Kirstin Aschbacher

Increased Framingham Coronary Heart Disease Risk Score in Dementia Caregivers Relative to Non-Caregiving Controls

Background: Elderly individuals who provide care to a spouse suffering from dementia bear an increased risk of coronary heart disease (CHD). Objective: To test the hypothesis that the Framingham CHD Risk Score would be higher in dementia caregivers relative to non-caregiving controls. Methods: We investigated 64 caregivers providing in-home care for their spouse with Alzheimer’s disease and 41 gender-matched non-caregiving controls. All subjects (mean age 70 ± 8 years, 75% women, 93% Caucasian) had a negative history of CHD and cerebrovascular disease. The original Framingham CHD Risk Score was computed adding up categorical scores for age, blood lipids, blood pressure, diabetes, and smoking with adjustment made for sex. Results: The average CHD risk score was higher in caregivers than in controls even when co-varying for socioeconomic status, health habits, medication, and psychological distress (8.0 ± 2.9 vs. 6.3 ± 3.0 points, p = 0.013). The difference showed a medium effect size (Cohen’s d = 0.57). A relatively higher blood pressure in caregivers than in controls made the greatest contribution to this difference. The probability (area under the receiver operator curve) that a randomly selected caregiver had a greater CHD risk score than a randomly selected non-caregiver was 65.5%. Conclusions: Based on the Framingham CHD Risk Score, the potential to develop overt CHD in the following 10 years was predicted to be greater in dementia caregivers than in non-caregiving controls. The magnitude of the difference in the CHD risk between caregivers and controls appears to be clinically relevant. Clinicians may want to monitor caregiving status as a routine part of standard evaluation of their elderly patients’ cardiovascular risk.

Yoga for Veterans with Chronic Low-Back Pain

OBJECTIVES Chronic back pain affects a large proportion of both the general population and of military veterans. Although numerous therapies exist for treating chronic back pain, they can be costly and tend to have limited effectiveness. Thus, demonstrating the efficacy and cost-effectiveness of additional treatment alternatives is important. The purpose of our study was to examine the benefits of a yoga intervention for Veterans Administration (VA) patients. SUBJECTS/INTERVENTION: VA patients with chronic back pain were referred by their primary care providers to a yoga program as part of clinical care. Before starting yoga, a VA physician trained in yoga evaluated each patient to ensure that they could participate safely. DESIGN The research study consisted of completing a short battery of questionnaires at baseline and again 10 weeks later. OUTCOME MEASURES Questionnaires included measures of pain, depression, energy/fatigue, health-related quality of life, and program satisfaction. Paired t-tests were used to compare baseline scores to those at the 10-week follow-up for the single group, pre-post design. Correlations were used to examine whether yoga attendance and home practice were associated with better outcomes. RESULTS Baseline and follow-up data were available for 33 participants. Participants were VA patients with a mean age of 55 years. They were 21% female, 70% white, 52% married, 68% college graduates, and 44% were retired. Significant improvements were found for pain, depression, energy/fatigue, and the Short Form-12 Mental Health Scale. The number of yoga sessions attended and the frequency of home practice were associated with improved outcomes. Participants appeared highly satisfied with the yoga instructor and moderately satisfied with the ease of participation and health benefits of the yoga program. CONCLUSIONS Preliminary data suggest that a yoga intervention for VA patients with chronic back pain may improve the health of veterans. However, the limitations of a pre-post study design make conclusions tentative. A larger randomized, controlled trial of the yoga program is planned.

Altered blood coagulation in patients with posttraumatic stress disorder

Objective: Posttraumatic stress disorder (PTSD) has been associated with an increased cardiovascular risk, though the pathophysiologic mechanisms involved are elusive. A hypercoagulable state before occurrence of coronary thrombosis contributes to atherosclerosis development. We investigated whether PTSD would be associated with increased coagulation activity. Methods: We measured resting plasma levels of clotting factor VII activity (FVII:C), FVIII:C, FXII:C, fibrinogen, and D-dimer in 14 otherwise healthy patients with PTSD and in 14 age- and gender-matched, trauma-exposed non-PTSD controls. Categorical and dimensional diagnoses of PTSD were made using the Clinician-Administered PTSD Scale (CAPS) interview. We also investigated to what extent the relationship between PTSD and coagulation measures would be confounded by demographics, cardiovascular risk factors, lifestyle variables, time since trauma, and mood. Results: Coagulation factor levels did not significantly differ between patients with a categorical diagnosis of PTSD and controls while controlling for covariates. In all subjects, FVIII:C was predicted by hyperarousal severity (&bgr; = 0.46, p = .014) independent of covariates and by overall PTSD symptom severity (&bgr; = 0.38, p = .045); the latter association was of borderline significance when separately controlling for gender, smoking, exercise, and anxiety (p values <.07). In patients, fibrinogen was predicted by hyperarousal severity (&bgr; = 0.70, p = .005) and by overall PTSD symptom severity (&bgr; = 0.61, p = .020), with mood partially affecting these associations. FVII:C, fibrinogen, and D-dimer showed no independent association with PTSD symptoms. Conclusions: PTSD may elicit hypercoagulability, even at subthreshold levels, offering one psychobiological pathway by which posttraumatic stress might contribute to atherosclerosis progression and clinical cardiovascular disease. BMI = body mass index; CAD = coronary artery disease; CAPS = Clinician-Administered PTSD Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; FVII:C = clotting factor VII activity; FVIII:C = clotting factor VIII activity; FXII:C = clotting factor XII activity; MBP = mean arterial blood pressure; MI = myocardial infarction; PTSD = posttraumatic stress disorder; SNS = sympathetic nervous system; IL = interleukin; HADS = Hospital Anxiety and Depression Scale.

