Mindfulness and Rumination: Stress Pathways for Caregivers of Persons Living with Dementia

The Gerontologist · 2026-05-08

BACKGROUND AND OBJECTIVES: Family caregivers of persons living with dementia face persistent caregiving demands that heighten risk for anxiety, depressive symptoms, and perceived stress. Although caregiving distress is well documented, less is known about the cognitive processes that link anxiety to broader psychological distress, or whether mindfulness-based interventions affect these processes. This study examined rumination as a cognitive mediator linking anxiety with these outcomes and tested whether mindfulness training moderated this association. RESEARCH DESIGN AND METHODS: Using data from a randomized controlled trial comparing the Practice of Awareness, Acceptance, and Compassion in Caregiving (PAACC) program with REACH-VA, we conducted a secondary mechanistic analysis using structural equation models (N = 133). Models tested whether post-intervention rumination mediated associations between post-intervention anxiety and depressive symptoms, perceived stress, and caregiver burden, while adjusting for baseline variables, and whether the anxiety-rumination association differed by intervention group. RESULTS: Rumination significantly mediated associations between anxiety and both depressive symptoms and perceived stress, but not caregiver burden. Mindfulness moderated the anxiety-rumination association, with stronger coupling at higher anxiety in PAACC participants. No direct group differences in post-intervention outcomes emerged. Alternate model specifications showed weaker overall fit than the hypothesized model. DISCUSSION: Findings highlight rumination as an important cognitive process linking anxiety with psychological distress and suggest that mindfulness training may influence how anxiety is cognitively elaborated, rather than uniformly reducing distress. Future research in diverse caregiver populations and with longer timeframes is warranted to clarify temporal ordering and variability in responsiveness to mindfulness-based approaches.

Artificial Intelligence in Depression–Medication Enhancement (AID-ME)

The Journal of Clinical Psychiatry · 2025-08-27 · 8 citations

There has been increasing interest in the use of artificial intelligence (AI)-enabled clinical decision support systems (CDSS) for the personalization of major depressive disorder (MDD) treatment selection and management, but clinical studies are lacking. We tested whether a CDSS that combines an AI which predicts remission probabilities for individual antidepressants and a clinical algorithm based on treatment can improve MDD outcomes. This was a multicenter, cluster randomized, patient-and-rater blinded and clinician-partially-blinded, active-controlled trial that recruited outpatient adults with moderate or greater severity MDD. All patients had access to a patient portal to complete questionnaires. Clinicians in the active group had access to the CDSS; clinicians in the active-control group received patient questionnaires; both groups received guideline training. Primary outcome was remission (<11 points on the Montgomery-Asberg Depression Rating Scale [MADRS]) at study exit. = .03). While limited by sample size and the lack of primary care clinicians, these results demonstrate preliminary evidence that longitudinal use of an AI-CDSS can improve outcomes in moderate and greater severity MDD. ClinicalTrials.gov identifier: NCT04655924.

Mindfulness and Rumination: Uncovering Stress Pathways in Caregivers of Persons Living with Dementia

Innovation in Aging · 2025-12-01

Abstract Mindfulness techniques, which encourage focusing on the present moment, have shown promise in reducing stress. However, the mechanisms through which mindfulness-based interventions alleviate stress in family caregivers, particularly those caring for persons living with dementia, remain less understood. This study aimed to determine whether a mindfulness-enhanced psychoeducational intervention could lower stress among caregivers of persons living with dementia by reducing rumination – a repetitive pattern of negative thinking. Data were drawn from a randomized controlled trial involving 142 family caregivers of veterans living with dementia (Mage = 67.2, SD = 9.8; 85% women; 82% White; 70% spouse caregivers; 90% co-residing). Participants were randomly assigned to either a standard REACH-VA multi-component skill-building intervention (n = 66) or a mindfulness-enhanced skill-building intervention, named PAACC (n = 67). Data were collected at baseline and at the end of the study. Rumination predicted higher depressive symptoms (using the Patient Health Questionnaire) and perceived stress (using the Perceived Stress Scale), but not caregiver burden (using the Zarit Burden Interview). Additionally, moderated mediation analysis showed that the relationship between anxiety (on the Generalized Anxiety Disorder Screener) and rumination (Rumination Reflection Questionnaire) was significantly stronger in the mindfulness-enhanced intervention group. These findings suggest that the mindfulness-enhanced intervention may be particularly beneficial for caregivers with higher anxiety levels by interrupting the cycle of negative, repetitive thinking, thereby reducing emotional stress even if caregiving burden remains unchanged. Incorporating mindfulness techniques may, therefore, provide meaningful benefits for caregivers by specifically targeting anxiety-driven rumination and improving emotional well-being.

