Abstract
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.
Keywords: caregivers, cognitive impairment, cognitive therapy, depression, meditation, memory, mindfulness, mindfulness‐based cognitive therapy, quality of life
1. INTRODUCTION
Besides early cognitive decline, increases in depression symptoms 1 , 2 and apathy 3 , 4 are often reported by individuals with mild cognitive impairment, Alzheimer's disease (AD), and other dementias. Heightened levels of depression are related to decreased cognitive function, changes in activities of daily living, 2 and lower quality of life. 5 Caregivers can also experience high levels of depression, emotional stress, and burden, 6 and often feel challenged to cope with their own distress. 7
Mindfulness‐based cognitive therapy (MBCT) has the potential to improve quality of life for individuals with memory difficulties and their caregivers. MBCT integrates aspects of cognitive behavioral therapy (CBT) with training in mindfulness meditation. 8 Through meditation, participants learn to pay greater attention, boost concentration, increase awareness of dysphoric thinking, and learn how to de‐center from problematic thoughts to apply more skillful means of coping. MBCT helps individuals regulate their emotions, and supports self‐focus, acceptance, and kindness. 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. 12 Among caregivers, MBCT interventions were associated with a decrease in self‐rated stress compared to a respite‐only control group. 13
Despite its potential, there is little research examining the effects of MBCT on older adults with cognitive impairment and their caregivers. However, to justify the resources and time required to conduct such a study, smaller feasibility studies are necessary. Accordingly, we aimed to: (1) examine recruitment and retention issues in mindfulness‐based research involving participants with cognitive impairment; (2) determine preliminary effect sizes after MBCT on depression, apathy, quality of life, mindfulness, and self‐compassion in individuals with cognitive impairment, and their caregivers; and (3) examine associations between changes in mindfulness and self‐compassion, burden, coping, and depression symptoms.
RESEARCH‐IN‐CONTEXT
Systematic review: Mindfulness‐based cognitive therapy demonstrates potential to improve depressive symptoms, quality of life, anxiety, and stress in certain populations. Yet, the utility of the intervention for older adults with cognitive decline or their caregivers is largely unexplored.
Interpretation: Results showed that while outcomes related to depression, stress, and anxiety did not change pre–post, increases in certain facets of mindfulness were associated with decreases in depression symptoms. These effects were more evident for caregivers than those with cognitive decline. A low completion rate suggests barriers to participation.
Future directions: Further research is necessary to explore how mindfulness is associated with improvements for older adults with cognitive decline and their caregivers. Future work must address the barriers that impede recruitment and retention in these populations.
2. METHOD
2.1. Participants
Participants were recruited from the community, through referral from a local geriatrician, physicians, the local Alzheimer's Society, posters in general practitioners’ offices, word of mouth, and media sources. Evidence of depression symptoms with either a minimum score of 10 on the Geriatric Depression Scale (GDS) and/or a score of 10 on the depression subscale from the Depression, Anxiety and Stress Scale (DASS) was required for participation (the only exception was when we recruited dyads, where at least one person was required to have depression symptoms). The difficulties with memory group (DG) consisted of individuals who scored between 19 and 25 on the Montreal Cognitive Assessment (MoCA). The caregiver group (CG) comprised caregiver participants who were either spouses of DM group participants (i.e., a dyad) or participated on their own. Participants were excluded if there was evidence of unusual psychological processes and neurological disorders as assessed by the Symptom Checklist‐90 Revised (SCL‐90‐R) and a demographic/health questionnaire. Other eligibility criteria included fluency in English, and normal or corrected‐to‐normal vision. The local university and hospital research ethics boards approved the study as research involving human participants; informed consent was obtained from each participant.
2.2. Measures
In addition to data mentioned above, we collected data specific to mindfulness, quality of life, and burden (for caregivers). We used the Five Facet Mindfulness Questionnaire (FFMQ), the Quality of Life in Alzheimer's Disease measure (QoL‐AD), the Self‐Compassion Scale (SCS), and the Apathy Evaluation Scale (AES). The CG completed informant versions of the latter two measures, the FFMQ, and two additional measures assessing burden and coping: the Zarit Burden Interview (ZBI)–short version, and the Brief Coping Orientation to Problems Experienced (Brief‐COPE) Inventory. All measures are cited in Appendix A.
