Chapter 24

Kirtan Kriya Meditation: A Promising Technique for Enhancing Cognition in Memory-Impaired Older Adults
Dharma Singh Khalsa and Andrew Newberg

Abstract This chapter reviews some of the predictors and markers for Alzheimers, focusing on stress for the breadth of its impact and because it is an amenable target for treatment. We then describe a low cost and easy to learn meditation technique, Kirtan Kriya, that can not only lower stress, but preliminary evidence suggests it also increases cognitive ability among those with incipient Alzheimers Disease.

Humankinds New Problem

Its easy to overlook the remarkableness of aging, exclaimed the renowned geronto logist, Ken Dychtwald (2010). He pointed out that for 99% of the history of humankind, average life expectancy at birth was less than 18 years of age. Long before they reached what we would consider old age, people during that time died first of infectious diseases, accidents, or violence. Over the last thousand years, life expectancy climbed from 25 years, reached 47 by the turn of the twentieth century, sky-rocketed to 78 by the twenty-first century, and is still climbing. Currently, the age group with the greatest population increase is centenarians. At the time that the Constitution of the United States was being ratified, arthritis, heart disease, and dementia were seldom, if ever problems that physicians were called upon to treat, in part because lifespan was too short for these conditions to emerge as medical problems. Beginning of the last century, however, something unprecedented has been happening. Advances in sanitation, public health, food science, pharmacy, medicine, and wellness-oriented lifestyles, have resulted in an eleven-fold increase in the number of Americans of 65 years or older age, from 3 to 33 million. The US Census Bureau predicts that number will increase to 70 million by the year 2035.
D.S. Khalsa(*) Alzheimers Research and Prevention Foundation, Tucson, AZ, USA Center for Spirituality and the Mind, University of Pennsylvania, Philadelphia, PA, USA e-mail: drdharma@alzheimersprevention.org P.E. Hartman-Stein and A. La Rue (eds.), Enhancing Cognitive Fitness in Adults: A Guide to the Use and Development of Community-Based Programs, DOI 10.1007/978-1-4419-0636-6_24, Springer Science+Business Media, LLC 2011 419

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While the increase in lifespan enjoyed by many people is to be applauded, increasing longevity brings with it a major problem: the dramatic increase in the incidence of cognitive decline, dementia, and particularly, Alzheimers disease (Alzheimers Association, 2010). Today there are 5.3 million people with Alzheimers disease in the United States with a price tag of $148 billion a year, not counting the over ten million unpaid caregivers. Alzheimers is the sixth leading cause of death. More telling however, is the fact that Alzheimers disease is now the number one worry of aging baby boomers, surpassing cancer and heart disease.

Predictors and Markers of Alzheimers

Age. The best predictor for Alzheimers disease (AD) is advancing age. As a person gets older, the probability of having AD increases. However, significant cognitive decline is not a normal part of aging. Subjective cognitive impairment (SCI). SCI describes the experience of healthy older adults who have the feeling that their memory is not functioning as well as it should, but for whom the subjective symptom cannot be verified objectively by clinicians. Where clinicians used to dismiss this complaint, it has recently emerged as an early marker for AD (Reisberg, Shulman, Torossian, Leng, & Zhu, 2010). These researchers reported that, over a 7-year period, study participants who had SCI progressed to mild cognitive impairment (MCI) and AD at a higher rate than those who did not. Of those without SCI at the start of the study but who did decline to MCI or AD over its course, mean time to decline was 3.5 year longer than for SCI subjects. In patients without pure cognitive complaints, such as those with multiple sclerosis, there is a relationship between depression, fatigue, SCI, and objective neuropsychological functioning (Kinsinger, Lattie, & Mohr, 2010). Mild cognitive impairment. Individuals with MCI have cognitive problems that exceed what is expected for their age and background but are not severe enough to meet the criteria for the diagnosis of dementia. MCI is a risk factor for developing AD or other dementias and is often considered a preclinical stage of dementia (see Chap. 21). Medical conditions. Medical conditions that are high risk factors for AD include cardiovascular disease, high cholesterol, Type 2 diabetes, high blood pressure, smoking, and obesity. Many of these factors are modifiable via medications and lifestyle changes; undertaking such modifications may decrease the likelihood of developing both heart disease and cognitive dysfunction. Although epidemiologic studies show associations with these factors and AD risk, randomized clinical trials have not clearly demonstrated yet that odds of getting dementia actually decrease with treatment or lifestyle changes. Stress. Stress occurs when a person is unable to cope with the demands placed upon him/her. When his/her ability to perform is exceeded by the demand, stress ensues. Individuals have different levels of tolerance to stress, and different responses at different times in their lives. Although well documented in the research

