may have been statistically signicant.
The overall aim of this study was to evaluate the effectiveness
of an MBCT program to reduce anxiety symptoms in a sample
of older people in residential care. In addition, the study
sought to investigate any benecial effects that would be
observed on dispositional mindfulness, anxiety sensitivity and
quality of life. The study sought to overcome some of the
shortcomings of prior research by the provision of an active
control group to the MBCT group in a randomized controlled
trial with a 2 £3 mixed design, the use of standardized spe-
cialized assessment instruments and the addressing of other
issues as summarized by Baer (2003).
As for the rst hypothesis, participants in the therapy
group showed improvements on all measures, while the con-
trol group showed no signicant changes. In contrast, how-
ever, the ndings provided only limited support for
hypothesis 2. Hypothesis 2 that the four dependent measures
would differ following treatment was partially supported with
signicant observed differences between groups on the GAI
at the end of the program and at one-month follow-up. Out-
come data did not support any of the other levels of hypothe-
sis 2 concerning the remaining outcome measures, which
showed limited group differences.
According to the GAI, anxiety symptoms were reduced sig-
nicantly in the treatment group after the intervention and at
one-month follow-up. Within-groups comparison showed
that the MBCT group showed notably greater improvements
in reported anxiety symptoms than in the control group.
Although the results plateaued, the gains observed at the end
of the treatment program were maintained at one-month fol-
low-up. Splevins, Smith, and Simpson (2009) conducted an
eight-week MBCT course that assessed changes in depression,
anxiety and stress. This study also found signicant reductions
in all three measures with the least robust effect for anxiety.
This study did not, however, employ a comparison group.
Young and Baime (2010) utilized a mindfulness approach
with a larger sample of older adults. There were signicant
improvements in all scales used, notably anxiety, with
reported reductions of about 50%. This study also did not
include a comparison group nor were measures validated for
an older adult population. The current results are consistent
with these previous studies in showing a reduction in anxiety
symptoms following MBCT. It is possible that the mindfulness
approach is particularly suited for older people, but this spec-
ulation needs to be conrmed empirically through a compari-
son of age groups.
Anxiety sensitivity as measured by the ASI showed signi-
cant decreases in scores from the commencement of the pro-
gram to the end of the follow-up. All these changes in the
therapy group ASI scores showed very large effect sizes.
The control group did not show signicant changes over time.
The results obtained on the ASI are of particular interest in the
current context as a state or trait and how it might be affected
by an MBCT intervention. The current study is one of the very
few to examine the effect of an MBCT program on ASI scores
in older people. The question for the present study is how clini-
cally relevant are the ASI scores. The drop in scores on the ASI
Table 3. Repeated measures t-tests for therapy group across time for all DVs.
Measure Comparison times Mean differences t
T1:T2 2.96 13.15 <.001 3.69
T2:T3 .15 .60 D.553 .18
T1:T3 3.10 8.71 <.001 2.53
T1:T2 ¡6.54 4.39 <.001 1.26
MAAS T2:T3 ¡3.76 3.81 D.001 1.07
T1:T3 ¡10.30 5.56 <.001 1.61
T1:T2 3.00 4.11 <.001 1.19
ASI T2:T3 2.88 3.93 <.001 1.10
T1:T3 5.88 6.57 <.001 1.83
T1:T2 ¡5.19 4.18 <.001 1.16
WHOQOL T2:T3 ¡.87 1.47 D.153 .41
T1:T3 ¡6.06 5.07 <.001 1.41
df D25.
Adjusted alpha level, pD.006.
Table 4. Between groups univariate t-tests for all DVs at all time points.
Measure Time Mean differences t
T1 .04 0.10 1.000 .028
T2 3.08 7.04 <.001 1.95
T3 3.01 6.02 <.001 1.67
T1 9.00 2.44 .018 .68
MAAS T2 1.46 0.42 .678 .12
T3 ¡2.02 0.62 .535 ¡.17
T1 ¡4.08 1.900 .063 ¡.53
ASI T2 ¡1.42 .670 .506 ¡.19
T3 1.06 0.49 .625 .14
T1 2.11 0.69 .495 .19
WHOQOL T2 ¡4.50 1.43 .160 ¡.40
T3 ¡4.81 1.58 .131 ¡.43
df D51.
