Mindfulness: A new approach to reduce COPD hospitalizations

Volume 8, Issue 1
Summary illustration - CPR research: Increasing survival after cardiac arrest


A Mayo Clinic researcher is helping patients with chronic obstructive pulmonary disease breathe easier and reduce their hospital stays through traditional care combined with mindfulness.

Roberto Benzo, M.D., who uses mindfulness training to help his patients.

Roberto Benzo, M.D., uses mindfulness training to help his patients.

Valerie Olson stands in her kitchen absorbed in a deliberate performance of coordinated, unhurried movements as she rolls out cookie dough. A green oxygen tube snakes across the floor. She exhales slowly as she moves the rolling pin away from her and inhales slowly as she rolls it back. Olson, 66, of Lanesboro, Minn., has end-stage chronic obstructive pulmonary disease (COPD).

Because of her COPD, Olson has struggled with air hunger for many years — a sensation that she can't get enough air to breathe. This past year, she also has had upper respiratory infections, a bladder infection, lung cancer surgery and a fungal infection of the lungs. She also needs continuous oxygen therapy to keep her blood properly oxygenated. Despite her numerous health challenges, Olson is actually faring better today than she was just a year ago thanks to a new treatment approach advocated by Mayo Clinic researcher Roberto P. Benzo, M.D. An optimistic woman by nature, Olson calls Dr. Benzo her "guardian angel" for helping her regain her optimism and for increasing her quality of life.

Dr. Benzo is a Mayo Clinic pulmonologist and an epidemiologist with an interest in behavioral medicine. Dr. Benzo's research combines conventional medicine with complementary medicine, creating a novel treatment technique that encourages patients to improve their health through training in self-efficacy and mindfulness meditation. Mindfulness, the act of intense awareness of what you are sensing and feeling at every moment, produces an acute understanding of the importance of one's own role in improving one's physical condition. This results in self-efficacy — patients themselves induce an effect that actually results in improved health outcomes.

His approach not only helps patients with COPD feel better physically and emotionally, but also reduces the number of hospital admissions and the time they stay in the hospital after surgery.

Shorter hospital stays, fewer hospital admissions

Chronic obstructive pulmonary disease is not a single disease but rather a group of lung diseases that blocks airflow as you exhale and makes it increasingly difficult to breathe. Emphysema and chronic asthmatic bronchitis are the two main conditions that make up COPD. Dr. Benzo's research in self-efficacy, mindfulness and meditation is helping patients find better ways to live with COPD.

In a Mayo Clinic study of patients with severe lung disease who underwent lung surgery, the patients who had self-efficacy training in mindfulness meditation before surgery reduced their hospital stay by three days (Lung Cancer, June 2011). Dr. Benzo's current multicenter study on this project was funded by the National Institutes of Health (NIH). A second NIH grant supports Dr. Benzo's study on hospital readmissions. Qualitative analysis from these ongoing studies suggests that his interventions might reduce hospital admissions by 20 percent for patients with COPD. The impact could be huge, not only for the individual but for national health care costs. Consider:

  • Seventy percent of the cost of COPD is related to hospitalizations.
  • COPD is typically a disease of older adults, and people are living longer.
  • Mindfulness meditation training is low cost.
  • Mindfulness meditation could be broadly applied to a wide variety of diseases and treatments.

In a recent study, Dr. Benzo evaluated 600 patients with COPD and showed that patient perception of their own health is the most important predictor of their hospital admissions (Respiration, 2010).

In this work, he collaborates with a team of biostatisticians headed by Jeff A. Sloan, Ph.D., a Mayo Clinic professor of biostatistics and oncology who evaluates the relationship of patient responses to therapy approaches and health care outcomes.

"Our findings show that if patients with severe COPD have the perception that their health is not good, they will be twice as likely to seek emergency care and be hospitalized," Dr. Benzo says. "When a person is sad or anxious, it influences the way they think about their situation. It turns out perception is a more reliable predictor of hospitalization than physiological tests, such as lung function or walking tests. Mindfulness — being completely present and seeing things as they really are, not as we want them to be — can, therefore, help improve patients' perceptions and, consequently, their health outcomes."

Understanding mindfulness and its benefits

Mindfulness has its origins in 2,500-year-old Buddhist traditions. The idea is to become fully aware of every movement you make, not with the goal of creating a positive outcome but simply to appreciate the moment by paying attention to what you are sensing and feeling.

