Editor's Note: As the population ages worldwide, the number of people living with dementia, especially Alzheimer's disease, is growing. Estimated direct and indirect global costs are staggering. In “Changing the Trajectory of Alzheimer's Disease,” the Alzheimer's Association targeted efforts to prevent and slow the progression of cognitive decline. Thus far, research has found limited efficacy for drug-based treatments in this area. For this edition of the Mind–Body Roundup, Drs. Wayne, Yeh, and Mehta explore recent mind–body research that may support this mission. Each of us has an iron in this fire.—John Weeks, Editor-in-Chief, JACM
Targeting Cognition and Fall Risk in Mild Cognitive Impairment with T'ai Chi
Peter M. Wayne, PhD
Director of Research, Osher Center for Integrative Medicine
Division of Preventive Medicine
Associate Professor of Medicine
Harvard Medical School and Brigham and Women's Hospital
Dementia and fall-related traumas are two of the greatest public health concerns facing our rapidly aging baby boomer generation. Their growing prevalence, burden, and associated economic and societal costs are epidemic and staggering. Historically, these age-related health concerns were considered as separate issues and, thus, treated independently. However, sound research now supports postural control and cognition as highly interdependent issues. Balance and healthy gait are no longer considered automated motor activities, but rather activities that require multiple higher order cognitive functions, including attention, multitasking, planning, and judgment of external and internal cues. Conversely, multiple large-scale epidemiologic studies support that how we move (or do not) in our middle-to-later years also predicts our future risk of dementia. This holistic view begs the study of mind–body exercise interventions such as t'ai chi, which explicitly target and promote the integration of cognitive and motor processes, for simultaneously preserving cognition and reducing fall risk.
Using this conceptual framework, researchers in Thailand conducted a sound pilot study to examine whether t'ai chi training can both improve cognitive ability and reduce fall risk in older adults with amnestic mild cognitive impairment (a-MCI).1 Community-dwelling adults over 60 years of age who met criteria for multiple-domain a-MCI were recruited. A total of 66 eligible participants (average age 67.9) were randomly assigned to either a t'ai chi program or an education control group. The simplified t'ai chi program was initially taught during nine 50-min in-person group sessions (three sessions per week) followed by 12 weeks of home-based video-guided t'ai chi training (50 min per session, thrice per week). The control group received educational materials related to cognitive impairment and fall prevention. Both groups were called weekly, and adherence in t'ai chi group was enhanced with several strategies (e.g., family member reminders). A battery of validated cognitive outcomes evaluated by blinded assessors included: Logical Memory (LM) delayed recall (episodic memory); Block Design Test (visuospatial memory), Digit Span forward and backward, and Trail-Making Test Part B–A (TMT B–A) (executive function). Fall risk was evaluated using the Physiologic Profile Assessment (PPA), a composite measure that includes five sensorimotor components relevant to postural control.
Attendance in t'ai chi classes was high (87.5%) and loss to follow-up relatively low (11%) and equal between groups. Amount of home practice was not reported, but authors indicated that videos were regularly utilized. No study related injuries or falls were reported. At the end of the trial, episodic memory (LM) and executive function (TMT B–A) were significantly better for the t'ai chi group than the control group after adjusting for baseline test performance. The t'ai chi group also had significantly better composite PPA score and PPA parameter scores: knee extension strength, reaction time, postural sway, and lower limb proprioception.
This study adds to a growing body of research supporting t'ai chi's potential benefits to both cognition and fall risk, but uniquely addresses both outcomes in the same study. The study specifically points to certain domains of executive function, namely task switching (measured with TMT B–A), which aligns well the training in movement transitions and visuospatial processing inherent in t'ai chi. Faster reaction times observed during the PPA also support that t'ai chi benefits from postural control may result, in part, from better executive function. Collectively, these promising findings support the value of follow-up large-scale trials evaluating t'ai chi for improving cognition and reducing fall risk in adults with a-MCI. They also lay the foundation for brain imaging studies that will help inform the neural basis of t'ai chi's impact on cognitive-motor integration, and more generally, the interdependence of what we loosely call mind and body.