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literature, the effect of chronic stress is an under-discussed and underappreciated aspect of maintaining brain fitness in an aging population. The next section offers historical and recent research results that show why stress management is so important to brain health.

Stress and the Brain

In the first authors personal and clinical experience, chronic, unrelenting stress may be near the top of the list of todays lifestyle factors that impact the cause and possibly the progression of AD. Why? Stress stimulates the adrenal glands to release the hormone cortisol, which then flows throughout the blood stream. Cortisol suppresses the immune system function. Stein-Behrins and Sapolsky (1992) found that illness and aging are times of decreased ability to handle stress. Cortisol also shortens the lifespan of cells and of the organism overall. The lifespan of a normal, healthy cell is controlled by its telomeres, a segment of DNA at the tip of the chromosome. Telomeres are believed to have a protective function, like the plastic tip of a shoe lace that prevents the lace from unraveling. Telomeres prevent chromosomes from losing genetic information needed in the replication process. Each time the cell divides, the telomere is shortened, until at last the telomere length is insufficient for the cell to replicate itself and it eventually dies. However, there is an enzyme, telomerase, which can rebuild the DNA sequence at the end of the chromosome and thus lengthen the telomere. Choi, Fauce, & Effros (2008) found that exposure to cortisol was associated with a reduction in telomerase activity in human T lymphocytes. By acting on telomerase, cortisol affects cell life. When cortisol reduces telomerase activity, the telomeres in the DNA shortened precipitously and, in turn, the shortened telomeres accelerate aging and illness. People with both chronic stress and AD are in double jeopardy in regard to their cells, as Lukens, Van Deerlin, Clark, Xie, & Johnson (2009) found, because telomere length in peripheral blood is already diminished in individuals who have AD. Of most interest here is the research into the direct role of stress and cortisol on the development of dementia. Early life stresses, such as abuse and neglect at a young age, result in the development of inflammation in the hippocampus, the brain structure that is fundamental to learning and commonly the site of initial deterioration in AD. Although causal linking has not yet been established, this early-age inflammatory process could potentially contribute to AD pathology (Anda et al., 2006; Bornstein, Copenhaver, & Mortimer, 2006). Newcomer etal. (1999) found decreased memory performance in healthy humans who were injected intravenously with stress-levels of cortisol. In a longitudinal study conducted over a period of 30 years, Crowe, Andel, Pedersen, and Gatz (2007) found a higher risk of dementia in individuals who reported a high incidence of work-related stress. Wilson etal. (2003) showed that Alzheimers disease is higher in people with a stress-prone personality. Peavy et al. (2007) showed that stress produced more reactivity and higher levels of cortisol with subsequent worse effects on memory function in older individuals who had a genetic risk for the development of AD (i.e., ApoE4 positive).