A Unique Delusion with Depression in Early Stage of Neurocognitive Disorder Due to Vascular Disease: Considerations for Clinicians

Psychopharmacology Bulletin · 2025-08-12

As global aging becomes more prominent, neurocognitive disorders (NCD) incidence has increased. Patients with NCD usually have an impairment in one or more cognitive domains, such as attention, planning, inhibition, learning, memory, language, visual perception, and spatial or social skills. Studies indicate that 50-80% of these adults will develop neuropsychiatric symptoms (NPS), such as apathy, depression, anxiety, disinhibition, delusions, hallucinations, and aberrant motor behavior. The progression of NCD and subsequent NPS requires tremendous care from trained medical professionals and family members. The behavioral symptoms are often more distressing than cognitive changes, causing caregiver distress/depression, more emergency room visits and hospitalizations, and even earlier institutionalization. This signifies the need for early identification of individuals at higher risk of NPS, understanding the trajectory of their NCD, and exploring treatment modalities. In this case report and review, we present an 82-year-old male admitted to our facility for new-onset symptoms of depression, anxiety, and persecutory delusions. He has no significant past psychiatric history, and his medical history is significant for extensive ischemic vascular disease requiring multiple surgeries and two episodes of cerebrovascular accident (CVA). On further evaluation, the patient was diagnosed with major NCD, vascular subtype. We discuss differential diagnoses and development of NPS from NCD in order to explain the significance of more thorough evaluation by clinicians for early detection and understanding of NCD prognosis.

Practice of Acceptance, Awareness, and Compassion in Caregiving (PAACC): A randomized controlled trial on mindfulness‐based intervention for caregivers of individuals living with dementia

Alzheimer s & Dementia · 2025-12-01

BACKGROUND: As the prevalence of dementia is predicted to increase three-fold in the coming decades, there is critical need for effective interventions to support caregivers who play essential role in the health and wellbeing of individuals with dementia. Current evidence-based caregiver interventions, such as Resources for Enhancing All Caregivers Health (REACH-VA), focus on cognitive and behavioral strategies to lessen caregiver burden. The Practice of Acceptance, Awareness, and Compassion in Caregiving (PAACC) combines mindfulness and practical caregiving skills to reduce caregiver strain and enhance caregiver's resilience. The goal of this intervention is to help caregivers develop increased present-focused acceptance and awareness of their reactivity to care-related stressors, while fostering empathy towards their loved one with dementia. This approach differs from strategies that challenge or replace negative or unrealistic stress-related thoughts, considering the often progressive and unchangeable nature of stressors in dementia. This study compared the effectiveness of a mindfulness based PAACC intervention to cognitive behavioral based REACH-VA intervention. METHOD: This study enrolled 133 dementia caregivers with moderate to severe levels of caregiver burden who were randomized to either cognitive behavior based (REACH-VA) or mindfulness based (PAACC) support intervention. Study assessed caregivers for stress levels, perceived stress, rumination as well as mindfulness using validated questionnaires. RESULTS: The mean age of caregivers was 67yrs, predominantly white and most lived with their loved one that they were caring for. Both interventions reduced perceived stress, caregiver burden, and rumination. Caregivers who received PAACC showed lower anxiety (B=-2.76, p <0.001) and depressive symptoms (B=-2.50, p <0.01). PAACC participants exhibited higher levels of mindfulness after the intervention, with a significant increase indicated by a coefficient of 6.04. CONCLUSION: The study shows that while both interventions are beneficial, PAACC offers an additional advantage in enhancing psychological well-being of the caregivers. The increase in mindfulness suggests that PAACC caregivers were able to internalize practices taught in the intervention leading to better coping strategies. The results highlight the potential benefits of integrating mindfulness into future caregiver interventions.