Adjusted alpha level pD:004:
at the end of treatment brings them to the level of adults with-
out anxiety (Blais et al., 2001; Peterson & Reiss, 1993).
The decline in scores observed in the control group was
not signicant, suggesting that the change in the ASI was due
to the mindfulness intervention.
The MAAS is one of the most widely used measures of
mindfulness. The two groups were equivalent in MAAS scores
at baseline, with differences becoming apparent at the post-
treatment evaluation that were maintained at one-month fol-
low-up. The control group actually showed an overall reduc-
tion in mindful awareness. Despite the promising ndings
here, the interpretation of MAAS scores is hindered by the
absence of research on it with older adults.
The quality of life of participants was measured using the
WHOQOL-OLD, a measure specically developed to assess
the construct in older adults (Power et al., 2005). Unlike
the other measures, there were no signicant differences in
WHOQOL-OLD scores between groups, although changes
were evident for the MBCT group at the post-intervention
time period. The presence of anxiety has been noted to have
a deleterious effect on quality of life. Bourland et al. (2000)
compared the quality of life of older people with anxiety com-
pared with a non-anxious control group and the anxious older
adults were found to have substantially diminished quality of
life. This study had no intervention, but it is important to note
that age alone does not predict diminished quality of life
(Brown & Roose, 2011). This issue is complicated by the use of
different measures of quality of life for different age groups
and the present sample is older than those in most studies
with the WHOQOL-OLD.
Many participants in both groups had multiple medical
comorbidities with some relying on care staff to get to the
groups. Despite their medical conditions, all participants man-
aged to attend the full eight weeks of the program. The care-
ful selection procedures likely also contributed to the high
program completion rate. It is also suggested that in the cur-
rent study simply being active and attending the weekly
group could be a major contributor to quality of life scores.
We suggest that the randomized controlled design of the
study, rather than the use of convenience samples, combined
with clearly dened and measurable inclusion and exclusion
criteria should address other issues of controlled research.
The benet of the study has been demonstrated and as out-
lined, the benets for individuals in the therapy group are
clear. There were large, meaningful changes in measures of
anxiety, quality of life and mindfulness that have yet to begin
being demonstrated as clearly elsewhere in the research liter-
ature. Further studies of MBCT for anxiety symptoms in care
facilities are clearly warranted, but the present results are suf-
ciently clear to warrant recommendations for its adoption in
broader clinical practice with older adults.
Among the limitations of the study is one of its strengths:
access to facilities in which to run the groups. This did intro-
duce the possibility of contamination between groups. Partici-
pants were asked not to discuss the relevant groups with
others, but people could of course see each other between
sessions. Thus, the issue of contamination must be considered
and cannot be completely discounted. Another limitation was
the relatively small sample size and resulting limited statistical
power to detect small- to medium-sized effects. Although the
current study did gather a great deal of information on partic-
ipants, there are areas that may have not been assessed. The
inuence of pharmacological treatment cannot be discounted
both for psychotropic medications and those for treating
medical conditions such as arthritis or cardiac problems.
While there is substantial variation in the delivery of mindful-
ness-based programs, one aspect is the scheduling of either a
full-day of mindfulness training or follow-up sessions some
months later (Segal et al., 2002; Smith, 2006). The provision of
such features was not possible within the constraints of the
facilities that were available.
We hope that this study may serve to advance knowledge
regarding contributions that mindfulness-based programs
may play in the treatment of anxiety in older people. The
presence of robust, therapeutic and group-based interven-
tions for use in residential aged care facilities is virtually non-
existent. An effective intervention that meets its objectives, is
cost effective to deliver and resonates with older population
has substantial potential in addressing some of the burdens
for this increasing population.
Disclosure statement
No potential conict of interest was reported by the authors.