2.3. Intervention
The MBCT intervention consisted of eight weekly 2‐hour sessions. Participants engaged in concurrent DG or CG sessions involving formal and informal mindfulness meditation, group discussion, and inquiry. Development of a daily meditation practice was assigned as homework (using a guided meditation CD), and participants were asked to self‐report their daily meditation time and observations (changes, difficulties, etc.) DG sessions were modified to accommodate memory difficulties by adjusting the speed, intensity, and methods of teaching. Control participants were placed on a wait list to receive the MBCT intervention.
2.4. Procedure
After screening, eligible participants were randomized (stratified by sex, age, and depression scores) to the control or intervention arm and completed additional baseline measures. After completion of the 8‐week intervention period, participants were re‐assessed. Control participants had the opportunity to receive the intervention, followed by an additional post‐intervention assessment.
2.5. Data analyses
We present separate analyses for individuals experiencing memory difficulties and caregivers (SPSS 24.0; IBM, 2016). Because the intervention and control group sizes were too small to conduct meaningful parallel analyses we combined all participants who completed the MBCT intervention (treatment arm and crossover controls) and conducted pre–post analyses using paired t‐tests. Change in mindfulness outcomes were correlated with changes in depression symptoms using Pearson's r.
3. RESULTS
Thirty‐six individuals volunteered. Twelve individuals did not start the trial (33% loss): seven individuals did not meet the MoCA eligibility criterion and five others declined to participate after enrolment, but before intervention initiation. The resulting 24 participants were randomized to the control and intervention arms of which 21 (11 interventions and 10 controls) completed the parallel phase of the trial (88% completion rate). Among the 5 DG and 5 CG control participants, respectively 4 (80% completion rate) and 2 (40% completion rate) completed the intervention after the cross‐over.
The pre–post analyses revealed one statistically significant change (quality of life scores improved in DG participants; see Table 1). There was a statistically significant negative correlation between non‐judgmental scores (measured by the FFMQ) and depression symptom scores (measured by the GDS) in both the DG (r = –0.90, 95% confidence interval [CI]: –0.98, –0.52) and the CG (r = –0.76, 95% CI: –0.95, –0.19), indicating that participants whose attitude became less judgmental had a reduction in depression symptoms (Table 2). Similarly, greater reductions in depression symptoms were observed among the CG participants who had greater improvements in acting with awareness scores (r = –0.69, 95% CI: –0.93, –0.05) and greater reductions in burden scores (r = 0.87, 95% CI: 0.49, 0.97).
TABLE 1.
