Aging & Mental Health

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Stress on health-related quality of life in older

adults: the protective nature of mindfulness

Cindy M. de Frias & Erum Whyne

To cite this article: Cindy M. de Frias & Erum Whyne (2015) Stress on health-related quality of
life in older adults: the protective nature of mindfulness, Aging & Mental Health, 19:3, 201-206,
DOI: 10.1080/13607863.2014.924090

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Aging & Mental Health, 2015
Vol. 19, No. 3, 201 206, http://dx.doi.org/10.1080/13607863.2014.924090

Stress on health-related quality of life in older adults: the protective nature of mindfulness
Cindy M. de Frias* and Erum Whyne
School of Behavioral and Brain Sciences, The University of Texas at Dallas, Richardson, TX, USA
(Received 14 January 2014; accepted 7 May 2014)

Objectives: The current study examined whether the link between stress and health-related quality of life was buffered by
protective factors, namely mindfulness, in a sample of middle-aged and older adults.
Methods: In this cross-sectional study, 134 healthy, community-dwelling adults (ages 50 85 years) were recruited from
Dallas, TX. The participants were screened for depressive symptoms and severity (using the Patient Health Questionnaire
[PHQ-9]). All participants completed measures of self-reported health status (i.e. SF36v2: mental and physical health
composites), life stress (using the Elders Life Stress Inventory [ELSI]), and trait mindfulness (i.e. Mindful Attention
Awareness Scale).
Results: Hierarchical regressions (covarying for age, gender, and education) showed that life stress was inversely related to
physical and mental health. Mindfulness was positively related to mental health. The negative effect of life stress on mental
health was weakened for those individuals with higher levels of trait mindfulness.
Conclusions: The results suggest that mindfulness is a powerful, adaptive strategy that may protect middle-aged and older
adults from the well-known harmful effects of stress on mental health.
Keywords: aging; mental health; mindfulness; stress

Introduction in mid-life or late life (Kulmala et al., 2013; Piazza et al.,

The road to successful aging may be determined by opti- 2013; Scott et al., 2013). Moreover, stressful life events
mal health outcomes (Rowe & Kahn, 1997), proactive negatively impact mental health and well-being (Charles
adaptations (Kahana, Kelley-Moore, & Kahana, 2012), or et al., 2013; Couto, Koller, & Novo, 2011; Dautovich
by drawing on mechanisms that overcome life challenges et al., 2013; Kahana et al., 2012). Stressful life events are
(Baltes & Baltes, 1993; de Frias, 2013). A variety of psy- typically major events that require significant adjustment
chosocial stressors in late life may hinder health-related by the individual, whereas chronic or daily stressors are
quality of life: a crucial ingredient for successful aging. minor events that accumulate overtime having proximal
Chronic stress (e.g. hassles of caregiving) and negative effects on health (Almeida et al., 2011). The mechanisms
life events (e.g. deterioration in memory or finances) have or pathways by which these stressors have a prolonged
been found to increase the risk of illness and diseases impact on health are stressor exposure (i.e. likelihood of
(Almeida, Piazza, Stawski, & Klein, 2011; Baum & experiencing an event based on situational or vulnerability
Posluszny, 1999). Protective factors may serve as resour- factors) and stressor reactivity (i.e. likelihood of showing
ces or mechanisms to buffer against the negative effects reactions (emotional or physical) to the stressors). The
of life stress on health in older adults. Mindfulness is a types of stressors that are examined in this study pertain to
mechanism for effective self-regulation and stress reduc- exposure. Stressful life events (i.e. stressor exposure) con-
tion (Kabat-Zinn, 2003). The aim of this study was to sume limited resources in aging which may weaken one’s
examine individual differences in life stress on health- resilience to manage environmental challenges.
related quality of life in middle-aged and older adults, and The availability of psychosocial resources may ease
the potential moderating effect of trait mindfulness. one’s adaptation to perceived losses in late life (Aldwin,
Psychological stressors are a public health concern as Spiro, & Park, 2006; Baltes & Baltes, 1993; de Frias,
they are adversely associated with poor physical and men- 2013). Adaptive mechanisms may protect individuals
tal health (Aldwin, 1990; Almeida et al., 2011; Charles, from a cascade of poor health outcomes. One viable pro-
Piazza, Mogle, Sliwinski, & Almeida, 2013; Dautovich, tective factor to curtail the hazards of life stress is termed
Dzierzewski, & Gum, 2013; Krause, 1986; McEwen, mindfulness. Mindfulness is a complex and adaptive pro-
2006; Piazza, Charles, Sliwinski, Mogle, & Almeida, cess that necessitates paying attention to the present
2013). Perceived stress symptoms (e.g. lack of energy), moment in a receptive and non-judgmental attitude
lifetime traumatic events (e.g. abuse or assault), or chronic (Brown & Ryan, 2003; Kabat-Zinn, 1994, 2003). Mind-
stressors, and daily stressors or hassles (e.g. spousal con- fulness has been shown to alleviate the symptoms of
flict) have been associated with poorer physical functioning clinical conditions (e.g. relapse reduction in depression;