A mindfulness‐based multicomponent caregiver intervention (PAACC): objectives, study design, and cohort description

Alzheimer s & Dementia Translational Research & Clinical Interventions · 2025-01-01 · 1 citations

Abstract INTRODUCTION Effective interventions are needed to reduce caregiver burden and stress, particularly among family caregivers of veterans with dementia. Unique risk factors such as traumatic brain injury (TBI) and post‐traumatic stress disorder (PTSD) further complicate caregiving. This study compares a four‐session mindfulness‐based multicomponent intervention (PAACC) with a cognitive behavioral intervention (REACH), both designed to alleviate caregiver burden, and provides a baseline evaluation of caregivers in the intervention. A two‐arm, blinded, randomized controlled trial assigned 133 dementia caregivers to PAACC ( n = 67) or REACH ( n = 66). Baseline assessments included caregiver stress, burden, mindfulness receptivity, rumination, compassion, depressive symptoms, anxiety, and care recipient behavior. Participants averaged 67.17 years, 85% were women, and 70% were spousal caregivers. Caregivers in PAACC reported higher depressive symptoms and anxiety and lower mindfulness receptivity. This study introduces the first mindfulness‐based intervention for veteran caregivers, designed to enhance cognitive flexibility, cultivate compassion, and provide practical skills to improve quality of life. METHODS The study utilized a two‐arm, blinded, prospective randomized controlled trial to compare the PAACC and REACH interventions. A total of 133 dementia caregivers experiencing moderate to severe caregiver burden were assigned to receive either the PAACC intervention ( n = 67) or the REACH intervention ( n = 66). Baseline evaluations included caregiver stress, burden, mindfulness receptivity, rumination, compassion, depressive symptoms, anxiety, and the memory and behavior problems of the veteran living with dementia, using widely accepted measures from caregiving literature. RESULTS Baseline assessments were conducted on 133 family caregivers of veterans living with dementia. The average caregiver age was 67.17 years (SD = 9.8), 85% were women, and 70% were spousal caregivers. No significant demographic differences were found between the two intervention groups. However, baseline comparisons showed that caregivers in the PAACC intervention reported higher depressive symptoms and anxiety, and lower mindfulness receptivity. A detailed protocol for the mindfulness‐based multicomponent caregiver intervention PAACC is described. DISCUSSION There is a growing need for multicomponent, skill‐building interventions tailored for dementia caregivers who are at high risk of stress. This study introduces the first mindfulness‐based intervention specifically for caregivers of veterans, designed to enhance cognitive flexibility, cultivate compassion, and equip caregivers with practical skills to improve their quality of life. Highlights PAACC is a mindfulness‐based multicomponent intervention for dementia caregivers of veterans. No demographic differences suggest psychological differences are not due to demographics. Baseline mental health and mindfulness readiness may impact intervention effectiveness.

FROM REACH TO MINDFULNESS: SHIFTING PARADIGMS IN SUPPORT OF CAREGIVERS OF VETERANS LIVING WITH DEMENTIA

Innovation in Aging · 2024-12-01

Abstract Enhancing interventions to alleviate stress among caregivers is a key area of focus for the Veterans Health Administration, especially given the anticipated tripling of dementia cases among Veterans in the upcoming years. Existing programs, like REACH-VA, have focused on cognitive behavioral approaches to reduce caregiver strain. However, mindfulness practices, known for stress reduction, psychological well-being improvement, and relationship enhancement, have not been extensively explored for caregivers of Veterans. This study evaluated the comparative effectiveness of a four-session, multi-faceted mindfulness-based intervention called Practice of Acceptance, Awareness, and Compassion in Caregiving (PAACC) to REACH-VA program for family caregivers of Veterans living with dementia. PAACC combines mindfulness with caregiver skill-development to improve the caregiving experience. It aims to assist caregivers in developing immediate awareness of stressors and their responses to stressors, while fostering empathy towards their relative with dementia. This approach differs from strategies that challenge or replace negative or unrealistic stress-related thoughts, considering the often progressive and unchangeable nature of such stressors. A randomized-controlled trial involving 133 family caregivers (Mage = 67 years; 81% White; 89% co-residing) assigned to either REACH-VA or PAACC demonstrated significant reductions in perceived stress, caregiver burden, and rumination after participating in either of the interventions. However, multi-level models revealed that caregivers who received PAACC showed lower anxiety (B=-2.76, p&amp;lt;0.001) and depressive symptoms (B=-2.50, p&amp;lt;0.01), and higher mindfulness (B=6.04, p&amp;lt;0.01) compared to caregivers who received the REACH-VA intervention. Findings will be discussed in the context of the intervention’s mechanisms, lessons learned, and alternative avenues for utilizing PAACC.