Depression, anxiety, stress, apathy, QoL, mindfulness and self‐compassion, burden and coping outcomes pre‐ and post‐ MBCT intervention in difficulty with memory and caregiver group participants
| Measure | Group | Pre mean score (SD) | Post mean score (SD) | t‐test mean difference | Paired t score (p‐value) | Effect size c |
|---|---|---|---|---|---|---|
| Depression (GDS) a | DG | 12.86 (8.73) | 10.88 (8.32) | −1.99 | −2.36 (0.050) | −0.23 |
| CG | 14.83 (8.50) | 12.56 (8.63) | −2.27 | −1.52 (0.168) | −0.27 | |
| Depression (DASS) a | DG | 6.13 (4.22) | 6.63 (4.41) | 0.50 | 0.41 (0.695) | 0.12 |
| CG | 7.89 (7.29) | 6.11 (4.68) | −1.78 | −1.39 (0.202) | −0.22 | |
| Anxiety (DASS) a | DG | 5.00 (3.78) | 5.25 (4.77) | 0.25 | 0.15 (0.888) | 0.06 |
| CG | 3.78 (3.63) | 3.56 (2.79) | −0.22 | −0.30 (0.772) | −0.06 | |
| Stress (DASS) a | DG | 6.38 (4.21) | 6.38 (4.10) | 0.00 | 0.00 (1.00) | 0.00 |
| CG | 6.44 (4.59) | 6.22 (4.27) | −0.22 | −0.24 (0.813) | −0.05 | |
| Apathy (AES) b | DG | 32.13 (6.45) | 33.00 (7.54) | 0.88 | 0.53 (0.610) | 0.12 |
| CG | 50.34 (13.59) | 51.56 (14.69) | 1.22 | 0.94 (0.377) | 0.08 | |
| Awareness (FFMQ) b | DG | 17.50 (3.07) | 17.25 (2.49) | −0.25 | −0.26 (0.802) | −0.09 |
| CG | 17.11 (3.89) | 14.44 (4.39) | −2.67 | −1.97 (0.084) | −0.64 | |
| Describing (FFMQ) b | DG | 16.38 (2.62) | 17.25 (3.81) | 0.88 | 0.68 (0.519) | 0.26 |
| CG | 17.56 (4.22) | 15.33 (4.03) | −2.22 | −1.71 (0.126) | −0.54 | |
| Non‐judging (FFMQ) b | DG | 15.63 (3.70) | 16.13 (3.98) | 0.50 | 0.27 (0.792) | 0.13 |
| CG | 13.33 (6.00) | 14.22 (5.09) | 0.89 | 0.45 (0.665) | 0.16 | |
| Non‐reactivity (FFMQ) b | DG | 15.25 (3.65) | 15.88 (2.59) | 0.63 | 0.38 (0.716) | 0.20 |
| CG | 14.56 (4.33) | 14.78 (3.38) | 0.22 | 0.13 (0.899) | 0.06 | |
| Observing (FFMQ) b | DG | 14.71 (3.64) | 14.00 (3.74) | −0.71 | −0.80 (0.454) | −0.19 |
| CG | 15.22 (3.53) | 14.22 (4.02) | −1.00 | −1.46 (0.184) | −0.26 | |
| Quality of life (QoL‐AD) b | DG | 2.46 (0.32) | 2.63 (0.38) | 0.17 | 2.53 (0.039) | 0.46 |
| CG | 2.04 (0.46) | 2.05 (0.49) | 0.02 | 0.29 (0.782) | 0.03 | |
| Self‐compassion (SCS) b | DG | 3.25 (0.39) | 3.39 (0.24) | 0.14 | 1.17 (0.280) | 0.40 |
| CG | 3.12 (0.78) | 3.00 (1.01) | −0.12 | −0.69 (0.509) | −0.12 | |
| Burden (ZBI) a | CG | 21.00 (14.34) | 17.33 (11.86) | −3.66 | −1.00 (0.345) | −0.27 |
| Coping (COPE) a | CG | 56.67 (9.71) | 58.56 (6.84) | 1.89 | 0.80 (0.445) | 0.21 |
Abbreviations: AES, Apathy Evaluation Scale; CG, caregiver group; COPE, Coping Orientation to Problems Experienced; DASS, Depression, Anxiety and Stress Scale; DG, difficulty with memory group; FFMQ, Five Facet Mindfulness Questionnaire; GDS, Geriatric Depression Scale; MBCT, mindfulness‐based cognitive therapy; QoL‐AD, Quality of Life in Alzheimer's Disease; SCS, Self‐Compassion Scale; SD, standard deviation; ZBI, Zarit Burden Interview.
Negative change scores are considered positive.
Positive change scores are considered positive.
Calculated using Dunlap Tc. 14
TABLE 2.
