REducing pSychological diSTress To Optimize Recovery of Elderly ICU Survivors and Caregivers (RESTORE-ICU)

Overview of the Study This study will evaluate the feasibility of implementing a mindfulness-based intervention, Inner Engineering (IE) practices, with concurrent EEG measurements among elderly ICU survivors aged 60 to 85 years and their caregivers. The intervention includes Isha Kriya and Nadi Shuddhi, two simple and accessible meditation practices delivered via a secure digital platform. The study aims to assess feasibility, acceptability, and barriers to implementation while testing paired EEG hyperscanning to explore neural congruency between participants. Conducted in two phases, the study will refine the research infrastructure and optimize the delivery of IE practices, first in the hospital setting and then remotely in home environments.

Overall Study Design This proof-of-concept pilot study utilizes an interventional, mixed-methods design combining experimental feasibility testing, EEG hyperscanning, and qualitative assessments. The study is divided into two phases: Phase 1 focuses on refining infrastructure for delivering IE and EEG monitoring in the hospital, while Phase 2 transitions to evaluating the feasibility of remote intervention delivery and monitoring in participants' homes.

Intervention Isha Kriya, a 15-minute guided meditation, and Nadi Shuddhi, a 3-5-minute alternate-nostril breathing practice. Participants in the intervention groups will be instructed to practice ideally twice or at least once daily. The study interventions will be introduced in-person for patients and either in-person or remotely for their caregivers. After the initial introduction, the interventions will be administered via the 3Cs app. This application has been used for meditation interventions and allows accurate tracking of usage metrics.

Nadi Shuddhi - a gentle 4-minute breathing practice for creating mental balance and relaxation, to be practiced for a minimum of 4 minutes daily.

https://www.youtube.com/watch?v=q5m6tMjcF8k

Isha Kriya - a 15-minute guided meditation that incorporates the breath and the awareness to create mental clarity and health, to be practiced at least once (ideally twice) daily. https://www.youtube.com/watch?v=EwQkfoKxRvo

Phase 1: Refining Hospital-Based Procedures Phase 1 focuses on establishing the research infrastructure within the hospital setting to optimize the implementation of Inner Engineering (IE) practices and EEG hyperscanning. Two ICU survivor-caregiver dyads will be recruited, with survivors defined as individuals aged 60-85 years who experienced an ICU stay of five or more days, and caregivers who self-identify as such and either live with or frequently visit the survivor. Baseline data collection will include high-fidelity EEG hyperscanning and psychological surveys. After learning and practicing IE, participants will complete another EEG hyperscanning data collection and post-intervention assessments. Semi-structured interviews will provide critical feedback on the intervention's acceptability and feasibility, helping to refine study processes for future phases.

Phase 2: Post-Discharge Implementation Phase 2 evaluates the feasibility of implementing IE practices after hospital discharge, focusing on participants' adherence to daily meditation practices. Five ICU survivor-caregiver dyads will be enrolled. At the hospital, baseline data collection will include EEG hyperscanning with the high-density R-Net system and psychological surveys. Participants will then learn the IE practices, with instructions to practice ideally twice or at least once daily. Post-intervention data will be collected afterwards, including EEG hyperscanning and surveys. After discharge to home, participants will be instructed to practice surveys will be completed at weeks 2, 4, and 6. At the end of week 6, a semi-structured interview will gather feedback on the intervention's feasibility, acceptability, and barriers to enrollment or retention.

Patient Inclusion/Exclusion Criteria

Inclusion criteria

• Provide signed and dated informed consent and understand the nature of the study sufficiently to allow completion of all study assessments.
• Elderly ICU survivors aged over 60 years who have experienced long ICU stays of more than five days.
• Caregivers who either live in the same household as the survivor or visit more than three times a week.

Exclusion criteria

Co-enrollment in other interventional studies will not be allowed.

• Age >=85 years (Justification: Assessment instruments not validated in this age group and patients in extremes of age may have limited proficiency to engage in proposed meditative practices)
• Non-English speaking/Low-English proficiency (Justification: assessment instruments are not validated in a sufficient range of languages, and the research team lacks polylingual capabilities or the financial resources to hire interpreters for the duration of all proposed assessments.)
• Non-US resident
• Recent or current meditation, yoga, breathwork or associated MBI intervention practice (> 2 times per week). (Justification: as the primary outcome is to evaluate the feasibility and adherence of patients to a multicomponent MBI, recent or current practice of the individual or combined components would directly influence the endpoint).
• Individuals discharged to a non-home location, such as a rehabilitation center, nursing home, or long-term acute care facility.
• Individuals with limited internet access, which would prevent access to online guided meditation
• Prisoners.
• Individuals who refuse to participate in the study.
• Not on vasopressor or inotropic support at the time of enrollment.
• Not on non-invasive ventilation, high-flow nasal cannula (HFNC), or mechanically ventilated.
• Not on continuous renal replacement therapy (CRRT).
• Failure to pass Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) screening (>3.6; Justification: Cognitive decline would limit the ability to engage with and complete the study interventions and assessments).
• Scores ≥ 5 on either the anxiety or depression subscales suggesting severe symptom levels.
• Known diagnosis of moderate or severe dementia.
• Neurological injury.
• Residing in a medical institution before admission.
• Patient on hospice at or before the time of enrollment.
• Mechanical ventilation at baseline or solely for airway protection.
• Patient not expected to go home (e.g., transfer to a facility).
• Patient not expected to survive two months or expected to transition to hospice.
• Patient died in hospital before enrollment.
• Attending physician declined enrollment.
• Patient discharged before being approached for consent.
• Either the patient or caregiver in the dyad declined participation (based on IQCODE or consent).

Caregiver Inclusion/Exclusion Criteria

Inclusion criteria

• Provide signed and dated informed consent and understand the nature of the study sufficiently to allow completion of all study assessments.
• Caregivers who either live in the same household as the survivor or visit more than three times a week.
• Age ≥18 years old.

Exclusion criteria

• Non-English speaking/Low-English proficiency (Justification: assessment instruments are not validated in a sufficient range of languages, and the research team lacks polylingual capabilities or the financial resources to hire interpreters for the duration of all proposed assessments.)
• Non-US resident
• Recent or current meditation, yoga, breathwork or associated MBI intervention practice (> 2 times per week). (Justification: as the primary outcome is to evaluate the feasibility and adherence of patients to a multicomponent MBI, recent or current practice of the individual or combined components would directly influence the endpoint).
• Individuals with limited internet access, which would prevent access to online guided meditation
• Prisoners.
• Individuals who refuse to participate in the study.
• Diagnosed with severe psychiatric disorders, such as schizophrenia, bipolar disorder, or ongoing substance abuse, that could interfere with participation.
• Individuals actively receiving treatment for recent trauma
• Scores ≥ 5 on either the anxiety or depression subscales suggesting severe symptom levels.
• severe or acute medical illness