Sindhu: Good afternoon everyone. Thank you for being here today. This presentation is divided into three parts. The first part is an introduction to meditation, its history, and the different types. The second part is where I will discuss the connection between meditation and cognition. We will go through current research that has shown the effects of meditation on the brain. The third and the last part is where I will discuss use of meditation for cognitive dysfunction in the elderly. The last five minutes of this presentation will be a short meditation practice, where I hope to give you some ideas on how to instruct a patient during meditation.
Introduction
Meditation is also known as Dhyana in Sanskrit. It is described as the seventh of the eight limbs of Astanga yoga by Patanjali. Patanjali was a scholar of Hindu philosophy who compiled his teachings in a text on yoga theory and practice. This text is called Yoga Sutras. In Figure 1, I have listed the eight limbs of Ashtanga yoga so you can see where meditation falls on this list.
Figure 1. Eight limbs of Astanga yoga.
In the practice of yoga, it is believed that each of these limbs prepares you for the next one. I am going to go down this list quickly. The first one is Yamas which are moral codes or ethical standards for a yogic life. The second is Niyamas which are habits or observances for self-discipline and a spiritual practice. The third is Asanas. This is the part that most people in the West are familiar with; these are poses for a healthy body and healthy mind. Then, there is Pranayama, which is control of breath. Pratyahara is mastery over external influences or withdrawal of the senses. This is followed by concentration, also known as Dharana. The step we will be talking about more today is meditation (Dhyana) followed by complete absorption, or Samadhi.
History and Types of Meditation
History
The exact date of origin of meditation is unknown. However, there are some sources that mention the use of meditative practices going back at least 15,000 years, and these were depicted as figures in cave paintings. However, the general consensus is that meditation is about 5,000 years old with the earliest documented records of meditation found in the Vedas in ancient India. Vedas are old scriptures in Sanskrit literature. From India, the practice of meditation spread to other countries, such as Tibet, China, and Japan. The teachings reached the West in the 18th century. In the 1960s, Hatha yoga and transcendental meditation became popular in the US. In 1979, John Kabat-Zinn, professor emeritus of medicine, founded MBSR, which is the Mindfulness Based Stress Reduction Program at the University of Massachusetts. I will discuss this program in more detail in the next section when I go over the types of meditation.
Types
There are countless meditation techniques that are practiced around the world. I will describe two of the well-known classifications for these various techniques. The first is a broad classification that divides meditation techniques into two categories. The two categories are focused attention and mindfulness, or open monitoring. Focused attention, as the name suggests, requires having a specific point of focus. This could be an object, a vision, a sound, or one's own breath. The practitioner brings his or her attention back to this focal point when the mind starts to wander. Open monitoring on the other hand does not require focusing on a specific object, but maintaining a sense of awareness of any experience that may arise without passing any judgment. This is the first broad classification.
There is another classification that has been proposed based on the pattern of brainwave activity during these techniques. The first category is transcendental, when alpha waves are predominant. This wave pattern is seen during a state of relaxation. The second category is focused, when beta waves are predominant. Beta waves are high frequency, low amplitude waves that are seen when one is engaged in performing a task and is focused. The third is mindfulness. In mindfulness, theta waves are predominant, and these are seen during deep relaxation, or a semi hypnotic stage. These waves are also associated with improved creativity.
Here are some of the popular meditation techniques
- Zen (ZaZen)
- Vipassana
- Transcendental
- Kundalini
- Mindfulness-based stress reduction
These are five techniques that we will talk a little bit more about.
Zen.
The first one is Zen, which is also known as Zazen . The literal meaning of Zen is seated meditation. It is based on Buddhist teachings and philosophy. In Zen, the two factors that are very important are personal study with a teacher and a correct posture. These two things are considered very important in the practice of this type of meditation. They have a very specific posture where you are required to be seated facing a wall. You could sit on a pillow, on the floor, or on a bench. If you are seated on the floor, you are required to have your knees touching the floor, have an erect spine, and the chin tucked in. It is a very specific posture so that the practitioner can concentrate on their posture and breathing. Practicing this helps the practitioner achieve the state of mind that they need to observe thoughts and emotions without judging any of these thoughts or experiences. The training is offered in several centers. These can be weekend retreats. Some of them offer even a year-long residency and are pretty intensive.
Vipassana.