Correlations between the pre‐ and post‐intervention change scores and depression symptoms in difficulty with memory and caregiver participants
| Depression symptoms (GDS) | ||
|---|---|---|
| Measures | DG r (95% CI) | CG r (95% CI) |
| Depression (DASS) | 0.55 (−0.26, 0.90) | 0.23 (−0.52, 0.77) |
| Anxiety (DASS) | 0.50 (−0.32, 0.89) | 0.26 (−0.49, 0.79) |
| Stress (DASS) | 0.46 (−0.36, 0.88) | 0.62 (−0.07, 0.91) |
| Quality of Life (QoL‐AD) | 0.14 (−0.63, 0.77) | 0.60 (−0.11, 0.90) |
| Non‐Reactivity (FFMQ) | −0.06 (−0.73, 0.67) | 0.13 (−0.58, 0.73) |
| Observing (FFMQ) | 0.59 (−0.30, 0.93) | 0.26 (−0.49, 0.79) |
| Awareness (FFMQ) | −0.54 (−0.90, 0.27) | −0.69 (−0.93, −0.05) |
| Describing (FFMQ) | 0.67 (−0.06, 0.93) | 0.15 (−0.57, 0.74) |
| Non‐Judging (FFMQ) | −0.90 (−0.98, −0.52) | −0.76 (−0.95, −0.19) |
| Self‐Compassion (SCS) | −0.48 (−0.88, 0.34) | −0.64 (−0.92, 0.04) |
| Burden (ZBI) | – | 0.87 (0.49, 0.97) |
Abbreviations: CG, caregiver group; CI, confidence interval; DASS, Depression, Anxiety and Stress Scale; DG, difficulty with memory group; FFMQ, Five Facet Mindfulness Questionnaire; GDS, Geriatric Depression Scale; QoL‐AD, Quality of Life in Alzheimer's Disease; SCS, Self‐Compassion Scale; ZBI, Zarit Burden Interview.
4. DISCUSSION
We sought to examine recruitment/retention issues and determine preliminary effect sizes after MBCT on several mental health and mindfulness outcomes, as well as associations between changes in mindfulness and changes in depression.
We experienced challenges in recruiting and retaining participants—only 17 of the 36 initial participants completed the study. Recruitment and retention issues with cognitively impaired populations are known. 15 , 16 , 17 Negative stigma around memory or other cognitive problems, and/or a caregiver's need for assistance may influence recruitment success in older adult populations, 17 particularly in minority, ethnic groups. 16 Moreover, caregivers may serve as the proxy, substitute decision‐maker for individuals with dementia. 15 While our sample population consisted of individuals who could consent to participating, it is possible that caregivers had some influence on DG group participation.
Recruitment and retention in our study may have been improved by addressing caregiver‐specific barriers including time limitations, routine disruptions, and cost‐benefit perceptions. It may also be desirable to address the unique challenges associated with differing severity of cognitive difficulties and/or other forms of impairment across individuals to support full involvement with the intervention. Hence, research on the specific accommodations required to facilitate participation, including cultural considerations, is desirable. Furthermore, work to investigate the value of the intervention at various stages of the condition, including with caregivers whose loved ones could not benefit from mindfulness interventions because of severe cognitive challenges, appears warranted.
Regarding the intervention results for the DG, MBCT did not result in statistically significant changes. The largest effect sizes identified were for quality of life, self‐compassion, and to some extent depression. For the CG, only quality of life improved post‐intervention. Effect sizes for awareness and describing were in the moderate range, but in the opposite direction from our expectations. MBCT may have, in some individuals, a negative impact. 18 This finding could be explained by challenging life events during the study, or simply an artifact of the small study sample size.
Overall, other researchers have reported similar results to ours. In persons with mild dementia and depression, both Payne 19 and Noone 20 found no improvements in quality of life after MBCT, nor reductions in depression symptoms. Oken et al. 13 found no improvements in mindfulness, coping, and depression for caregivers of people with dementia compared to controls who participated in a separate education program, but did compared to a respite‐only control group. 13
We found that becoming less judgmental correlated with reductions in depression symptoms in both groups. Among caregivers, our results indicated that acting with greater awareness and reductions in burden were associated with lower levels of depression. This reflects MBCT's aim to improve self‐awareness of, and disengagement from, negative judgmental thinking about one's own depression symptoms. 21
Our study was limited by small sample sizes, yielding imprecise estimates and possible spurious findings. Our effect sizes were low, except for a few variables, and a larger sample size might not make a meaningful difference. Nonetheless, focusing interventions on those aspects of MBCT that were most highly correlated with reductions in depression symptoms might be an avenue worth pursuing. Such direction must consider the barriers to participation that these populations experience to improve recruitment and retention.
CONFLICTS OF INTEREST
The authors report no conflicts of interest.
ACKNOWLEDGMENTS
This research was funded by The Alzheimer Society of Canada and by the Canadian Frailty Network (Technology Evaluation in the Elderly Network), which is supported by the Government of Canada through the Networks of Centres of Excellence (NCE) program.