*Corresponding author. Email: [email protected]

Ó 2014 Taylor & Francis

202 C.M. de Frias and E. Whyne

Piet & Hougaard, 2011) and to be beneficial in multiple were 50 85 years of age (M D 65.43, SD D 9.50) and the
domains of functioning, including improvement in health average level of education was 15.51 years (SD D 2.62).
(e.g. Kabat-Zinn, Lipworth, & Burney, 1985; Teasdale The participants were screened prior to recruitment and
et al., 2000); psychological well-being in healthy young were excluded if there was a self-report of concurrent or
adults (e.g. Brown & Ryan, 2003); stress reduction (e.g. history of health conditions known to impair cognitive
Epel, Daubenmier, Moskowitz, Folkman, & Blackburn, health (i.e. dementia, Parkinson’s disease, stroke, brain
2009; Gallegos, Hoerger, Talbot, Moynihan, & Duber- injury, schizophrenia) as well as taking antipsychotic medi-
stein, 2013); better cognitive functioning (e.g. see Chiesa, cations. All participants attained scores above 23 (M D
Calati, & Serretti, 2011, for review; Greenberg, Reiner, & 27.68, SD D 1.79) on the Mini-Mental Status Examination
Meiran, 2012); and cognitive resilience via less need for (Folstein, Folstein, & McHugh, 1975), a screening measure
compensatory strategy use in older adults (de Frias, of global cognition. Participants reported their general
2013). The way an individual reacts to an event may be health as being good to very good (on a scale of 1 5) rela-
more important in predicting emotional health than the tive to a perfect state (M D 4.37, SD D .62) and relative to
event itself. Mindfulness meditation techniques tend to same age peers (M D 4.48, SD D .62). All participants
shift the appraisal of a situation (i.e. stressor reactivity) scored below 15 (M D 2.47, SD D 3.04) on the Patient
such that it is no longer perceived as a threat. Mindfulness Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Wil-
is an emotion-regulation strategy that disarms the path- liams, 2001), a screening measure of depressive symptoms
ways of stressor reactivity such that exposure to a stressor and severity. The participants were recruited from the local
is no longer hazardous to health. In this way, mindfulness community via advertisements (e.g. flyers distributed in
as a protective psychological process alters the stress local community centers, public libraries) and online news-
pathways which would otherwise contribute to cellular letters. The overarching study examines multiple influences
aging (Epel et al., 2009). In sum, mindfulness has been on healthy aging. The study was approved by the Univer-
linked to numerous health, psychosocial, and cognitive sity of Texas at Dallas Ethics Review Board. A description
outcomes, but no study to date has examined the synergis- of the sample is presented in Table 1.
tic effects between trait mindfulness and life stress on
health outcomes in middle-aged and older adults.
This study explores the additive and interactive effects Procedure
of stressful life events and trait mindfulness on mental and Participants who met initial screening criteria (e.g. during
physical health functioning in middle-aged and older a telephone interview) were later invited to receive a bat-
adults. First, similar to other studies, we expected that tery of tests at the University of Texas at Dallas. As part
those adults who experience more stressful life events of the telephone screening procedure, the tester asked if
will also have poorer health. In addition, trait mindfulness the participants were fluent in English and if they said no,
is expected to positively impact health functioning. Sec- or the tester was not convinced of their fluency based on
ond, we expected that trait mindfulness would have a the telephone conversation, then the participant was
moderating effect on the stress-health link. It is expected excluded from the study. Participants drove to campus,
that higher trait mindfulness will alleviate the negative and a research assistant met with them at the campus park-
path between life stress and health functioning. ing lot and walked with them to the laboratory. The testing
session lasted approximately three hours. The same order
of test administration was provided for all participants.
Method
Both paper-and-pencil and computerized tasks were
Participants administered. Participants received a nominal fee for their
A total of 134 community-dwelling adults (93 women, 41 time. Written informed consent was obtained from all par-
men) were recruited from Dallas, TX. The participants ticipants before test administration.

