Discussion
memory complaints, cognition and mood among older adults, MCI, SD, cognitive complaints
MINOR, RECRUITMENT
In this convergent mixed-methods, single-blind, pilot RCT we demonstrated that a 9-week occupational therapy-led MBSR program was feasible for practice among community-dwelling, older adult primary care patients living with SCD or MCI. However, based on the lower-than-expected rates of recruitment, retention, and adherence, our study as designed did not meet the feasibility bench marks that were set. However, with minor modifications to the design, including changing how participants who drop-out are analyzed, extending recruitment, adding multiple sites, this intervention would be well suited to further study using a full-scale RCT.Following our research protocol, we used last observation carried forward (LOCF) method to manage drop-outs. As such, since three participants withdrew early from the study for reasons unrelated to the MBSR program, the retention rate was below our specified 75–80% benchmark because a small number of drop-outs impacted our results based on the LOCF approach used in our protocol. Excluding participants who withdrew, the study’s retention rate would have been higher. Similarly, the study had low adherence and true adherence rates but, excluding participants who withdrew early, the true adherence rate would have been moderate, compared to other mindfulness adherence studies [As the study proceeded, we made two changes to the original study protocol. The first change was to modify the inclusion criteria to clarify how MCI was determined. An MCI diagnosis in the EMR would meet the study’s eligibility, but in cases where there was no MCI confirmation in the EMR, but a participant’s MoCA score was ≤23, we used Petersen et al.’s (2014) MCI criteria for eligibility [Our findings are consistent with the growing body of literature on the benefits of mindfulness-based interventions in primary care [Our study also supports other recent RCT findings that MBSR is feasible for practice and is an optimal early intervention for the SCD population [Our qualitative investigation found that MBSR program supports individuals with cognitive complaints such as SCD or MCI through a broad range of positive effects, such as mental health benefits of group process including “social support” and “feeling safe.” These findings were consistent with a mixed-methods study by Berk et al. (2018), which found similar themes in a group process among middle-aged and older adults with memory complaints while attending an MBSR program [Embedding MBSR in a primary care setting may effectively meet the complex and unique needs of this population by supporting and managing their health care needs, including psychosocial support. The unique feature of collaborative practice in primary care is communication between providers. With this collaborative practice, it is developing a partnership between interprofessional primary care providers and patients to negotiate and navigate their health care needs. This results in patients establishing a more personal connection with interprofessional primary care providers on the team. Feelings of trust and safety are pre-established elements that can be leveraged for adopting such a program in an interprofessional primary care setting.Participants with SCD or MCI were open and receptive to and were capable of learning how to use computer tablets. This receptiveness was demonstrated in Wahbeh et al.’s study (2016), where they found a high recruitment rate (75%) and acceptability of an internet-based mindfulness meditation intervention for cognition and mood among older adults. However, Wahbeh’s et al. (2016) study contradicts ours slightly; they stated that it was too difficult for older adults to use iPads or iPod touch and they had to be switched over to participants’ desktop and laptop computers if they owned them. The Wahbeh et al. (2016) study is 6 years old (and the data is potentially older) which could explain the discrepancies as older adults are becoming more and more proficient with using technology. Wahbeh et al. (2016) also recommended that older adults need some basic knowledge of computers and how they work and to have their own computers to access online programs. Only 38% (3/8) of our study participants who used the tablets had minor issues accessing the App or Wi-Fi access. However, once support was provided, they independently used the tablets thereafter. Providing technological support in the initial phase of the study was crucial. The literature supports the importance of providing assistance with technology and that technology-based instructions require a high structure environment along with ensuring helpful resources are readily available [A recent systematic review and meta-analysis of 43 interventional mindfulness studies by Parsons et al. (2017) found that average home practice was 180 minutes (SD = 43) a week (e.g., 30 minutes per day, six days a week) among participants (general adults). In our study, based on the direct measure (i.e., tablets), participants practiced for 96.4 minutes/week (SD = 61.1) at home (e.g., 16 minutes per day on average). However, based on the subjective self-report measure (i.e., home practice diary), participants practiced for 131.6 mins (SD = 68.8) a week for 13 weeks (e.g., 22 min per day, 6 days per week on average) outside of class time. This demonstrates approximately 6 minutes or about 27% inflation in subjective self-report (i.e., home practice diaries). This study is consistent with the literature reporting a discrepancy between direct versus subjective self-reported measures [Direct measure (i.e., tablet) does come with limitations and consideration of using subjective self-reporting may be worthwhile to include in the overall evaluation of home practice data. The adherence rate of completing formal home meditation practice on tablets was 40% (4/10), as opposed to the higher true adherence rate which was 50% that also captured informal homework practices or behavioural change. Informal practices such as deliberately adopting attention to everyday activities and noticing the experience (e.g., walking, eating, washing dishes, etc.) are important. The lower adherence rate was accounted for by situations when participants could not capture home practice data. For example, one participant did not have Wi-Fi access when she was at her cottage, while other participants travelled during the summer months without their tablets for fear of damaging or losing them. Self-reported home practice dairy sheets were, therefore, necessary to determine the true adherence rate. The true adherence rate is essential since attending weekly MBSR sessions alone is insufficient. Excluding participants that withdrew, the higher true adherence rate positively reflects participants’ high level of engagement and adherence to the MBSR program, and it also validates their overall practice quality [Some minor barriers in this tablet-based practice included lack of reliable or general Wi-Fi access, which was similarly noted by Schepens et al. (2018), where unreliable Wi-Fi made it difficult at times in carrying out the intervention [