APPENDIX A.
A.1.
Apathy Evaluation Scale (AES): Marin RS, Biedrzycki RC, Firinciogullari S. Reliability and validity of the Apathy Evaluation Scale. Psychiatry Res. 1991;38(2):143‐162.
Brief COPE Inventory: Cooper C, Katona C, Orrell M, Livingston G. Coping strategies, anxiety and depression in caregivers of people with Alzheimer's disease. IntJGeriatrPsychiatry. 2008;23(0885‐6230; 9):929‐936.
Depression, Anxiety and Stress Scale (DASS): Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. In: Vol Sydney.; 1995.
Five Facet Mindfulness Questionnaire (FFMQ): Bohlmeijer E, ten Klooster PM, Fledderus M, Veehof M, Baer R. Psychometric properties of the Five Facet Mindfulness Questionnaire in depressed adults and development of a short form. Assessment. 2011;18(3):308‐320. https://doi.org/10.1177/1073191111408231;
Geriatric Depression Scale (GDS): Yesavage JA, Brink TL, Rose TL, Lum O. Development and validation of a geriatric depression screening scale: A preliminary report. JPsychiatrRes. 1983;17(Journal Article):37‐49.
Montreal Cognitive Assessment (MoCA): Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. JAmGeriatrSoc. 2005;53(0002‐8614; 4):695‐699.
Quality of Life in Alzheimer's Disease measure (QoL‐AD): Logsdon RG, Gibbons LE, McCurry SM, Teri L. Assessing quality of life in older adults with cognitive impairment. Psychosom Med. 2002;64(3):510‐519.
Self‐Compassion Scale (SCS): Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the Self‐Compassion Scale. ClinPsycholPsychother. 2011;18(3):250‐255. https://doi.org/10.1002/cpp.702;
Symptom Checklist‐90 Revised (SCL‐90‐R): Derogatis LR. SCL‐90‐R Administration, Scoring, and Procedures Manual. Vol Third Edition. Minneapolis: National Computer Systems; 1994.
Zarit Burden Interview (ZBI) ‐ short version: Bédard M, Molloy DW, Squire L, Dubois S, Lever JA, O'Donnell M. The Zarit Burden Interview: A new short version and screening version. Gerontologist. 2001;41(Journal Article):652‐657. https://doi.org/10.1093/geront/41.5.652
Ozen LJ, Dubois S, English MM, et al. The efficacy of mindfulness‐based cognitive therapy to improve depression symptoms and quality of life in individuals with memory difficulties and caregivers: A short report. Alzheimer's Dement. 2022;8:e12252. 10.1002/trc2.12252
REFERENCES
- 1. Gallagher D, Kiss A, Lanctot KL, Herrmann N. Toward prevention of mild cognitive impairment in older adults with depression: an observational study of potentially modifiable risk factors. J Clin Psychiatry. 2018;80:18m12331. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Espiritu DA, Rashid H, Mast BT, Fitzgerald J, Steinberg J, Lichtenberg PA. Depression, cognitive impairment and function in Alzheimer's disease. Int J Geriatr Psychiatry. 2001;16:1098‐1103. [DOI] [PubMed] [Google Scholar]
- 3. Robert PH, Verhey FRJ, Byrne EJ, et al. Grouping for behavioral and psychological symptoms in dementia: clinical and biological aspects. Consensus paper of the European Alzheimer disease consortium. Eur Psychiatry. 2005;20:490‐496. 10.1016/j.eurpsy.2004.09.031. [DOI] [PubMed] [Google Scholar]
- 4. Ginsberg TB, Powell L, Emrani S, et al. Instrumental activities of daily living, neuropsychiatric symptoms, and neuropsychological impairment in mild cognitive impairment. J Am Osteopath Assoc. 2019;119:96‐101. 10.7556/jaoa.2019.015. [DOI] [PubMed] [Google Scholar]