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The hormone cortisol has been shown to kill brain cells in the hippocampus, the brain structure fundamental to learning and sometimes considered to be the memory center of the brain (Sapolsky, 1992; McEwen & Sapolsky, 1992). Prolonged exposure to stress leads to loss of neurons, particularly in the hippocampus (Lupien, McEwen, Gunnar, & Heim, 2009). In both humans and animals, reactions to stress and also regulation of many other body processes, including digestion, mood, immune function, energy are controlled by means of communications among a set of structures in the midbrain called the hypothalamic-pituitary-adrenal axis, or the HPA axis. If the functioning of the HPA axis becomes impaired, the ability to regulate the body functions just listed is also impaired. A connection between cognition in the older adult and the HPA has been found. For example, MacLullich etal. (2006) showed that a smaller anterior cingulate cortex (ACC) is associated with an impaired hypothalamicpituitary-adrenal axis (the HPA axis) regulation in healthy elderly men. The ACC plays an important role in rational cognitive functions, including focusing attention and decision-making. It is a central station for processing stimuli and assigning appropriate control to other areas in the brain. It is involved in learning and problemsolving tasks. Hence, the Alasdair et al. finding associating diminishment of the ACC to impaired stress regulation is especially significant. To summarize, chronic, unmanaged stress causes excessive cortisol release from the adrenal gland into the blood stream. This cortisol then travels to the hippocampus, where it causes brain cell death and shuts off the inhibition of production of further cortisol from the adrenal gland. The excess of cortisol causes inflammation and hippocampal neuronal cell death, and also accelerates aging by decreasing telomere length, which in turn may lead to more inflammation, cardiovascular disease, cancer, and Alzheimers.

Stress Response Versus Relaxation Response

Humans and most animals exhibit a stress response when facing a situation whose difficulty is beyond their perceived ability. Humans also possess a counterbalancing capability, the relaxation response. The main difference between the two is that the stress response may occur as a result of environmental stimulation, but the relaxation response requires the individual to take action. The stress response and the relaxation response were first demonstrated by Walter Hess in 1949 by stimulating two discrete areas of the hypothalamus in the brain of a cat. Table24.1 shows that these two phenomena are opposites of each other. The relaxation response was popularized by Benson in 1975. This is a relaxed, self-healing state, and requires positive action to experience. In addition to the effects listed in Table24.1, it is said to activate the bodys natural healing mechanism. There are four requirements to enter it (Benson, 1975): . A comfortable position. 1 2. A quite environment.

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. A tool or mental device. 3 4. A specific attitude. The comfortable position can be achieved by simply sitting on a chair, or on the floor in a comfortable, cross-legged posture. The environment should be quiet with an absence of distraction. The next two requirements to enter into a relaxation or basic meditative state are perhaps the most important. The tool can be any thought, sound, phrase, or object on which one focuses. Examples include a chosen word such as one, or peace, or an object such as the breath flowing in and out. The attitude has to do with not becoming attached to any thoughts that enters consciousness, but rather to acknowledge them and then go back to the chosen focus. So it is an attitude of accepting that ones mind will wander in spite of the desire to focus, and of not being harsh with oneself when it happens. The relaxation response is a way to manage stress. Meditation is closely related to this technique, sharing both the four requirements listed above and also outcomes in regard to stress management. There are at least 13 physiological effects of basic meditation that have been observed (Khalsa, 2001). In addition to the four listed in Table24.1, these include decreases in the stress hormones epinephrine, norepinephrine, and cortisol; decrease in lactic acid, which signifies a decrease in anxiety level; decrease in lipid peroxidase, which reveals a decrease in free radical formation; an increase in the hormone DHEA; increase in the sleep and antiaging hormone, melatonin; enhanced immune system function, and a reduction in inflammatory molecules. Meditation is frequently, if not always, associated with positive psychological changes (See Kaszniaks review, chapter 5). These changes, in turn, are related to telomerase activity in immune cells (Jacobs etal., 2011), which has the potential to promote longevity in those cells, as explained above. Older adults who learned and continued to practice Transcendental Meditation (TM) were indeed found to have the highest survival rates 3 years after completion of a study that compared the effects of TM, relaxation training, mindfulness, and no treatment (Alexander, Langer, Newman, Chandler, & Davies, 1989). Neuroimaging studies of meditators with such scanning techniques such as magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT) have provided evidence that meditation has direct benefits on the brain. These include increased activity in the hippocampus (Lazar, Bush, Gollub, & Fricchione, 2000), increased cortical thickness (Lazar etal., 2005), diminished loss of brain volume with age (Newberg etal., 2001) and enhanced activity in the prefrontal cortex (Newberg etal., in press). This last finding is especially significant because the prefrontal cortex is associated with attention, concentration, focus, decision-making, and short-term memory.
Table24.1 Walter Hesss (1968) discovery of the stress response Stress response Relaxation response Blood pressure Increased Decrease Pulse Increased Decrease Respiratory rate Increased Decrease MVO2 or oxygen demand Increase (rise) Decrease (drop)

