Clinical Handbook of Mindfulness (118 page)

reducing tension and anxiety in elders. In 1996, Moye and Hanlon reported

that introducing nursing home residents to relaxation training enhanced

morale and decreased pain. Results for residents with cognitive impairment

suggested the most helpful interventions were focused, frequent, and sim-

ple in structure. A six-month, weekly yoga class for healthy elders 65–85

demonstrated improvement in quality-of-life measures of well-being, energy

and fatigue as well as balance and flexibility compared to exercise and wait-

list control groups
(Oken et al., 2006).
Similar to mindfulness training, the experimental yoga groups included not only yoga poses or asanas, but also

meditation and encouragement of practice outside the class.

In 1996, I co-led a group based on the principles of MBSR and adapted for

residents on a dementia unit of a nursing home. Following the program, staff

perceived a reduction in agitation and behavioral problems (Lantz, Buchal-

ter, & McBee,
1997).
Shalek and Doyle (1997)
found that distressed and agitated residents on a dementia unit appeared “peaceful and smiling” after

their relaxation group. In research published in 2004, I described modified

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Lucia Mc Bee

MBSR groups offered to nursing home residents with cognitive and physical

frailties. Following each of 10 groups, residents reported feeling less sad and

a trend toward feeling less pain as compared to a recreational activity pro-

gram
(McBee, Westreich, & Likourezos,
2004). In qualitative interviews, 41%

of the participants reported increased sense of relaxation and mentioned

benefits from the “sense of community.”

Smith
(2004, 2006)
has offered MBSR classes slightly modified in length to community dwelling elders with mild cognitive and physical impairments.

Anecdotal findings of six groups were mixed – some participants (and their

health care workers) reported benefits while others reported no benefits.

Further research may discern the commonalities among those who report

benefits, as well as those who do not. Smith also studied three mindfulness-

based cognitive therapy groups for adults over age 65 with at least three

episodes of unipolar depression but without significant cognitive impair-

ment. Yoga stretches were modified. One year after this class, 62% of the

participants reported global as well as specific improvements that were

“Extremely useful.”
Lynch, Morese, Mendelson, and Robins (2003)
found that a group of 34 depressed elders (60 and over) treated with dialectical behavior

therapy (DBT; the core practice in DBT is mindfulness) experienced a statis-

tically significant remission of depression as compared to a group treated

with medication only. In 2005, Lindberg published a review of research con-

ducted in the previous 25 years about elders, meditation and spirituality.

She found reported evidence of physical and emotional benefits, and also

that elders, even those in the nursing home, could be taught meditative

practices.

Mindfulness training targeting caregivers can also benefit care receivers

(Singh, Lancioni, Winton,
Wahler, Singh, & Sage 2004).
Informal caregivers of frail elders in Spain were offered a stress-management program that

included cognitive restructuring, diaphragmatic breathing and the home-

work of increasing pleasant events
(Lopez, Crespo, & Zarit, 2007).
Stress management was offered as a traditional group and in a minimal therapist

contact (MTC) format. The MTC format provides skill training and support

via phone contact, brief meetings, manuals and audiovisual material. A con-

trol group was wait-listed. The traditional group experienced higher reduc-

tions in anxiety and depression than both the MTC and wait-listed control

groups.

To date, no empirical studies have been published that demonstrate the

effectiveness of mindfulness training for informal or formal caregivers of

frail elders.
Waelde, Thompson, and Gallagher-Thompson (2004)
described

a six-session yoga and (mantra focused) meditation intervention offered to

12 dementia caregivers. Participants were significantly less depressed and

anxious following the series.

In 2005, I led an eight-week MBSR class for informal caregivers of nurs-

ing home residents and found a moderate effect size for reduction in stress

and burden after the intervention and again four weeks following the end

of the group
(Epstein-Lubow, McBee, & Miller, 2007).
Several published studies report positive outcomes post mindfulness training for formal and

informal caregivers of multiple populations with chronic and end-of-life

conditions
(Bruce & Davies, 2005;
Minor, Carlson, Mackenzie, Zernicke,

2006;
Schenstr¨

om, R¨

onnberg, & Bodlund, 2006).

Chapter 23 Mindfulness-Based Elder Care

435

Mindfulness-Based Elder Care in the Nursing Home

Elders in the nursing home cope with trauma, loss, disability, pain, and life-

threatening illness. While traditional MBSR programs might prove unfeasible

for those with these physical and cognitive limitations, adaptations to the

model can offer it in an acceptable format. I have found older adults and

their caregivers generally to be receptive to mindfulness groups and inter-

ventions, and many report benefits. Key to adapting mindfulness teaching

for those with cognitive and physical disabilities was my own mindfulness

practice. I also found it helpful to be flexible and creative in communicating

mindfulness both verbally and non-verbally (McBee, 2008).

Nursing Home Resident Groups

MBEC groups in the nursing home are quite feasible when knowledge

about working with elders is integrated into the teaching practices. Adap-

tations consider the possibility of poor hearing or eyesight, physical limita-

tions, longer processing times, and cognitive impairments. Shorter sessions

(approximately one hour) and ongoing, rather than time-limited, groups

prove to be more effective. I adopt the gentle yoga exercises for participants

in wheelchairs, and with significant disabilities. I am more directive and less

open-ended in groups with frail elders. The skills I teach include: diaphrag-

matic breathing, meditation, gentle yoga, and informal mindfulness practice.