- 5. Naglie G, Hogan DB, Krahn M, et al. Predictors of patient self‐ratings of quality of life in Alzheimer disease: cross‐sectional results from the Canadian Alzheimer's disease quality of life study. Am J Geriatr Psychiatry. 2011;19:881‐890. 10.1097/JGP.0b013e3182006a67. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Gallagher D, Ni Mhaolain A, Crosby L, et al. Self‐efficacy for managing dementia may protect against burden and depression in Alzheimer's caregivers. Aging Ment Health. 2011;15:663‐670. 10.1080/13607863.2011.562179. [DOI] [PubMed] [Google Scholar]
- 7. Schulz R, Martire LM. Family caregiving of persons with dementia: prevalence, health effects, and support strategies. Am J Geriatr Psychiatry. 2004;12:240‐249. [PubMed] [Google Scholar]
- 8. Segal ZV, Williams JMG, Teasdale JD. Mindfulness‐Based Cognitive Therapy for Depression. Guilford Press; 2013. [Google Scholar]
- 9. Smith A. Clinical uses of mindfulness training for older people. Behav Cogn Psychother. 2004;32:423‐430. 10.1017/S1352465804001602. [DOI] [Google Scholar]
- 10. Churcher Clarke A, Chan JMY, Stott J, Royan L, Spector A. An adapted mindfulness intervention for people with dementia in care homes: feasibility pilot study: mindfulness for people with dementia in care homes. Int J Geriatr Psychiatry. 2017;32:e123‐e131. 10.1002/gps.4669. [DOI] [PubMed] [Google Scholar]
- 11. Helmes E, Ward BG. Mindfulness‐based cognitive therapy for anxiety symptoms in older adults in residential care. Aging Ment Health. 2017;21:272‐278. 10.1080/13607863.2015.1111862. [DOI] [PubMed] [Google Scholar]
- 12. Foulk MA, Ingersoll‐Dayton B, Kavanagh J, Robinson E, Kales HC. Mindfulness‐based cognitive therapy with older adults: an exploratory study. J Gerontol Soc Work. 2014;57:498‐520. 10.1080/01634372.2013.869787. [DOI] [PubMed] [Google Scholar]
- 13. Oken BS, Fonareva I, Haas M, et al. Pilot controlled trial of mindfulness meditation and education for dementia caregivers. J Altern Complement Med. 2010;16:1031‐1038. 10.1089/acm.2009.0733. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14. Dunlap WP, Cortina JM, Vaslow JB, Burke MJ. Meta‐analysis of experiments with matched groups or repeated measures designs. Psychol Methods. 1996;1(2):170‐177. 10.1037/1082-989X.1.2.170. [DOI] [Google Scholar]
- 15. Murphy MR, Escamilla MI, Blackwell PH, et al. Assessment of caregivers’ willingness to participate in an intervention research study. Res Nurs Health. 2007;30:347‐355. 10.1002/nur.20186. [DOI] [PubMed] [Google Scholar]
- 16. Rabinowitz YG, Gallagher‐Thompson D. Recruitment and retention of ethnic minority elders into clinical research. Alzheimer Dis Assoc Disord. 2010;24(Suppl):S35‐S41. [PubMed] [Google Scholar]
- 17. Schneider LS. Recruitment methods for United States Alzheimer disease prevention trials. J Nutr Health Aging. 2012;16:331‐335. [DOI] [PubMed] [Google Scholar]
- 18. Van Dam NT, van Vugt MK, Vago DR, et al. Mind the hype: a critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspect Psychol Sci. 2018;13:36‐61. 10.1177/1745691617709589. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Payne J. Mindfulness Based Cognitive Therapy for People with Mild Dementia and Depression: A Feasibility Pilot Randomised Controlled Trial examining changes in Quality of Life and Cognition. Doctoral Dissertation. University College London; 2017. [Google Scholar]
- 20. Noone D. The Impact of a Mindfulness Based Cognitive Therapy (MBCT) for Depression in People with Dementia Attending Memory Clinics: A Feasibility Randomized Controlled Trial. Doctoral Dissertation. University College London; 2017. [Google Scholar]
- 21. Segal ZV, Teasdale JD, Williams JM, Gemar MC. The mindfulness‐based cognitive therapy adherence scale: inter‐rater reliability, adherence to protocol and treatment distinctiveness. Clin Psychol Psychother. 2002;9:131‐138. [Google Scholar]