Table 1. Descriptive statistics for background and performance variables (n D 134).

Measure M SD Range Skewness Kurtosis

Age (in years) 65.43 9.50 50.41 85.11 .13 1.05

Education (in years) 15.51 2.62 8 22 .24 .30
Health (relative to peers) 4.48 .62 3 5 .77 .38
Health (relative to perfect state) 4.37 .62 3 5 .44 .64
MMSE 27.68 1.79 24 30 .38 .93
PHQ-9 2.47 3.04 0 14 1.58 2.26
SF36v2: PCS 49.04 9.07 24.07 69.28 .77 .07
SF36v2: MCS 52.11 8.93 20.47 65.60 1.46 2.10
MAAS 4.33 .78 2 6 .25 .07
ELSI 4.99 3.14 0 1 .56 .27

Note. MMSE D Mini-Mental Status Examination; PHQ-9 D Patient Health Questionnaire; PCS D Physical Composite Score; MCS D Mental Composite
Score; MAAS D Mindfulness Attention Awareness Scale; ELSI D Elder’s Life Stress Inventory (total events).
 Aging & Mental Health 203

Measures Table 2. Associations (standardized betas) among health, life

stress, and trait mindfulness scores.
Medical outcomes study 36-item short form version
(SF36v2) Quality of life
The SF36v2 (Ware, Kosinski, & Dewey, 2000) is a self- Correlates Physical health Mental health
report questionnaire which measures eight functional
health domains and two psychometrically based summary Block 1
scores [i.e. physical component summary (PCS) and Age .09 .17
mental component summary (MCS)]. The eight health Gender .07 .09
domains which consist of Likert-scale items are as fol- Education .07 .06
lows: mental health (MH; five items); role limitations due R2 .02 .04
to emotional problems (RE; three items); general health F .89 1.57
perceptions (GH; five items); vitality (VT; four items); Block 2
physical functioning (PF; 10 items); role limitations due Age .17 .07
to physical problems (RP; four items); social functioning Gender .05 .05
(SF; two items); and bodily pain (BP; two items). The Education .11 .04
SF36v2 time frame used in this study was one-week Stress .33 .25
recall. The SF36v2 uses norm-based scoring for the scales Trait mindfulness .06 .45
and derives two psychometrically based component sum- R2 .13 .32
mary scores. For each subscale, higher scores indicate bet- DR2 .11 .29
ter health. For this study, the physical health (PCS: F 3.85 12.25
subscales PF, RP, BP, and GH) and mental health (MCS: Block 3
subscales MH, RE, SF, and VT) standardized composite Age .16 .05
scores were used in the analyses. Gender .06 .01
Education .11 .04
Stress .31 .30
Elders life stress inventory (ELSI) Trait mindfulness .06 .45
The ELSI (Aldwin, 1990) is a 31-item self-report inven- stress £ mindfulness .10 .21
tory that measures the number of stressful events experi- R2 .14 .36
enced in the last year. Items in the ELSI represent DR2 .01 .04
stressful life events relevant to older adults (e.g. death of a F 3.43 12.03
spouse, retirement, divorce, poor health, financial hard- Note. p < .05. p < .01. p < .001.
ship, changes in job or residence). A total of 10% of the
ELSI items pertained to health-related events. The total
number of events experienced was analyzed in this study. (ELSI total events) and trait mindfulness (MAAS)
(Block 2). The third correlate was the life stress £ trait
mindfulness interaction (Block 3). The main effect terms
Mindful attention awareness scale (MAAS)
were centered before the interaction term was computed.
The MAAS (Brown & Ryan, 2003) is a 15-item self- Alpha levels of p < .05 were specified as the threshold
report questionnaire that assesses trait mindfulness, to indicate statistical significance. The results are dis-
namely, open or receptive awareness of and attention to cussed for those models with a significant change in
what is occurring in the present moment. Each item con- R2. Results for the analyses are reported in Table 2 and the
sists of a 6-point Likert scale (1 D almost always; 6 D correlations between correlates are presented in Table 3.
almost never). A sample item includes, ‘I find it difficult
to stay focused on what’s happening in the present’. Items
reflect inattention across several everyday situations and Results
domains (e.g. cognitive, physical, emotional, general). Demographics
The scale was scored by computing a mean of the
Gender, age, and education were not significant predictors
15 items. In this study, the internal consistency was high
of physical health or mental health. The demographic
(a D .87).
characteristics did not account for significant variance in
the quality of life composite scales.