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... 9 Past research has found associations between MBCT interventions and reductions in depression symptoms in adults with prior major depression. [10][11][12][13] In individuals with mild neurocognitive deficits, ...
... MBCT increased quality of life 10,11 and mindfulness. 11 Results from a qualitative study indicated that older adults with depression and/or anxiety who participated in MBCT experienced fewer anxious and intrusive thoughts and saw improvements in their sleep. ...
... MBCT increased quality of life 10,11 and mindfulness. 11 Results from a qualitative study indicated that older adults with depression and/or anxiety who participated in MBCT experienced fewer anxious and intrusive thoughts and saw improvements in their sleep. 12 Among caregivers, MBCT interventions were associated with a decrease in selfrated stress compared to a respite-only control group. ...
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Introduction: Depression symptoms are common for older adults with memory difficulties and their caregivers. Mindfulness-based cognitive therapy (MBCT) reduces the risk of relapse in recurrent depression and improves depression symptoms. We explored recruitment and retention success and preliminary effect sizes of MBCT on depression and anxiety symptoms, as well as mindfulness facets, in individuals with memory difficulties and their caregivers. Methods: A difficulty with memory group (DG) and caregiver group (CG) were randomized into either the MBCT intervention or waitlist control. After serving as controls, participants received the intervention. Mean pre-post changes by group were compared and effect sizes computed. Correlations between mindfulness facets and depression symptoms are also presented. Results: Only 47% of the initial participants completed the study. The intervention did not have an effect on the outcome variables examined. However, improvements in non-judgmental scores were associated with reductions in the number of depression symptoms reported by DG participants (r = -0.90, 95% confidence interval [CI]: -0.98, -0.52) and CG participants (r = -0.76, 95% CI: -0.95, -0.19). Furthermore, improvements in awareness scores (r = -0.69, 95% CI: -0.93, -0.05) and level of burden (r = 0.87, 95% CI: 0.49, 0.97) also significantly correlated with reduced depression symptoms in the CG group. Conclusions: By determining preliminary MBCT effect sizes in individuals with memory difficulties and their caregivers, research with larger, controlled samples is now justified to determine the true effects of MBCT in these populations.
... As opposed to previous studies [44,47], no significant differences were found for anxiety. Nevertheless, the studies cited evaluated this variable with other instruments and populations with other diagnoses, including clinical anxiety disorders. ...
... It is risky to describe solid conclusions with these mixed results, having in mind the scarcity of the studies that have addressed this specific subject. Accordingly, significant differences were not found in the mindfulness skills when the treatment ended, in agreement with other previous studies with headaches [50,55], and in disagreement with other research studies, where differences were found in the short [47] and long term (6 months) [56]. However, there is a possibility that the effects on the mindfulness skills found in the present study may be long-term, for example some authors have found [56] improvements in mindfulness skills 6 months after training, with patients who had coronary disease and depression. ...
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The prevalence of chronic pain in Spain is 15%. The objective of this study was to evaluate the efficacy of mindfulness-based cognitive therapy on patients with chronic pain. A quasi-experimental design of repeated measures pre- and post-test (N = 57) was carried out at three hospitals from the province of Alicante. Self-reported assessment measurements of pain intensity, anxiety-depression symptoms, perception of health status, interference of pain on sleep, self-efficacy in pain, acceptance, and mindfulness attitude were included. The T-test indicates significant differences in intensity of present pain, mental quality of life, and depression (medium effect sizes), as well as in self-efficacy: total score, symptom management and pain control (medium effect sizes), sleep disturbances and quantity of sleep (large effect sizes). MBCT is effective in reducing many symptoms in patients with chronic pain, although its maintenance needs to be further investigated.
... By teaching individuals to relate to their present moment experience in a nonjudgemental and acceptant manner, MBI could help people with SCD to recognize and disengage from worry processes and respond to cognitive failures with more acceptance, which may thus reduce anxiety. While mindfulness-based research in older adults is still in its infancy [10][11][12], there is considerable evidence that MBI can reduce anxiety in a number of populations [13,14]. In order to investigate the specific benefits that such an approach might offer, comparison against an active control is advisable as MBI contain a number of nonspecific elements, such as social interaction, education, and the provision of treatment expectancies. ...
