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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
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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
To link to this article: http://dx.doi.org/10.1080/13607863.2015.1111862
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
ARTICLE HISTORY
Received 3 July 2015
Accepted 14 October 2015
ABSTRACT
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.
KEYWORDS
Anxiety; cognitive-behavioral
therapy; group treatment;
randomized controlled trial;
mindfulness
Introduction
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 edward.helmes@jcu.edu.au
© 2015 Taylor & Francis
AGING & MENTAL HEALTH, 2017
VOL. 21, NO. 3, 272278
http://dx.doi.org/10.1080/13607863.2015.1111862
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.
Method
Participants
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.
Measures
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).
Sample
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.
AGING & MENTAL HEALTH 273
Design
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,
MAAS, ASI and WHOQOL-OLD.
Procedure
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)
Deceased
Allocated to intervention (n = 26)
Received allocated intervention (n = 26)
Did not receive allocated intervention
Lost to follow-up (give reasons) (n = 2)
Deceased
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)
Allocation
Anal
y
sis
Follow-U
p
Randomized (n = 52)
Enrolment
Total number of residents (n = 370)
Figure 1. CONSORT ow chart of study recruitment.
274 A. HELMES AND B. G. WARD
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.
Results
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
(X
2
(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
2
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
Measure MSD MSD MSD MSD MSD MSD
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
y
p
Cohensd
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
y
df D25.
Adjusted alpha level, pD
.
006.
AGING & MENTAL HEALTH 275
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
meaningful.
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,
p
D.
004).
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.
Discussion
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
y
p
Cohensd
GAI
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
y
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
y
p
Cohensd
GAI
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
y
df D51.
Adjusted alpha level pD:004:
276 A. HELMES AND B. G. WARD
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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278 A. HELMES AND B. G. WARD
... 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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