Citation: 1. Sungkarat S, Boripuntakul S, Chattipacorn N, et al. Effects of Tai Chi on cognition and fall risk in older adults with mild cognitive impairment: A randomized controlled trial. J Am Geriatr Soc 2017;65:721–727.
Prevention of Neurocognitive Aging in Older Adults: Can Mindfulness Make a Clinical Difference?
Gloria Yeh, MD, MPH
Director, Research Fellowship in Integrative Medicine
Director of Mind–Body Research
Division of General Medicine and Primary Care
Beth Israel Deaconess Medical Center
Harvard Medical School
Encouraging findings and theoretical considerations from indirect lines of evidence suggest that mindfulness practices might be promising for older adults to counteract the cognitive decline associated with aging. However, relatively large gaps in knowledge exist in these lines of inquiry and there is still much to understand.
One of the primary ways that mindfulness practices purportedly exert beneficial effects is through modulation of attention networks, such as monitoring and regulation of one's attentional state. Refined attentional skills have, in turn, been linked to improved emotion regulation and processes involving the executive control network. Clinically, there is a robust literature on changes in attention and emotional distress with mindfulness interventions in general populations. A much smaller body of the mindfulness literature describes potential cognitive effects (changes in attention, processing speed, memory, and cognitive control). Only a handful of these studies are in populations with neurocognitive impairments. Clear understanding is largely lacking on: the impact of mindfulness on specific cognitive and related processes; the intervention components that are important; and the actual therapeutic or preventative role of mindfulness for neurocognitive health. Importantly, there is a paucity of clinical studies that examine mindfulness interventions explicitly to enhance neurocognitive capacity in older adults or prevent age-related cognitive decline.
One recent, well-done, multisite randomized controlled trial by Wetherell et al. investigated the impact of mindfulness-based stress reduction (MBSR) in older adults with an anxiety or depressive disorder and subjective neurocognitive difficulties (without diagnosis of dementia).1 The authors suggest a theoretical model based on the presumed association between neurocognitive function and stress. Declines in cognitive function with age are accelerated by states of stress, anxiety, and depression. With dynamic neuroplasticity, this stress-induced neurobiologic process may be reversible.
In the study, 103 participants aged 65 years or older meeting the above criteria were randomized to either once-weekly group MBSR or a time and attention-matched health education control for 8 weeks. The primary outcomes were memory (composite score based on immediate and delayed paragraph and list recall) and cognitive control (composite score based on Delis–Kaplan Executive Function System Verbal Fluency Test and Color Word Interference Test). Other outcomes included clinical symptoms and peak salivary cortisol. Investigators were thoughtful and rigorous in many important details. Among these were the descriptions of the study during recruitment to minimize expectation bias, assessing condition credibility, and using an additional neuropsychiatric test to control for the Hawthorne effect.
Investigators found that at 8 weeks, those in the MBSR group compared to education improved their memory composite score (p = 0.046). However, the groups did not differ in cognitive control. There were between-group differences in clinical symptoms with improvement in MBSR and sustained effect (for worry, depression, anxiety) at 3 and 6 months post-treatment. Cortisol level decreased with MBSR, but only among those with high baseline levels.
While the study results were promising on several measures, including memory, cognitive control did not improve as expected. Investigators question the sensitivity of their measure to detect relatively short-term changes. They also note that not all subjects had documented baseline cognitive impairment despite all reporting subjective problems. This study is clinically relevant and provides valuable information although it is just a small piece of the overall puzzle. Whether mindfulness offers the coveted chance at early intervention for neurocognitive difficulties before the development of more advanced disorders is yet to be determined.
Citation: 1. Wetherell JL, Hershey T, Hickman S, et al. Mindfulness-based stress reduction for older adults with stress disorders and neurocognitive difficulties: A randomized controlled trial. J Clin Psychiatry 2017;78:e734–e743.