Hundreds of scientific studies have shown that the way we think can have a significant effect on our physical condition. One study showed that patients with psoriasis who received ultraviolet light treatments and had mindfulness meditation training healed four times faster than patients in the control group who received only the light treatment. Another study suggested that mindfulness produced a significantly stronger antibody response in the immune system after a flu vaccine. Still other studies have shown that mindfulness changes the electrical activity of the prefrontal cerebral cortex, the part of the brain involved in the expression of emotions.

Mayo Clinic provides the latest and best medical treatment for patients with COPD. Many patients, however, have frequent complications because they simply give up. Dr. Benzo's mindfulness approach is based on the knowledge that when patients understand the importance of their own role in improving their well-being, they bring an extra edge to the effort.

Patients in Dr. Benzo's clinical trials undergo an active eight-week rehabilitation program. A wellness coach uses motivational interviewing, a style of communication, to identify an appropriate exercise and develop an individualized plan. Participants are also trained to become aware of their body sensations and motions as they exercise. Active coaching is followed by monthly calls to keep them motivated.

"Daily practice is the core of the rehabilitation," Dr. Benzo says. "This means carving out a special time to be present with what is going on with their body and coming to terms with their life as it is."

Encouraging activity

Patient inactivity is one of the most important predictors of mortality in COPD (Respiratory Medicine, 2010). Having found activity monitors to be an objective method to assess activity in COPD patients (COPD, 2007), Dr. Benzo is now evaluating how the information from those monitors, connected to smartphones, encourages activity.

For people who are severely short of breath because of COPD, activity doesn't mean a round of golf or a brisk walk. It means doing any simple task, such as washing the dishes. Any physical activity is valid as long as it's performed mindfully. Dr. Benzo explains the process as a positive spiral with patients "re-cognizing" — that is, they consciously and purposefully think about the activity as they are doing it. The mental reinforcement, along with the physical activity, helps them regain confidence in their ability. The result is that they want to do more.

Valerie Olson is one of those patients who has benefited from Dr. Benzo's ongoing research. Until a few years ago, Olson was in constant high gear in both her hair salon and her kitchen. Today, baking has become an important way for her to stay active. Rolling out the cookie dough isn't just a step in the baking process — those are deliberate, yoga-like movements that help keep her active. And the mindfulness that she's been practicing for the past year as part of her treatment with Dr. Benzo has helped her come to terms with the lifestyle changes she's had to make because of her COPD. Despite many health problems last year, Olson was admitted to the hospital only once, and that was for lung surgery.

"Before the training, there were days when I would just sleep," Olson recalls. "Dr. Benzo has taught me that it's important to still do something on bad days, just not as much. I do walking meditation, one slow step at a time. Mindfulness practice has made me feel OK with COPD. It's not curable, but I still have lots of life left in me."

Embracing mindfulness is hard work — it means committing to daily practice sessions that take time and effort. But the rewards are real. Some studies have shown that mindfulness relieves stress and pain and improves athletic performance. From Dr. Benzo's own experience as an athlete — he plays squash and competes in triathlons and marathons — and as a student of meditation, he understands how mindfulness can give elite athletes a competitive edge. It is this edge that he hopes to give his patients, not so they can perform like an athlete, but so they can approach today's limitations with resilience and determination. For patients with end-stage lung disease, worrying about what is going to happen tomorrow or in a year or two years isn't productive.

"Awareness and appreciation of the life that they have right now is the key," Dr. Benzo says. "When they undertake this personal commitment to life, they learn to accept their limitations and start to feel contentment with life as it is and they actually feel better, which likely stimulates mechanisms that improve health care outcomes."

Looking ahead

One future research project includes collaborating with Mayo Clinic's Center for the Science of Health Care Delivery to study the biological effects of mindfulness. Dr. Benzo also is collaborating with physiologist Bruce D. Johnson, Ph.D., to develop ways to analyze the stress response on the autonomic nervous system. And with thoracic oncologist Dennis Wigle, M.D., Ph.D., and molecular biologist Martin E. Fernandez-Zapico, M.D., Dr. Benzo is working on several ideas to observe the effects of mindfulness on genomic expression. He is even pursuing the idea of using video games to train cognitive functions.

"These are not expensive interventions and they make the patients feel better," Dr. Benzo says. "My research is right in line with Mayo Clinic's mission, and I look forward to working toward instituting them into the way we practice at Mayo Clinic."