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This extensive menu of benefits from meditation is available at a relatively low cost (patients time) and generally no side effects, resulting in a high benefit-to-cost ratio, not only for the patient, but for society. The forms of basic and more advanced meditation are legion, and some require the investment of many years of practice to master. However, one form of particular interest is Kirtan Kriya (KK) meditation because it can be performed even by those whose memory has some impairment, and the benefits accrue from the very first practice session, based upon preliminary evidence from our research. Before describing the research on which these claims are based, the next section describes the KK practice.

Kirtan Kriya Meditation

Kirtan Kriya is a 12-min singing exercise in the Kundalini yoga tradition that people have been practicing for thousands of years. A kirtan is a song. Kriya refers to a specific set of movements. In the Eastern meditation tradition, kriyas are used to help bring the body, mind, and emotions into balance, thus creating healing. The Kirtan Kriya form of meditation is meant to be practiced for greater attention, concentration, improved short-term memory, and better mood. KK brings together several modalities of behavior: singing or chanting, finger movements (mudras), visualization, and sequence tracking. Hence, it is a multifaceted, multisensory exercise that engages several areas of the brain. The complexity of the method thus absorbs attention to such a degree that the likelihood of distracting thoughts entering the mind is greatly diminished. KK shares the four requirements listed above for the relaxation response and basic meditation. It applies the standard meditation behaviors for posture, eye direction, and breath as well. The technique is described by Khalsa (2001). Posture. The individual can sit comfortably in a chair with their feet flat on the floor. Alternatively, one can sit on the floor with legs crossed, although older adults are not likely to choose this option. The essence of the posture is to be comfortable and sit with spine straight with only the natural curvature. Breath. The practitioner simply breathes naturally as the meditation unfolds. Eyes. Eyes are closed. The chant or mantra. The chant uses the sounds, Saa, Taa, Naa, Maa. These ancient primal sounds from Sanskrit, taken together, mean my true identity or my highest self. The tune to which these sounds are sung is the first four notes of the familiar childrens song, Mary had a Little Lamb. That is, the notes are Mar-y had a. See Fig.24.1. The mudras or finger movements. The thumb is touched to each of the other four fingers in sequence. Both hands perform the same mudra set simultaneously. Figure24.1 illustrates.

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Fig.24.1 Tooch fingers on sequence as you sing the sounds Fig.24.2 Visualize the sound entering the top of the head and out the forhead

On Saa, touch the index fingers of each hand to the thumbs. On Taa, touch your middle fingers to your thumbs. On Naa, touch your ring fingers to your thumbs. On Maa, touch your little fingers to your thumbs. Always go forward in sequence: thumb to index finger, middle finger, ring finger, and pinky; never go backwards. The visualization. Visualize energy coming down from above into the middle of the top of the head, proceeding straight down into your brain, and then changing to a lateral direction so that this force comes out of your head at a point in the middle of your forehead, in the center lined up with the nose (the spot referred to as the third eye in some Eastern traditions). Hence, the energy is visualized as following the path of a capital letter L. One may think of this action as sweeping through like a broom. See Fig.24.2. The sequence 1. Chant the sounds Saa Taa Naa Maa while also performing the mudras with the fingers of both hands. At the same time, visualize the L coming into and leaving the head. With each syllable, imagine the sound flowing in through the top of your head and out the middle of your forehead (your third eye point). 2. For 2min, sing in your normal voice. 3. For the next 2min, sing in a whisper.

