Kav Vedhara

Chronic stress in elderly carers of dementia patients and antibody response to influenza vaccination

BACKGROUND There are many reports of psychological morbidity in spousal carers of patients with dementia. The consequences of this increased stress on the immune system are unclear. We investigated whether antibody responses to influenza vaccination differed between carers and a control group, and the relation of the antibody response to the hypothalamic-pituitary-adrenal (HPA) axis. METHODS 50 spousal carers of dementia patients, median age 73 years (IQR 66-77), and 67 controls (68 years [66-71]) of similar socioeconomic status were enrolled. Anxiety and depression were measured by the Savage Aged Personality Screening Scale and stress by the Global Measure of Perceived Stress scale. Principal-component analysis was used to yield a summary score of emotional distress from these two scales. Salivary cortisol concentrations were measured over a single day at three times (0800-1000, 1100-1300, and 2000-2200). Participants received a trivalent influenza vaccine and IgG antibody titres to each strain were measured on days 0, 7, 14, and 28. FINDINGS Mean scores of emotional distress were significantly higher in carers at each time point than in controls (all p<0.0003). Mean (SD) salivary cortisol concentrations, calculated as area under the curve (AUC), were higher in carers than controls at all three assessments (6 months 16.0 [8.0] vs 11.2 [4.4], p=0.0001; respectively). Eight (16%) of 50 carers and 26 (39%) of 67 controls had a four-fold increase in at least one of the IgG titres (p=0.007). There was an inverse relation between AUC cortisol and IgG antibody titre to the Nanchang strain that was significant on day 14 (r=-0.216, p=0.039). INTERPRETATION Elderly carers of spouses with dementia have increased activation of the hypothalamic-pituitary-adrenal axis and a poor antibody response to influenza vaccine. Carers may be more vulnerable to infectious disease than the population of a similar age.

An investigation into the relationship between salivary cortisol, stress, anxiety and depression.

This study examined the relationship between indices of self-reported emotional distress and absolute versus change in cortisol levels. Fifty-four women attending a diagnostic breast clinic completed scales measuring stress, anxiety and depression and provided five saliva samples over the course of a single day for the measurement of cortisol. No significant relationships were evident between absolute cortisol levels and the distress measures. Analysis of the change in cortisol levels revealed a non-linear interaction effect between stress and anxiety and time of day. There was a non-linear relation between time of day and cortisol levels, but the extent of the non-linearity was dependent upon levels of stress and anxiety, not depression. A relationship was apparent between indices of distress and change in cortisol levels, but not absolute levels of the hormone.

The role of stressors and psychosocial variables in the stress process: a study of chronic caregiver stress.

Objective An investigation was conducted 1) to examine the relative importance of stressor types (ie, daily hassles, caregiving-specific stressors, and life events) on the stress response, 2) to assess the stability of relationships between psychosocial variables and stress over a 6-month period, and 3) to explore how the nature and magnitude of the contributions made by stressors and psychosocial factors to the stress process varied according to the qualitative characteristics of the stress response (ie, anxiety, depression, and stress). Methods Fifty spousal caregivers of patients with dementia were recruited and asked to participate in a detailed psychosocial evaluation at 3-month intervals; the evaluation involved measurement of stressor frequency, psychosocial variables, and indices of the stress response (ie, anxiety, depression, and stress). Results The data revealed that the effects of stressors and psychosocial factors on the stress response were considerable (accounting for 49–63% of the variance in stress response measures). Furthermore, there was some evidence of stability in the effects of the stressor and mediator variables on the stress response. Specifically, the contributions of life events and caregiver difficulties were largely consistent at both 3 and 6 months, and the psychosocial factor of “reactive coping and self-appraisal” influenced all three stress response indices at both 3 and 6 months. Conclusions There is some evidence of stability in the effects of stressors and psychosocial variables on the stress process over a 6-month period. However, it would also seem that the nature of the stress process differs according to the qualitative characteristics of the stress response.

Habitual prospective memory in elderly patients with Type 2 diabetes: implications for medication adherence

Habitual prospective memory (HPM) may be important in medication adherence. The present study utilized a computer-based task of HPM to (1) examine the relationship between HPM performance and medication adherence and (2) explore whether, and under what conditions, HPM could be enhanced. Forty-eight elderly diabetic patients were randomly allocated to one of four HPM task conditions: no cue, visual cue, auditory cue or dual cue (auditory and visual cue) to aid performance. Medication adherence was monitored for at least 10 days using electronic dose event monitors. HPM task performance was optimal in the dual cue condition and there was some evidence of a relationship between HPM task performance and indices of medication adherence.

Mineralocorticoid and glucocorticoid receptors and their differential effects on memory performance in people with Addison’s disease

The effects of corticosteroids on memory performance have been the subject of some controversy. Whilst many studies have shown that high levels of corticosteroids can impair memory performance, others have shown they can facilitate it. One explanation for these discrepant effects arises from the differential activation of the two types of corticosteroid receptor--the mineralocorticoid receptor (MRs) and the glucocorticoid receptor (GRs), and the function each subserves during memory formation. Studies in rats and chickens suggest that activation of the MRs is essential during sensory storage (i.e. encoding), whereas normal levels of activation of the GRs (in addition to the already activated MRs) is essential during memory consolidation and retrieval. By using a repeated measures design with nine people with Addisons disease (mean age, 37.9 years), the effects following activation of the MRs only, GRs only, and a combination of MRs/GRs, on working memory and the episodic and semantic components of declarative memory were investigated. MRs and GRs were activated using either MR specific (9 alpha fluorohydrocortisone) or GR specific (dexamethasone) exogenous steroids, respectively. The results showed that participants performed better in the Digits Backward task when both receptors were activated compared to when GRs only were activated (P<0.01). They also performed better in recall in the Hopkins Verbal Learning Test when both receptors were activated compared to when MRs only were activated (P<0.05) and GRs only were activated (P<0.01). Whilst significant effects were not consistent across memory tasks, these results lend further support to the view that balanced activation of MRs and GRs is necessary for optimal memory function in humans.