Artificial Intelligence in Depression – Medication Enhancement (AID-ME): A Cluster Randomized Trial of a Deep Learning Enabled Clinical Decision Support System for Personalized Depression Treatment Selection and Management

Research Square · 2024-06-25 · 1 citations

Artificial Intelligence in Depression – Medication Enhancement (AID-ME): A Cluster Randomized Trial of a Deep Learning Enabled Clinical Decision Support System for Personalized Depression Treatment Selection and Management

medRxiv · 2024-06-13 · 1 citations

Abstract Background There has been increasing interest in the use of Artificial Intelligence (AI)-enabled clinical decision support systems (CDSS) for the personalization of major depressive disorder (MDD) treatment selection and management, but clinical studies are lacking. We tested whether a CDSS that combines an AI which predicts remission probabilities for individual antidepressants and a clinical algorithm based on treatment can improve MDD outcomes. Methods This was a multicenter, cluster randomized, patient-and-rater blinded and clinician-partially-blinded, active-controlled trial that recruited outpatient adults with moderate or greater severity MDD. All patients had access to a patient portal to complete questionnaires. Clinicians in the active group had access to the CDSS; clinicians in the active-control group received patient questionnaires; both groups received guideline training. Primary outcome was remission (&lt;11 points on the Montgomery Asberg Depression Rating Scale (MADRS)) at study exit. Results 47 clinicians were recruited at 9 sites. Of 74 eligible patients, 61 patients completed a post-baseline MADRS and were analyzed. There were no differences in baseline MADRS (p = 0.153). There were more remitters in the active (n= 12, 28.6%) than in the active-control (0%) group (p = 0.012, Fisher’s exact). Of three serious adverse events, none were caused by the CDSS. Speed of improvement was higher in the Active than the Control group (1.26 vs. 0.37, p = 0.03). Conclusions While limited by sample size and the lack of primary care clinicians, these results demonstrate preliminary evidence that longitudinal use of an AI-CDSS can improve outcomes in moderate and greater severity MDD.

What Should Be the Scope of Long-Term Care Organizations’ Obligations to Offer Culturally and Linguistically Appropriate Services to Patients?

The AMA Journal of Ethic · 2023-10-01

Limited access to health services, decreased quality of care, and worse health outcomes are well documented barriers people with limited English proficiency (LEP) face in US health care.Laws enacted since the 1964 Civil Rights Act recognize such barriers and have helped generate demand for culturally respectful health service provision, assessment of cross-cultural relations, and adaptation of services that fail to meet persons' needs and improve quality of life.Yet, as this commentary on a case considers, even with legal protections for language services for patients with LEP, long-term care facilities face limited resources and thus have limited capacity to offer such services.Case JK is an 85-year-old, widowed, native Bosnian speaker with limited English language proficiency (LEP), who is admitted to a nursing home.JK experiences chronic physical illness and cognitive dysfunction and can no longer live in her home since the death of her 69-year-old daughter, who was her caregiver.JK came from Bosnia-Herzegovina to the United States many years ago with her husband to live with her daughter and has no remaining family in the United States.JK briefly communicates via an online interpreter service daily with staff during rounds, but otherwise she interacts only minimally with others.JK has become socially withdrawn and depressed, has minimal appetite, and is losing weight.When JK is visited by a Bosnian-speaking friend of her daughter, who brings Bosnian food, she eats and converses with ease and joy.JK's visitor informs the staff that JK is not comfortable talking about her body or how she is feeling with the interpreter offered by the online international language service, who is Serbian.JK's caregivers' encounter with JK's visitor illuminated for them how profoundly the linguistic and food services they have been offering JK undermine her well-being and