Subjective cognitive decline (SCD) denotes self‐reported cognitive concerns in the absence of objective cognitive impairment. Individuals with SCD convert to dementia at twice the annual rate of healthy controls, with relatively poorer cognition in SCD conferring additional risk. Non‐pharmacological interventions are currently undergoing intensive evaluation for promoting cognitive function in SCD. This study utilized data from the SCD‐Well randomized controlled trial. One hundred forty‐seven older adults with SCD, recruited from clinics in four European countries, were randomized to one of two 8‐week non‐pharmacological interventions: the Caring Mindfulness‐Based Approach for Seniors (CMBAS), or a Health Self‐Management Program (HSMP). Participants’ objective cognitive performance was assessed at baseline, post‐intervention, and 24‐weeks follow‐up using a battery of tests. Four of these (RAVLT, WAIS‐IV Coding, Mattis DRS‐2 and Category Fluency) were combined to yield an abridged version of the Preclinical Alzheimer’s Cognitive Composite 5 (PACC5Abridged). Linear mixed models estimated the change in outcome measures (the PACC5Abridged and its constituents) within and between arms. All models were adjusted for country and participant demographics (sex, age, and education), as well as the time‐varying effect of participants’ repeated practice with the outcome measures. There was a statistically significant improvement in the PACC5Abridged in both arms of the trial (p<.001), which did not differ between groups. The mean change in PACC5Abridged from baseline to 24‐weeks was 0.28 for CMBAS, and 0.22 for HSMP (pooled baseline SD 0.72). The effect of participants’ repeated practice on the PACC5Abridged was non‐significant, ruling out retest effects as a substantive explanation for results. Amongst the PACC5Abridged constituent tests, significant improvement was observed in the RAVLT and WAIS‐IV Coding. This clinical trial evaluated the effect of two 8‐week non‐pharmacological interventions on objective cognitive performance in SCD. Scores on a composite measure of early Alzheimer’s disease related cognitive dysfunction improved in both arms, even after accounting for practice effects. These results paralleled those of the primary outcome measure (trait anxiety), for which scores also improved in both arms. This work adds to the growing body of evidence that non‐pharmacological interventions can impact cognition in individuals at increased risk of dementia.
... T2 and T3 post intervention data collection: At the end of the first intervention, all participants will be contacted by telephone to conduct individual T2 assessments. For T3 data collection, all participants will be contacted by telephone by RA1 to conduct individual assessments has been validated for use in community dwelling adults over the age of 60, with excellent test-retest reliability of r = .91 to .95 [35,[53][54][55]. This anxiety scale was selected because it is commonly used in a range of clinical settings [56]. ...
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Background The worldwide prevalence of anxiety in older adults is estimated at between 6 and 10%. In Canada, adults 65 and older experience anxiety at a rate of 6.4%, affecting more than 300,000 people. Anxiety in older adults has been linked to difficulties retaining new information and engaging in instrumental daily activities of living. Due to COVID-19 restrictions, novel methods of delivering therapy programs remotely are needed; however, data is limited. There is some evidence that older adults prefer non-pharmacological approaches for anxiety that can be delivered in the community. Emotion-focused mindfulness therapy (EFMT) is a mindfulness-based intervention that emphasizes meditation and observing thoughts and emotions as they arise. This emphasis has been demonstrated to reduce symptoms of anxiety in general populations. This study aims to evaluate the feasibility of EFMT with older adults. Methods This pilot feasibility randomized controlled trial will use a wait list control trial design. Due to COVID-19 restrictions, we will use telehealth delivery via Zoom rather than in-person delivery. The first 48 people to meet the eligibility criteria will be randomly allocated to either receive EFMT immediately, or in approximately 8 weeks time from enrollment (1:1 allocation ratio). Data will be collected at baseline, 8 weeks following baseline, and 16 weeks following baseline. The primary outcomes will determine the feasibility of the intervention based on recruitment, enrolment, retention, and adherence to all components of the intervention. The secondary outcome will be changes to anxiety over time. Discussion The results of this trial will determine the feasibility and potential effectiveness of video-delivered EFMT for late-life anxiety compared to no treatment. If the results are promising, a larger randomized controlled trial may be conducted. Trial registration, NCT04415528 . Registered on June 4, 2020 Protocol version Protocol version 2, January 2, 2021
Despite the prevalence of mental health concerns among those who live in residential aged care, many residential aged care facilities (RACFs) provide little by way of psychological support. Drawing on qualitative data obtained from interviews with residents from across 15 RACFs in Victoria, Australia, this article adds to understandings about the diversity and impact of mental health challenges experienced by residents, and gaps in the knowledge of staff about how to address such. Thus, it also offers evidence of the urgent need for RACFs to provide residents both better access to specialist mental health practitioners and training to care staff on mental health issues.
