Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Improvement of Quality of Life after the Application of Mindfulness-Based Cognitive

Therapy in Subjects Aging with HIV Infection

Carmina R. Fumaz

HIV Unit-LLuita contra la Sida Foundation Germans Trias i Pujol University Hospital

Badalona, Barcelona, Spain

2nd Workshop on HIV and Aging

27-28 October 2011, Baltimore, USA

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Background

• Aging is a multidimensional process of physical, psychological and social changes. Successful aging is based not only on the absence of illness but also on the achievement of an adequate quality of life, understanding this as the concept of wellness. • In the field of healthcare, quality of life includes physical and mental health, education, recreation and leisure time, and social belonging, among others. • Aging involves a number of diverse factors which may favour the impairment of quality of life and emotional status like functional decline, physical dependence, decrease of economic capacity and changes in social activity and relationships.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Natural aging

Impact on emotions and quality of life

Adams et al. Occup Ther Int 2010 Vance et al. J Neurosci Nurs

2010;42(3):150-6. Comorbidity

Chronic condition

Mansky KC. Clin Interv Aging 2010;5:285-92

Justice AC. Curr HIV/AIDS Rep 2010;7(2):69-76.

Premature aging?

Desai et al. Curr HIV/AIDS Rep 2010;7(1):4-10.

Comorbidity

Guaraldi et al. Clin Infect Dis 2009;49 (11):1756-62

Background

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Methods

- Objective: To determine the efficacy of mindfulness-based cognitive therapy to improve the quality of life of subjects aging with HIV infection. - Design: Prospective randomized two-arm study with 40 subjects (20 men and 20 women). - Inclusion criteria: HIV infection diagnosis ≥ 15 years ago Deficits in quality of life (scores ≥65 Nottingham Health Profile) Written consent - Exclusion criteria: Diagnosis of schizophrenia or bipolar disorder Documented psychotic episode Documented epileptic episode Other ongoing psychotherapeutic interventions

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Methods

- Psychometric instrument used to evaluate quality of life: Nottingham Health Profile First section: 38 statements that assess 6 different dimensions of normal living: energy, pain, emotional reactions, sleep, social isolation and physical mobility. Scores for each dimension can range from 0 "no problems” to 100 “all problems listed are present”. Second section: 7 single statements about 7 areas of daily life: work, looking after the home, social life, relationships at home, sex life, interests and hobbies, and the ability to take holidays. Patients are asked to answer whether their health causes problems in any of these areas.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Methods

- Statistical analysis:

Continuous variables were described as median (IQR) and categorical variables as percentages (number of patients). Univariate linear regression analyses were fitted to evaluate the difference between pre and post measurements considering the group of treatment as explanatory variable.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Methods

Recruitment

N= 20 men; 20 women

Assessment only

N= 10 men; 10 women

MBCT

N= 10 men; 10 women

Pre-evaluation Pre-evaluation

8 weeks 8 weeks

Post-evaluation Post-evaluation Drop-out

N= 0

Drop-out

N= 1

Evaluation at month 3 and 6 post-intervention

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Methods

- Intervention used to evaluate quality of life:

Mindfulness-based Cognitive Therapy MBCT combines cognitive therapy with mindfulness techniques as a treatment for major depressive disorder.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Structured intervention adapted from Kabat-Zinn (1990), consisting of eight 3-hour weekly sessions and a daylong retreat with about an hour or more of homework per day, 6 days per week.

Designed to develop mindfulness: a consciousness focused on the present moment free of judgment, promoting an attitude of acceptance.

Directed at teaching meditation techniques whilst sitting and in movement, yoga, conscious breathing and body exploration to encourage the participants to appreciate the present moment instead of focusing on worries about future or past, often ruminative and automatic, and potential generators of psychological stress.