Data analyses
A series of concurrent hierarchical regression analyses Life stress and mindfulness
was conducted separately for the physical-health and Life stress was a significant predictor of physical health
mental-health composites. The purpose was to examine and mental health. Higher ELSI (total events) was related
the independent and relative contributions of the two qual- to poorer physical and mental health. Trait mindfulness
ity of life indices. The first cluster of correlates included was significantly related to mental health, but not physical
demographic information (age, gender, and education) health. Higher dispositional mindfulness was related to
(Block 1). The second cluster of correlates was life stress better mental health. Life stress and trait mindfulness
204 C.M. de Frias and E. Whyne

Table 3. Pearson product moment correlations for continuous body (McEwan, 2006). Moreover, the cognitive theories
measures. of emotional health advise that how an individual
Measure 1 2 3 4 5 6 responds to a stressful situation may lead to more deleteri-
ous health outcomes than the event itself.
1. Age The second predictor of health-related quality of life
2. Education .01 was trait mindfulness which was strongly related to men-
3. PCS .10 .08 tal health in this study. Individuals, who have a greater
4. MCS .16 .03 .01 unbiased awareness of their actions (i.e. are more mind-
5. MAAS .08 .13 .08 .50 ful), reported better emotional health in late life. Our find-
6. ELSI .22 .10 .29 .34 .16 ings are similar to several other studies showing the
Note. p < .05. p < .01. p < .001. positive mindfulness-health link in adulthood (e.g. David-
son et al., 2003; Kabat-Zinn et al., 1985; Teasdale et al.,
2000). Mindfulness lowers rumination and reduces exces-
accounted for an additional 11% 29% of the variance in sive elaborative processing of negative information in the
physical and mental health, after controlling for the back- face of emotional challenge; therefore, it may buffer
ground variables. against stresses that limit resources (Epel et al., 2009). A
recent study by de Frias (2013) showed that having a
more mindful pre-disposition was related to less frequent
Moderating effects of mindfulness use of memory compensatory efforts in older adults, indi-
Trait mindfulness moderated the effect of life stress on cating that mindfulness may serve as a mechanism for
mental health. In order to probe the significant interaction resiliency in late life. The protective effects of trait mind-
between the two continuous variables, the trait mindful- fulness (as a between-person resiliency factor) may be
ness composite variable was split into two groups: low- most evident in situations when an aging individual is
MAAS skill (below the mean) versus moderate-to-high- accumulating stressful life events, which would otherwise
MAAS skill (above the mean). (The MAAS mean (4.33) further deplete one’s quality of life.
and MAAS median (4.37) scores were nearly identical.) The significant life stress £ trait mindfulness interac-
Post hoc analyses of simple slopes for levels of MAAS tion for mental health supports the finding that mindful-
skill showed that the strength of the stress health associa- ness has a buffering effect on the hazardous effects of
tion was stronger for individuals lower in MAAS (b D stress on mental health. In this study, the link between