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. For the next 4min, say the sound silently to yourself. 4 5. Then whisper the chant for 2 min, and then out loud for 2 min, for a total of 12min. 6. To come out of the exercise, inhale very deeply, stretch your hands above your head, and then bring them down slowly in a sweeping motion as you exhale. The first author has made a video demonstrating the KK meditation, which can be seen by going to www.alzheimersprevention.org/kkmeditation.

Effect of KK Meditation on Brain and Cognition

According to Kundalini yogic tradition, there are several mechanisms by which Kirtan Kriya conveys its benefits. The use of the tongue in Kirtan Kriya during the chanting is believed to stimulate the 84 acupuncture meridian points on the roof of the mouth in a certain permutation and combination that sends a signal to the hypothalamus, as well as to the brain itself. How this works on a chemical level is theoretical, but the first author conjectures that practicing KK may rejuvenate the brain synapse by increasing important brain chemicals, such as acetylcholine. The dense nerve endings in the fingertips, lips, and tongue are associated with a high level of representation in the motor and sensory areas of the brain. Therefore, when the practitioner utilizes the fingertips in conjunction with the sound, specific areas in the brain, as seen on SPECT scans, are activated. Khalsa, Amen, Hanks, Money, and Newberg (2009) showed particular cerebral blood flow changes during the practice of Kirtan Kriya. As shown in Fig. 24.3 the frontal lobes exhibited

Fig.24.3 SPECT scan before and after Kirtan Kriya: brain healing in action

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Fig.24.4 Activation of the posterior cingulate gyrus (Source: Khalsa etal. (2009) unpublished data)

increased cerebral blood flow. The posterior cingulate gyrus was activated (Fig.24.4). This is significant, because the posterior cingulate gyrus is one of the first areas that demonstrate decreased activity on a scan when one develops Alzheimers disease. One might therefore conjecture that consistent practice of the KK meditation and the concomitant activation of the posterior cingulate gyrus, potentially lead to a decreased risk for cognitive decline and Alzheimers disease. Long-term studies involving clinical outcomes as well as brain imaging will be needed to determine whether this conjecture is true. At present, exploratory studies are showing some intriguing cognitive benefits when Kirtan Kriya is practiced on a regular basis. Newberg, Wintering, Khalsa, Roggenkamp, and Waldman (2010) described positive effects of Kirtan Kriya on cognitive function and cerebral blood flow in subjects with memory loss. Significantly, this is the first study in which the KK meditation has been explored in people diagnosed with memory impairment although it is not the first study of people with memory loss; Alexander, Langer, Newman, Chandler, and Davies (1989) also included subjects with dementia in all treatment groups, including the TM group. In our preliminary study, participants who complained of memory loss symptoms were recruited, and either practiced KK for 12min per day (the experimental group) or listened to music for an equal amount of time (the comparison group). The 15 experimental participants ranged in age from 52 to 77 (mean 64, SD 8). Their MMSE scores ranged from 16 to 30. Seven had mild age-associated memory impairment (i.e., SCI), five had MCI, and three