Objectives: Worry has been shown to have a negative impact on many aspects of neurocognitive performance. Interestingly, research indicates mindfulness both improves aspects of cognitive ability and reduces worry symptoms. Yet, the impact of mindfulness on the relationship between worry and cognition has yet to be explored. Based on research discussed herein, we hypothesize that those with higher levels of dispositional mindfulness will have better cognitive performance than those with lower levels of dispositional mindfulness, regardless of worry level. The present study investigated the potential moderating influence of mindfulness on the relationship between worry and cognitive performance. Methods: The sample included 113 older veterans who were screened at the VA Palo Alto Health Care System in Palo Alto, CA. Cognitive domains of interest included learning and memory, processing speed, attention, working memory, and executive function. Mindfulness was assessed with the Five Facet Mindfulness Questionnaire (FFMQ), and worry symptoms were assessed using the Penn State Worry Questionnaire (PSWQ). Hypotheses were tested with multiple regression analyses using the Hayes (2003) PROCESS macro. Results: Contrary to what was hypothesized, only mindful awareness significantly moderated the relationship between worry and processing speed. Conclusion: This finding has important implications for introducing mindfulness techniques into older adults’ routines to decrease worry and mitigate its negative effects on processing speed.
This study examined the effectiveness of dialectical behavior therapy intervention on emotion regulation and death anxiety in old women. This quasi-experimental study was conducted using a pretest-posttest design with a control group. The research population included elderly women aged 60–75 years who were members of the Tehran Municipality Retirees Association in 2020. A total of 30 women were assigned to intervention and control groups (15 persons in each group). The participants in the intervention group received the dialectical behavior therapy (DBT) intervention for 10 sessions while the participants in the control group did not receive any intervention. The results of the analysis of covariance (ANCOVA) showed that there was a significant difference between the women in the intervention and control groups in terms of cognitive emotion regulation and death anxiety on the posttest. This therapy can be used for the elderly living in nursing homes and aging associations and institutions.
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Older adults often avoid seeking psychological treatment, challenging their ability to adaptively deal with anxiety, stress and depression. The aim of the current study was to compare the effects of a mindfulness intervention vs. cognitive-behavioral-therapy (CBT) on measures of emotional distress and attitudes towards seeking mental-health treatment among older adults. Twenty-four seniors were assigned to: 1) MBIS (Mindfulness-Based Intervention for Seniors); and 2) CBT for anxiety, or to a care-as-usual control group. Attitudes towards seeking psychological treatment, levels of depression, anxiety and worry were measured before and after the interventions. Following the intervention, participants more positively addressed the possibility of utilizing psychological treatment, while no changes were observed in the control group. Interestingly, levels of worry improved only in the MBIS group, and anxiety levels only improved in the CBT group. It seems that attending cognitive group interventions are effective to their focus and positively impact attitudes towards psychological treatment.