A New Lumosity—Bringing A Wisdom Tradition to a Modern Problem
Darshan H. Mehta, MD, MPH
Medical Director, Benson-Henry Institute for Mind Body Medicine
Massachusetts General Hospital
Associate Director of Education
Osher Center for Integrative Medicine
Harvard Medical School and Brigham and Women's Hospital
Mild cognitive impairment (MCI) is a clinical syndrome that is characterized by deficits in both memory and nonmemory cognitive domains. Analysis of published studies has found that 15%–20% of adults over the age of 60 suffer from some form of mild cognitive decline. On average, anywhere between 5% and 10% of these individuals progress to dementia annually. With an ever-increasing aging population, alongside a dearth of pharmacologic options, there is an imperative to find treatment options that are based in the community. As such, mind–body therapies have become of interest, due to its ease of availability, as well as the possibility of large-scale dissemination, especially in nonclinical settings.
In this study by Eyre et al., participants with MCI were randomized to either a 12-week Kundalini Yoga (KY) intervention or memory enhancement training (MET).1 In brief, KY is a tradition that is composed of various Hatha yoga techniques. It was popularized in the United States by Yogi Bhajan and his followers, in which these yoga techniques were joined with mantras in the Sikh tradition. In this study, the intervention was composed of a weekly 60-min class. The class had an amalgamation of various yoga practices; the core practice from the KY tradition they focused is known as Kirtan Kriya (KK). KK involves repetitive chanting of specific mantras, coordinated with simple hand movements (known as mudras). Participants in the intervention were told to have a daily 12-min KK practice and were given CD recordings and handouts to follow.
The study also had an active control arm, consisting of MET. MET is a manualized approach, developed at the study institution (UCLA). Participants met weekly with a trained facilitator and were also given 20-min daily homework. Outcomes were reported at baseline, 12 weeks, and 24 weeks. The primary outcomes were memory (verbal and visual), as well as executive function. Secondary outcomes included measurements of depression, apathy, and resilience. A total of 79 subjects were randomized to KY or MET.
While there were no significant differences between KY and MET, there were significant pre–post effects within each group in several different measures of memory at 24 weeks, including the Wechsler Memory Scale (WMS-IV) and the Rey–Osterrieth (Rey-O) test 3- (immediate) and 30-min (delayed) recall, which measure visual spatial skills and visual memory (p < 0.05). In addition, there were significant (p < 0.05) within-group differences at 24 weeks in measures of executive function (Trail Making Test part B), which measures cognitive flexibility. No significant differences were seen in secondary outcomes between the groups; however, there were sustained within-group differences for depression in the KY group, whereas there were sustained differences for apathy in the MET group. It is slightly difficult to understand these changes in the absence of a nonintervention control group.
MET is the basis of many popular self-help books, as well as online and interactive programming. What is fascinating about this study is that the key ingredient within the KY intervention was the KK or simple chanting in coordination with simple hand movements. In addition, there was a measured improvement in depression, as measured by the Geriatric Depression Scale. What is not clear is whether participants continued their practice (in either arm) after they stopped attending the group.
This study is the first study to compare a yoga intervention with an active control in the treatment and management of MCI. Given that such a simple and short intervention can be used for MCI, the study begs the question of what training is needed by the instructor to effectively have a treatment effect. Furthermore, is there something specific to KK or do we expect to see similar findings with any type of chanting combined with hand movements or do we expect to see similar findings with any group support and expectation of benefit?
This study paves the way as pilot data for a longer study to examine whether such an intervention will result in a clinically meaningful change in the progression of MCI to dementia. The optimal trial should randomize individuals to KY/KK, MET, or group support (controlled for time and size of group). That way, we will be able to discern between group effects, time effects, expectation effects, and intervention effects. Finally, as the progression of MCI to dementia is often over many years, future trials will need to have provisions for long-term follow-up.
Citation: 1. Eyre HA, Siddarth P, Acevedo B, et al. A randomized controlled trial of Kundalini yoga in mild cognitive impairment. Int Psychogeriatr 2017;29:557–567.