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had a diagnosis of AD and moderate impairment. However, one of those with AD, whose MMSE score was 16, was found to be incapable of following the directions for performing the meditation, and her data was not included further in the results. Thus, 14 participants constituted the final experimentation group, two of whom had AD. The experimental group participants were individually instructed in how to perform the KK meditation. The training began with a 20-min video of one of the investigators explaining and demonstrating the technique. In this video and in further instructions to participants, the visualization component was not included. Then the participant was told to perform KK for a 12-min period while being supervised by one of the researchers. Participants were told to perform the 12-min KK practice daily for 8 weeks, and provided a CD to help guide them. The CD was a recording of the audible aspects, plus some background music as an aid in the rhythm. The comparison group comprised two people with MCI and three with ageassociated memory impairment (SCI), for a total of five participants who ranged from 56 to 79 years old (mean 65, SD 10). The mean MMSE score was 29 (SD 1). They were to listen daily to a CD on which had been recorded 12min of two Mozart violin concertos. The participants in the experimental group kept a practice log revealing a high degree of compliance (75%, on average). Participants were scanned (SPECT) both on the first day at which they had been instructed, and at the follow-up session after 8-weeks of at-home practice. They were also given a battery of neuropsychological tests on both occasions. The testing revealed a significant improvement in scores on a verbal fluency test, animal naming, and a test of divided attention, trailmaking, Part B. Both of these neuropsychological tests tap into executive functioning skills. Subjectively, the experimental participants also reported improvement in their overall memory functioning. Given Reisberg etal.s (2010) findings about SCI, this may be significant, as individuals with SCI may be at higher risk for progression to MCI and later Alzheimers disease. As stated above, this is the first study of the effects of the Kirtan Kriya meditation on people who are experiencing memory loss, and it revealed that KK had a positive effect in enhancing cerebral blood flow and improving cognitive functioning. Previous studies of meditators using attention-focusing practices other than KK have revealed activations in brain structures in the frontal lobe and ACC. Previous studies of meditators using mantras (not KK) have revealed changes in the temporal lobe. As can be seen in the scans below in Fig.24.5, from Newberg, Wintering, Khalsa, Roggenkamp and Waldman (2010), KK practice produced a difference in activation in the frontal lobe, posterior cingulate gyrus, and anterior cingulate gyrus, both the first time the subjects practiced the meditation on the day of instruction, and more prominently after 8 weeks of doing the meditation only 12min a day. MacLullich etal.s (2006) result reported earlier on the association between the ACC and the bodys ability to regulate stress, we speculate that enhancing activity of the anterior cingulate gyrus could improve hypothalamic-pituitary-adrenal axis function, and normalize the stress response so that not much of cortisol bathes the hippocampus.

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Fig.24.5 Enhanced cerebral blood flow in the anterior cingulate gyrus

Conclusion
Mitigating the biochemical effects of stress on the body and brain is an important, although rarely discussed, target of prevention for Alzheimers disease. Meditation has been shown to be helpful in lowering anxiety and stress as well as a variety of other positive health outcomes. However, some meditation techniques appear to be unattractive to older adults and too complex to be utilized by those whose memory is already compromised. This chapter described a form of meditation, Kirtan Kriya, that has been successfully used in preliminary studies by this population at risk for Alzheimers disease. Participants reported that it was enjoyable and subjectively beneficial, including a perception of improved cognition. Directed to practice it daily over a period of 8 weeks, participants did indeed practice it 75% of the days, on average. Newberg, Wintering, Waldman, Amen, Khalsa and Alavi (2010) found objective evidence of cognitive benefit as well. Hence, the Kirtan Kriya meditation appears to also improve a number of aspects of psychological well-being. Most noteworthy are the facts that this was a self-directed training program using a CD, after only a brief one-on-one instruction; the amount of time necessary was only 12min a day for 8 weeks for these results to be observable; it is both a practical and a low cost intervention; and it has no side effects, and does not interfere with medications. Our preliminary findings suggest KK meditation is a promising

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intervention for enhancing cognition in older adults with mild memory impairment that warrants further research and possible inclusion in complementary treatment protocols.

First Authors Final Comment

Yogi Bhajan, Ph.D., Master of Kundalini Yoga who brought KK to the West, was once asked: Sir, does meditation prevent dementia? Not only does it prevent dementia he replied, But it takes you to another dimension. In Khalsas opinion, this other dimension is one where the regular practitioner of KK will discover optimal health, psychological well-being, and brain longevity.

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