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Randomized study with 84 breast cancer survivors

Lengacher CA et al. J Behav Med 2011

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Lengacher CA et al. J Behav Med 2011

Mindfulness

Randomized study with 84 breast cancer survivors

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Randomized study with very stressed 38 women and 19 men

Nyklicek I et al. Ann Behav Med 2008

Perceived stress Quality of life

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Witek-Janusek L et al. Brain Behav Immun 2008

Non-randomized study with 75 breast cancer patients

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Witek-Janusek L et al. Brain Behav Immun 2008

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing and perspective taking

Hölzel et al. Psychiatry Res 2011;191(1):36-43

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Creswell JD et al. Brain Behav Immun 2009

Randomized study in 67 subjects

+ 20 CD4

- 185 CD4

Mindfulness

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Sociodemographic Characteristics: Groups

* Values expressed as median (IQR) Φ Values expressed n (%)

Characteristics

Total n=40

Intervention n=20

Control n=20

p Value

Age* 50 (46- 52) 50 (45- 54) 49 (48- 51) 0.93

Years since HIV diagnosis*

20 (16-24) 20 (16-24) 19 (15-24) 0.73

Years on ARV* 16 (12-18) 15 (13-19) 17 (12-18) 0.93

Nadir CD4 cell count (cells/mm3)*

156 (68-253) 195 (163-243) 108 (31-176) 0.28

CD4 cell count (cells/mm3)*

527 (364-633) 576 (439-693) 463 (354-612) 0.19

HIV RNA VL<25 copies/mlΦ

39 (98) 19 (95) 20 (100) 1

Stable partnerΦ 17 (43) 11 (57) 6 (30) 0.10

RetireesΦ 20 (50) 9 (47) 11 (55) 0.52

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Sociodemographic Characteristics: Genders

* Values expressed as median (IQR) Φ Values expressed n (%)

Characteristics

Total n=40

Men n=20

Women n=20

p Value

Age* 50 (46- 52) 50 (48- 54) 49 (45- 51) 0.08

Years since HIV diagnosis*

20 (16-24) 20 (16-23) 19 (15-24) 0.58

Years on ARV* 16 (12-18) 17 (13-19) 16 (10-18) 0.49

Nadir CD4 cell count (cells/mm3)*

156 (68-253) 140 (73-302) 159 (41-218) 0.53

CD4 cell count (cells/mm3)*

527 (364-633) 525 (362-677) 527 (439-633) 0.92

HIV RNA VL<25 copies/mlΦ

39 (98) 19 (95) 20 (100) 1

Stable partnerΦ 17 (43) 6 (30) 11 (58) 0.05

RetireesΦ 20 (50) 10 (50) 10 (50) 1

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Dimensions of Normal Living: Pre-evaluation

0

20

40

60

80

100

Energy Pain Emotionalreactions

Sleep Socialisolation

Physicalmobility

Intervention Control

100 88

38 51 53 49 53 50

0.80 0.54 0.41 0.79 0.66 0.40

41

21

41 32

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Dimensions of Normal Living: Post-evaluation

0

20

40

60

80

100

Energy Pain Emotionalreactions

Sleep Socialisolation

Physicalmobility

Intervention Control

0

76

23

48 53

8 0 12 0.01 0.03 0.001 0.02 0.001 0.008

0 22

40

19

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Areas of Daily Life: Pre-evaluation

0

20

40

60

80

100

Work

Looking after the home

Social life

Relationships at homeSex life

Interests and hobbies

Ability to take holidays

Intervention Control

75

40

60 65

45

1 0.31 1 0.74 0.50 0.74

70 60 60 65

0.50

30 40

65

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Areas of Daily Life: Post-evaluation

0

20

40

60

80

100

Work

Looking after the home

Social life

Relationships at homeSex life

Interests and hobbies

Ability to take holidays

Intervention Control

65 60 55 50 47 31

5 0.005 0.42 0.14 0.001 0.74 0.01

67

50 60

15 0.07 15

40

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Impact of the intervention

No differences were observed between genders regarding the efficacy of the intervention.

Benefits observed in other areas assessed: stress, anxiety and depressive markers, subjective effort to deal with the disease, subjective perception of physical status.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

Conclusions

Quality of life improved very importantly after the implementation of mindfulness-based cognitive therapy in this sample of long-term diagnosed HIV-infected subjects. Mindfulness may be a recommendable strategy in subjects aging with HIV infection.

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

HIV Unit-Germans Trias I Pujol University Hospital Maria Jose Ferrer Marian Gonzalez-Garcia Jose A. Muñoz-Moreno Jordi Puig Christian Brander Eugenia Negredo Bonaventura Clotet

Presented at the 2nd Int. workshop on HIV & Aging, 27 – 28 Oct 2011, Baltimore, USA

The energy of the mind is the essence of life

Aristotle

Thank you