Correlates and Predictors of Self-reported Psychological and Physical Morbidity in Chronic Caregiver Stress.

An investigation was conducted to explore: (1) whether psychological and physical morbidity share similar psychosocial determinants; (2) the long-term stability of these determinants; and (3) the role of neuroticism in predicting psychological and physical morbidity. Fifty spousal caregivers of dementia patients were recruited into a 12-month study. Participants were followed up at six-monthly interva ls during which they completed scales measuring psychosocial mediators, psychological morbidity, physical morbidity and neuroticism. Psychological morbidity was influenced primarily by indices of coping and neuroticism. Physical morbidity was influenced primarily by indices of psychological morbidity (increased psychological morbidity was associated with perceptions of greater physical morbidity). Neuroticism exhibited significant cross-sectional and longitudinal relationships with the indices of psychological morbidity, but only cross-sectional relationships with the indices of physical morbidity.

Predicting adherence to eye patching in children with amblyopia: An application of protection motivation theory

OBJECTIVES This study reports an application of protection motivation theory (PMT) to the prediction of parental adherence to eye patching recommendations for children with amblyopia over a 2-month period. The study also considered the role of past behaviour in PMT. DESIGN AND METHODS A total of 151 parents of children with amblyopia who were attending follow-up appointments for orthoptic treatment participated. They completed questionnaires based on PMT to assess their beliefs about amblyopia and eye patching. Of the parents, 105 were contacted again at 2-month follow-up to obtain a measure of adherence to the recommended treatment for their child. RESULTS PMT was found to be predictive of adherence intentions and behaviour at 2-month follow-up. Regression analyses revealed perceived vulnerability, response efficacy and self-efficacy to be significant predictors of protection motivation, whereas perceived vulnerability and response costs were significant predictors of adherence behaviour. Past adherence behaviour was found to have a direct effect on future adherence behaviour over and above the influence of PMT. CONCLUSIONS The results are discussed in relation to the sufficiency of PMTas a model of adherence behaviour. The practical implications for attempts to increase adherence to eye patching among children with amblyopia are outlined.

Psychosocial vulnerability to stress: A study of HIV-positive homosexual men ☆

Sixty-one homosexual men with HIV infection participated in a 12-month investigation into the role of stressful life events and mediating variables in the stress process. The results revealed that frequency of stressful life events and psychosocial resilience (a factor indexing levels of support, worry, personal self-esteem, and effective coping efforts) significantly predicted levels of emotional distress in this sample. The combined influence of these variables accounted for 53% (Phase 2) and 55% (Phase 3) of the variance in levels of emotional distress. The data point to a need to incorporate measures of life event frequency and several, rather than single, mediating variables in studies investigating the stress process.

Do patients’ beliefs about type 2 diabetes differ in accordance with complications: An investigation into diabetic foot ulceration and retinopathy

Background: Previous research has examined patients’ beliefs in diabetes and how these beliefs may affect patient outcomes. However, changes in symptoms and complications are a common feature of diabetes, and these can significantly alter the patient’s “disease experience.” However, no consideration has been given to how beliefs about diabetes vary according to the complications patients have. Purpose: The present study was designed to compare the beliefs of 22 patients with diabetic foot ulcers and 22 age- and gender-matched patients with diabetic retinopathy, and 22 age- and gender-matched controls with type 2 diabetes but without either complication. Methods: Beliefs about diabetes were assessed with the Revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002). Results: Patients with foot ulcers held a greater belief in personal control of diabetes, but perceived treatment control was lower than that of diabetic controls without serious complications (p < .05). Patients with foot ulcers also demonstrated less illness coherence than patients with retinopathy and diabetic controls (p < .01) and also perceived their diabetes to be more cyclical in nature (p < .01). Conclusion. Differences were found in diabetic patients’ beliefs according to their complications. Future interventions should consider how the complications associated with diabetes may affect patients’ beliefs and subsequent emotional and behavioral responses to the disease.

Quality of partner relationship and emotional responses to a health threat

This study investigated whether existence of a cohabiting relationship and its quality was related to psychological distress in women facing an acute stressor - a health threat. Levels of social support and self-esteem were tested as predictors of distress. One hundred and fifty-eight women with symptomatic breast problems referred to a diagnostic one-stop breast clinic participated in the study. Levels of psychological distress (stress, anxiety, depression), social support, self-esteem and, for women with partners, quality of partner relationship were measured using standardized self-report instruments. No differences were found between women with and without partners in terms of distress and psychosocial variables. However, women in low quality relationships experienced significantly more distress and received less support than women in high quality relationships. Self-esteem was not related to partner relationships. Low personal self-esteem significantly predicted distress on the appointment day for all groups of women, accounting for between 19% and 54% of the variance. Social self-esteem and ideal social support were also found to be significant predictors of distress for women without partners and cohabiting women in low quality relationships. It would appear that women with self-rated poor quality spousal relationships are at risk of elevated psychological morbidity in the context of investigation for suspected breast disease.