.42, p < .001) compared to those individuals who were stressful life events and mental health was weaker among
more mindful (b D .25, p < .05). The MAAS stress more mindful individuals. In fact, the stress-health link
interaction on health accounted for an additional 4% of was nearly twice as strong for less mindful older adults.
the variance in mental health, after controlling for demo- Life stress and mindfulness accounted for nearly one-third
graphic variables, life stress, and trait mindfulness. of the variance in mental health. Exposure to a given
stressor may be differentially experienced depending on
person-level characteristics, and this study shows that
Discussion mindful individuals are less encumbered by the mere
This study examined additive and interactive effects of exposure of a stressor which benefits health functioning.
life stress and trait mindfulness on two indicators of Mindfulness cultivates cognitive and emotional skills
health-related quality of life (i.e. mental and physical which is especially important when stressful life events
health), after controlling for age, gender, and education, may lead to the depletion of resources (e.g. social, cogni-
in middle-aged and older adults. The results of this study tive, financial). Less mindful individuals may be more
are consistent with our hypotheses. The additive effects prone to the negative effects of stressors. Mindful individ-
showed that life stress was inversely related to mental uals are less likely to form habits of negative thinking or
health and physical health, and trait mindfulness had a rumination which tend to increase distress (Epel et al.,
positive effect on mental health. More importantly, life 2009), indicating that when exposed to stressors these
stress and trait mindfulness had a synergistic effect on individuals regulate their attention to the present moment
mental-health functioning. which functions to optimize emotional well-being. The
The detrimental effect of stress on mental health and most frequently endorsed stressful life events were a com-
physical health in middle-aged and older adults is consis- bination of egocentric (e.g. deterioration of memory and
tent with numerous studies. Other researchers have finances) and non-egocentric (illness of a friend/relative),
reported the negative effects of stressful life events or all of which are ongoing stressors in late life. The discrete
stressors on well-being (e.g. Couto et al., 2011; Kahana events (e.g. divorce) were endorsed less frequent. The
et al., 2012; Mancini, Bonanno, & Clark, 2011). Stressful accumulation of these types of stressors is known to have
life events may affect physical and mental health through the most adverse effect on health functioning (Almeida
biochemical pathways, such as elevated cortisol levels et al., 2011). The benefits of mindfulness training on low-
(Epel et al., 2009) and neurotoxicity (Lupien, McEwen, ering stress responses (e.g. lower cortisol) in patient sam-
Gunnar, & Heim, 2009). The accumulation of stressful ples has been reported elsewhere (e.g. Carlson, Speca,
life events may be associated with prolonged physiologi- Faris, & Patel, 2007). For older adults with severe depres-
cal arousal, resulting in a wear and tear of the human sion, the benefits of mindfulness-based stress reduction
 Aging & Mental Health 205