Anxiety is a debilitating condition that adversely affects people's quality of life. It is challenging to differentiate anxiety from other physical and mental health conditions in older people, particularly those with co-morbid dementia or depression. The coronavirus 2019 pandemic has compounded social isolation and loneliness in older people, causing increased levels of anxiety. Nurses need to be able to detect and assess anxiety in older people and offer short, low-intensity interventions to support older people's mental health or refer them to specialist assessment and treatment. While research on anxiety in older people is lacking, cognitive behavioural therapy, mindfulness, yoga, music therapy and pleasant activities have shown potential as non-pharmacological interventions for alleviating anxiety in older people. This article explores the role of nurses in identifying when an older person may be experiencing anxiety and then choosing the optimal non-pharmacological intervention to support them.
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The aim of this study was develop a training package of coping with job stress and compare its effec with mindfulness-based cognitive therapy on anxiety and depression of Tam Kar’s employees.This research was a combination of exploratory research projects. The phenomenological qualitative method- content analysis was used to develop a training package to coping with job stress that 7 main codes (anxiety,depression,low emotional intelligence, ineffective coping strategies, cognitive problems,weakness of social skills and weakness of religious beliefs) were obtained And the coping with stress training package was adjusted based on these dimensions. The quantitative research method was a three-stage three-group pilot project in which the statistical population included all employees working in the technical departments of Tam Kar’s Company in Isfahan city Which the use ofpurposeful sampling, 45 employees were selected and randomly assigned to three groups (15 for each group). The Beck's Anxiety Inventory, and Beck's Depression Inventory were used to gather information. Experimental group 1 under the knowledge of mindfulness-based cognitive therapy 8 sessions of 90 minutes and experimental group 2 was trained to coping with job stress in 10 sessions 90-minute. Analysis of covariance was used to analyze the research findings. The results showed that both trainings made significant changes in depression and anxiety in the post-test and follow-up stages (p≤0.05). Further, the results of Bonferroni’s follow-up test implied that there is effectiveness of package of Coping with Job Stress was higher than cognitive therapy based on mindfulness. Therefore, the result of this study provide experimental support for both training to improve depression and anxiety in industry employees. Keywords: anxiety, depression, mindfulness-based cognitive therapy, coping with job stress, TamKar’s employees.
Generalized anxiety disorder (GAD) is a chronic, pervasive disorder for which we have yet to develop sufficiently efficacious interventions. In this article we propose that recent research and theory regarding this disorder supports the integration of acceptance-based treatments with existing cognitive-behavioral treatments for GAD to improve the efficacy and clinical significance of such approaches. The bases for this proposal (from both the GAD and the acceptance-based treatment literature) are reviewed, and a new treatment stemming from this conceptual integration is described.
The present article describes the basic therapeutic techniques used in the cognitive-behavioral therapy (CBT) of generalized anxiety disorders and reviews the methodological characteristics and outcomes of 13 controlled clinical trials. The studies in general display rigorous methodology, and their outcomes are quite consistent. CBT has been shown to yield clinical improvements in both anxiety and depression that are superior to no treatment and nonspecific control conditions (and at times to either cognitive therapy alone or behavioral therapy alone) at both posttherapy and follow-up. CBT is also associated with low dropout rates, maintained long-term improvements, and the largest within-group and between-group effect sizes relative to all other comparison conditions.
This chapter describes the experience of providing six mindfulness-based stress reduction (MBSR) courses for older people in routine clinical practice, and three mindfulness-based cognitive therapy (MBCT) courses as qualitative research. Work with individual clients using these approaches is also considered. MBSR and MBCT are jointly referred as mindfulness training (MT). Older people refer to those aged over 65 years, the official beginning of old age in the United Kingdom, with statutory entitlement to retirement and state pension. Older people are particularly vulnerable to only those mental health difficulties with which MT is effective. The MBCT pilot research and clinical experience with MBSR is described, which suggests that the older people can be benefited as much as younger people. This pilot study was intended to determine acceptability of MBCT to older people, the way it may need adapting, and whether results would support the need for more extensive quantitative research. It is important to acknowledge that MT is no panacea, yet it may have wide application if used flexibly and in a way that is sensitive to the particular clinical issues being targeted. MT has potential to make a great contribution to meeting significant underresourced and undertreated mental health needs for older people internationally.