Vipassana is an ancient Indian technique that was started by Gautama Buddha thousands of years ago. The term Vipassana means to see things as they really are or understanding the true nature of our existence in this world. It gets us in touch with the reality of impermanence. This is a seated meditation. It can be done on the floor or in a chair. Vipassana combines mindfulness of breath, body, and emotions. This is done to increase our awareness of the nature of our experiences and that of our responses to our surroundings. This again helps develop steadiness of mind, even as our external environment changes. Regardless of what is going on around us, we develop that steadiness. Vipassana is offered as a 10-day course for different age groups in several centers around the world. There is no charge for Vipassana. These courses are run on a voluntary donation basis.
Transcendental meditation.
Transcendental meditation is very popular in the US. It was founded by Maharishi Mahesh Yogi in India in the mid-1950s. It gained popularity in the 60s and 70s. This type of meditation involves the use of a sound or a mantra. This sound is assigned specifically by a teacher to that practitioner. It is practiced for 15 to 20 minutes twice a day, and the purpose is to gain access to the quiet and stillness within the mind. Here the goal is believed to be not only awareness of the impermanence of our existence, but to transcend and rise above it. Again, it is a seated meditation with eyes closed. The training for this type of meditation is offered as a four-day course, and then there are some follow-up sessions.
Kundalini.
Kundalini yoga was brought to the West in 1968 by Yogi Bhajan. Meditation is just one of the steps in the practice of Kundalini yoga. It is also a seated meditation. The body is guided through use of breath mantra, mudra, and focus. Now, mudras are hand gestures, and we will talk about these more in another section in this presentation. In Kundalini meditation, the practitioners have access to techniques that are for specific applications such as: stress reduction, boosting the immune system, increasing energy, and improving sleep and the nervous system. The training for Kundalini yoga is offered at a variety of different centers.
Mindfulness-Based Stress Reduction (MBSR).
Again, MBSR was founded by Dr. Jon Kabat-Zinn at the University of Massachusetts in 1979. This program is a merger of science and Buddhist teachings. It is not meditation alone. It is a combination of meditation, body awareness, and yoga. During the practice, the practitioner will assume different positions, including sitting, standing, lying down, walking around. Throughout this, the practitioner is asked to be aware of the present moment. MBSR is offered as an eight-week program at The Center for Mindfulness, which is at the University of Massachusetts. It is also offered as an online program and a five-day residential program at various locations around the world. The same center also offers another program for those at risk for relapse of depression, and this program is called Mindfulness Based Cognitive Therapy (MBCT). This is an eight-week program that can be taken in person or online.
These are the different types of meditation. There are several types, but I just picked five to show you the differences between these techniques. We are now going to switch gears and talk about cognition.
Cognitive Dysfunction
Definition
What is cognitive dysfunction? It involves deficits in any of the following areas:
- Attention
- Working memory
- Long-term memory
- Perception
- Speech and Language
- Decision-making
- Executive control
Risk Factors
Figure 2 shows a list of risk factors for cognitive dysfunction.
Figure 2. Risk factors for cognitive dysfunction.
The list is quite long. I have compiled this list from various sources that are listed at the bottom of the slide. The right side gives you the list of various diagnoses and then left side gives you various other factors that have been found to be associated with cognitive dysfunction. Some of these factors are important from the meditation standpoint. We will talk about that a little bit more as when we discuss research.
Current Cognitive Therapies
I would like to briefly talk about a few current cognitive therapies that have been found to be beneficial. I thought it would be good to include these in the presentation because for some patients a combination of meditation and maybe one of these therapies may provide the best treatment. It is good to be aware of the different options we have.
Cognitive stimulation therapy (CST).
The first one is Cognitive Stimulation Therapy. This is a non-pharmacological treatment for people with mild to moderate dementia. It was developed in the UK. It is offered as a group program that has 14 or more sessions of themed activities and every session has a different theme. It is offered twice weekly. They also offer a longer or a maintenance cognitive stimulation therapy program. The aims are to engage people with dementia by providing stimulation in an optimal learning environment. As this is offered in a group setting, it also encourages socialization. There have been some clinical trials conducted on this therapy which have demonstrated improvement in cognition or delayed decline, and the effects have been found to be comparable to those reported with the currently available antidementia drugs.
Working memory training.
Working memory refers to retaining and manipulating information for use in complex tasks. The Cogmed working memory training is an evidence-based computerized program for improving attention. The program includes an initial interview, a startup session, five weeks of training (25 sessions), and each session is 30 to 45 minutes long with weekly coach calls. There is a six-month follow-up interview, and then there is also an extension training program for 12 months.