I also use guided imagery.

Environmental challenges of running groups in an institution should also

be considered. My groups are taught in busy dining areas or the nursing home

units. I use aromatherapy and gentle music, at times, to create a calming

milieu. Group discussion and mutual support are an important component

for this population. Finding poor compliance with homework assignments,

I nevertheless encourage participants to use the techniques of deep breath-

ing and mindfulness outside of the group. The underlying focus on ability,

not disability proved to be quite appropriate and successful. Nursing home

residents often struggle with dependency issues; MBEC practices remind par-

ticipants of what is still under their control.

Mindfulness on a Dementia Unit

Elders with dementia often manifest physical and verbal agitation, and behav-

ior problems. Current thinking attributes these behaviors to an attempt to

communicate. While traditional communication skills may be diminished by

dementia, feelings remain. MBEC for those with dementia provides solace

and skills in a supportive environment. Classes I offer on a dementia unit

follow a simple, repeated structure, but have the flexibility to allow for

unpredictable events. I often begin with breath awareness, followed by deep,

belly breathing. Aromatherapy and music help create a sacred space in the

midst of a noisy hospital dining room where confused residents often wan-

der in and out. I explain simple chair stretches verbally as well as phys-

ically demonstrate, and assist hands-on when needed. I usually end the

group with a guided meditation- either the body scan or imagery – using

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Lucia Mc Bee

simple, concrete language. I focus on non-verbally communicating mindful-

ness practices using body language, voice tone and pacing, and facial expres-

sion to convey acceptance and presence. When I am centered and calm,

even residents who cannot follow instructions or respond cognitively to the

class practices usually respond positively.

Isolated Elders

Elders are often isolated in the nursing home or the community, adding to

their distress. In the nursing home, some elders are in their rooms for medical

conditions, or are unable to participate in groups due to communication or

cognitive problems. In those cases, I offer individualized meditation, mindful-

ness, and instruction in gentle stretches. Yoga stretches may be adapted for

those in wheelchairs or bedbound. Participants who are physically disabled

are especially receptive to adapted poses. These poses offer a powerful mes-

sage that, as stated by
Kabat-Zinn (1990),
there is more right with us than wrong with us.

Persons at the end of life also are often isolated. Concerned caregivers may

feel helpless at times. MBEC creates a supportive environment in which the

patient and the caregiver can fully experience sadness and yet appreciate

each available moment. I have found that aromatherapy and hand massage

can be a mindful experience that benefits both the care receiver and the

caregiver. Breath work can also allow for communication. By observing the

breath’s rhythm, it is possible to connect to patients who are no longer com-

municative otherwise. A connection may be established by synchronizing

one’s breath to the patient’s, and breathing in harmony
(Mindell, 1989).

Homebound Elders

The Telephone Mindfulness Group

Many elders are confined to their homes. While for some, it is preferable

to nursing home placement, it can be isolating. I offered a series of five,

50-minute stress-reduction classes to eight homebound participants over a

conferenced telephone call. The class received pre-mailed handouts and cas-

sette tapes for homework practice, visually demonstrating and supporting

the classwork. I verbally gave instructions on the mindfulness skills, and

group members shared questions and feedback. Following the group, class

members reported continued use of the skills, especially the deep breathing.

One participant, Ms. C, states that during the past 6 years, the mindfulness

“guidance and your wonderful tape kept me alive and helped me to become

the real person I am today. Without your help I never would have reached

my 90th birthday, and had the courage to go to Florida after my dear son

passed.”

Use of CDs and Tapes

In a long-term, home health care program, CDs and tapes of meditation, a

body scan exercise, and other mindfulness practices help homebound elders

and their caregivers. Social work or nursing staff provide initial guidance

on tape and CD use. Following this introduction, the homebound elder and

Chapter 23 Mindfulness-Based Elder Care

437

the caregiver can follow instructions on the CD or tape. Both benefit by

the shared experience of listening to the CDs together and practicing the

mindfulness exercises.

Formal and Informal Caregivers

Staff Caregivers

Stress-reduction classes and mindfulness training for caregivers can benefit

both the caregiver and the elder. A one-hour class for interdisciplinary staff

can provide a basic introduction to stress and stress management. I include

an introduction to stress and to the mind–body connection; simple deep

breathing; a brief experience of mindfulness with chair and standing yoga;

and a guided meditation. I find it is helpful to offer practical tips on coping

with the real job stress that staff experience daily, and to provide a resource

list for those who wish to pursue further options.

A more substantial commitment is required for a traditional MBSR class,

although it, too, can be slightly altered to enable increased participation. I

offered a seven-week, one-hour, traditional MBSR class to approximately 100

staff members. Staff were encouraged to participate in all sessions and asked

to do practice homework. Following the group, staff retention on the units

that participated in the class was 100%, and nursing staff satisfaction showed

improvement.

I have also adapted mindfulness and stress reduction for the nursing units.

I have found that the most successful programs offered “mini-breaks” at the

times we knew staff were more available. These mini-breaks take place in

the dining area and last around 15 minutes. Smaller numbers of staff sit in,

and some come and go, as they are able to make time. While the practices

of meditation and yoga were foreign to many, there was a broad acceptance

and enthusiasm for them in all of the above formats. Direct care workers

often reported practicing the skills outside of groups and even sharing them