may be slightly weakened (Gallegos et al., 2013) and our psychology of aging (7th ed.). (pp. 191 206). San Diego,
study shows mindfulness is effective in reducing the nega- CA: Academic Press.
tive effects of stress on mental health in older adults who Baltes, P.B., & Baltes, M.M. (1993). Successful aging: Perspec-
tives from the behavioral sciences. New York, NY:
are screened for depression. By being mindful of momen- Cambridge University Press.
tary physical, affective, and cognitive experiences, the Baum, A., & Posluszny, D.M. (1999). Health psychology: Map-
individual may improve affect regulation in stressful sit- ping biobehavioral contributions to health and illness.
uations which would then protect mental-health function- Annual Review of Psychology, 50, 137 164.
ing and boost successful aging. Brown, K.W., & Ryan, R.M. (2003). The benefits of being pres-
ent: Mindfulness and its role in psychological well-being.
A few limitations of this study are worth noting. First, Journal of Personality and Social Psychology, 84,
the study focused exclusively on stressful life events. 822 848. doi:10.1037/0022-3514.84.4.822
Future research could examine the benefits of mindfulness Carlson, L.E., Speca, M., Faris, P., & Patel, K.D. (2007). One year
as a buffer to other dimensions of stress (e.g. daily hassles, pre-post intervention follow-up of psychological, immune,
chronic stressors). Second, since participants were screened endocrine and blood pressure outcomes of mindfulness-based
stress reduction (MBSR) in breast and prostate cancer outpa-
for clinical depression and were generally healthy, the tients. Brain Behavior and Immunity, 21, 1038 1049.
results may not generalize to older adults with depression. Charles, S.T., Piazza, J.R., Mogle, J., Sliwinski, M.J., &
Third, the effects on physical health were minimal and Almeida, D.M. (2013). The wear and tear of daily stressors
other research may examine older adults with known phys- on mental health. Psychological Science, 24(5), 733 741.
ical limitations. All testing for this study was conducted at doi: 10.1177/0956797612462222
Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness
the university campus and participants were mobile. training improve cognitive abilities? A systematic review of
Strengths of this study are also noted. First, this study neuropsychological findings. Clinical Psychology Review,
extends prior research by showing that the detrimental 31, 449 464. doi:org/10.1016/j.cpr.2010.11.003
effects of exposure to stressors on mental health in mid- Couto, M.C.P.P., Koller, S.H., & Novo, R. (2011). Stressful life
life and late adulthood are buffered by mindfulness, a events and psychological well-being in a Brazilian sample
of older persons: The role of resilience. Ageing Interna-
resiliency factor. The results from this study offer targets tional, 36, 492 505.
for mental-health interventions aimed at promoting Dautovich, N.D., Dzierzwski, J.M., & Gum, A.M. (2013). Older
healthy aging. Second, all participants were screened for adults display concurrent but not delayed associations
clinical depression. between life stressors and depressive symptoms: A micro-
In sum, this study found that individual differences in longitudinal study. American Journal of Geriatric Psychia-
try. Advance online publication. doi:10.1016/j.
mindfulness had a moderating effect on the life stress jagp.2013.02.008
mental-health link. The clinical impact of the synergistic Davidson, R.J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M.,
effect is that older adults experiencing high levels of stress Muller, D., Santorelli, S.F., . . . Sheridan, J.F. (2003). Altera-
would benefit most from formal mindfulness meditation tions in brain and immune function produced by mindfulness
training as a means to gain or maintain a healthy mind. meditation. Psychosomatic Medicine, 65, 564 570. doi:10.
1097/01.PSY.0000077505.67574.E3
Targeting vulnerable older adults (e.g. those who have Epel, E., Daubenmier, J., Moskowitz, J.T., Folkman, S., &
recently lost a loved one) early may be the key to prevent- Blackburn, E. (2009). Can meditation slow rate of cellular
ing more serious mental disorders. aging? Cognitive stress, mindfulness, and telomeres. Annals
of the New York Academy of Sciences, 1172, 34 53.
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Acknowledgments Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). Mini-
Mental State: A practical method for grading the cognitive
We thank the participants of the study for their time and lab staff state of patients for the clinician. Journal of Psychiatric
members for their assistance with data collection. Research, 12, 189 198. doi:org/10.1016/0022-3956(75)
90026-6
de Frias, C.M. (2013). Memory compensation in older adults:
Funding The role of health, emotion regulation, and trait mindfulness.
This work was supported by a seed grant and start-up funds from Journal of Gerontology: Psychological Sciences. Advance
The University of Texas at Dallas to Cindy de Frias. online publication. Retrieved from http://www.ncbi.nlm.nih.
gov/pubmed/23811295
Gallegos, A.M., Hoerger, M., Talbot, N., Moynihan, J.A., &
Duberstein, P.R. (2013). Emotional benefits of mindfulness-
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