Transcranial direct current stimulation (Cappon, Jahanshahi, & Bisiacchi, 2016; Pope, 2015).
Transcranial direct current stimulation involves delivering a low, direct current continuously through a pair of electrodes for about 15 to 20 minutes. Typically, this is one electrode on the scalp of the area of interest and the other at a distant site such as the cheek or the shoulder on the contralateral side. The studies that have been conducted on this have shown a positive effect in Alzheimer's disease. They are still investigating it further to see if these beneficial effects can be generalized to ADLs or daily functioning.
Drugs.
I just want to mention a few drugs that have been approved by FDA (Mayo clinic, 2016). Aricept is a common drug used. There is Exelon, Reminyl, and Namenda. FDA has not approved any drugs for mild cognitive impairment, but cholinesterase inhibitors, which the are the first three that I just mentioned, (Aricept, Exelon, and Reminyl). They have been approved for Alzheimer's disease, and sometimes physicians will prescribe these for MCI as well. Common side effects are nausea, vomiting, and diarrhea. If you look for a detailed list, there are several other side effects, but these are the common ones.
Research
I would like to discuss a meta-analysis of studies on meditation that was published in 2015 (Boccia, Piccardi, & Guariglia, 2015). For those who may not be familiar with research terminology, a meta-analysis is a study design that is used to statistically analyze the results of several studies put together to form a conclusion with greater statistical power. This meta-analysis included 37 individual functional MRI experimental studies on functional activations seen during meditation, 63 functional MRI studies on functional changes that were ascribable to meditation, and 10 experimental structural MRI studies. The aims of this meta-analysis were to identify the neural network activated during meditation, explore the structural and functional brain modifications in expert meditators, and explore the relationship between the practice of meditation and the neural mechanisms that allow maintaining these positive effects seen during meditation.
On these images, I want to show you some of the areas that were found to be more highly activated during meditation.
The first part that I want to talk about is the precuneus, being shown below at the green arrow (see Figure 3).
Figure 3. Location of the precuneus.
The precuneus is located in the posterior medial portion of the parietal lobe. This part of the brain has widespread connections with cortical and subcortical brain regions, and it is involved in highly integrated tasks such as visual spatial imagery, episodic memory retrieval, and self-processing operations. This was one of the areas that was more highly activated during meditation.
The second area that I want to show you is the anterior cingulate cortex (see Figure 4).
Figure 4. Location of the anterior cingulate cortex.
This area is involved in decision making, detection of errors, and preparation of a task.
The third is the cerebellum, as shown in Figure 5.
Figure 5. Location of the cerebellum.
The cerebellum controls timing of complex actions, such as speech and writing. This is all very important for cognitive functioning. There are some other areas that I am not able to show on these images that were highly activated, and one of these was the caudate nucleus, which is a part of the basal ganglia. The caudate nucleus is involved in storing and processing of memories and communication skills. The other area was a parahippocampal gyrus, and it is known that the parahippocampal cortex is involved in memory formation and retrieval, as well as high-level perception. There were several other areas like the temporal and frontal gyri. Overall, this network of areas that was found to be highly activated during meditation. These were involved in processing of self-relevant information, focused problem-solving, adaptive behavior, interoception,monitoring of internal body states, and reorienting attention. Figure 6 shows an overview of this research.
Figure 6. Overview of brain areas highly activated during meditation as compared to controls.
In addition to these areas that I showed you, there was also the thalamus that was found to be highly activated. The thalamus plays an important role in learning by routing sensory information to memory centers of the cerebrum. This area was found to have increased functional activation in meditators (see Figure 7).
Figure 7. Overview of brain areas with increased functional activation in meditators.
The other change was a structural change. Increased gray matter volume was found in meditators in certain areas. This was in the frontal lobe.
Figure 8. Overview of brain areas that increased in grey matter.
The frontal lobe is involved in higher cognitive skills, such as problem-solving, thinking, planning, and organizing. Increased gray matter was also found in the anterior cingulate cortex and also in the frontal gyri. Increased gray matter volume was also found in the precuneus and also in the right thalamus. All of this, especially the gray matter volume in the anterior cingulate cortex, was thought to account for improved self-regulation, focused problem-solving, and adaptive behavioral responses.