Effects of Alzheimer caregiving on allostatic load.

This study aimed to determine if Alzheimer caregivers have increased allostatic load compared to non-caregivers. Potential psychological moderators (mastery, depression, and role overload) of the relationship between caregiving status and allostatic load were also explored. Eighty-seven caregivers and 43 non-caregivers underwent biological assessment of allostatic load and psychological assessments. Caregivers had significantly higher allostatic load compared to non-caregivers ( p < .05). Mastery, but not depression or overload, moderated the relationship between caregiving status and allostatic load. In conclusion, allostatic load may represent a link explaining how stress translates to downstream pathology, but more work is necessary to understand the role of psychological factors.

Personal mastery is associated with reduced sympathetic arousal in stressed Alzheimer caregivers.

OBJECTIVES Spousal caregivers of Alzheimers disease patients are at increased risk for cardiovascular disease, possibly via sympathetic response to stressors and subsequent catecholamine surge. Personal mastery (i.e., belief that one can manage lifes obstacles) may decrease psychological and physiological response to stressors. This study examines the relationship between mastery and sympathetic arousal in elderly caregivers, as measured by norepinephrine (NE) reactivity to an acute psychological stressor. DESIGN Cross-sectional. SETTING Data were collected by a research nurse in each caregivers home. PARTICIPANTS Sixty-nine elderly spousal Alzheimer caregivers (mean age: 72.8 years) who were not taking beta-blocking medication. INTERVENTION After assessment for mastery and objective caregiving stressors, caregivers underwent an experimental speech task designed to induce sympathetic arousal. MEASUREMENTS Mastery was assessed using Pearlins Personal Mastery scale and Alzheimer patient functioning was assessed using the Clinical Dementia Rating Scale, Problem Behaviors Scale, and Activities of Daily Living Scale. Plasma NE assays were conducted using pre- and postspeech blood draws. RESULTS Multiple regression analyses revealed that mastery was significantly and negatively associated with NE reactivity (B = -9.86, t (61) = -2.03, p = 0.046) independent of factors theoretically and empirically linked to NE reactivity. CONCLUSIONS Caregivers with higher mastery had less NE reactivity to the stressor task. Mastery may exert a protective influence that mitigates the physiological effects of acute stress, and may be an important target for psychosocial interventions in order to reduce sympathetic arousal and cardiovascular stress among dementia caregivers.

Chronic stress increases vulnerability to diet-related abdominal fat, oxidative stress, and metabolic risk

BACKGROUND In preclinical studies, the combination of chronic stress and a high sugar/fat diet is a more potent driver of visceral adiposity than diet alone, a process mediated by peripheral neuropeptide Y (NPY). METHODS In a human model of chronic stress, we investigated whether the synergistic combination of highly palatable foods (HPF; high sugar/fat) and stress was associated with elevated metabolic risk. Using a case-control design, we compared 33 post-menopausal caregivers (the chronic stress group) to 28 age-matched low-stress control women on reported HPF consumption (modified Block Food Frequency Questionnaire), waistline circumference, truncal fat ultrasound, and insulin sensitivity using a 3-h oral glucose tolerance test. A fasting blood draw was assayed for plasma NPY and oxidative stress markers (8-hydroxyguanosine and F2-Isoprostanes). RESULTS Among chronically stressed women only, greater HPF consumption was associated with greater abdominal adiposity, oxidative stress, and insulin resistance at baseline (all ps≤.01). Furthermore, plasma NPY was significantly elevated in chronically stressed women (p<.01), and the association of HPF with abdominal adiposity was stronger among women with high versus low NPY. There were no significant predictions of change over 1-year, likely due to high stability (little change) in the primary outcomes over this period. DISCUSSION Chronic stress is associated with enhanced vulnerability to diet-related metabolic risk (abdominal adiposity, insulin resistance, and oxidative stress). Stress-induced peripheral NPY may play a mechanistic role.

Maintenance of a positive outlook during acute stress protects against pro-inflammatory reactivity and future depressive symptoms

UNLABELLED Cognitive and affective responses to acute stress influence pro-inflammatory cytokine reactivity, and peripheral cytokines (particularly interleukin-1 beta (IL-1β)), can act on the brain to promote depressive symptoms. It is unknown whether acute stress-induced changes in positive affect and cognitions (POS) and pro-inflammatory reactivity predict future depressive symptoms. We examined acute stress responses among women, to determine prospective predictors of depressive symptoms. HYPOTHESES (1) Stress-induced decreases in POS will be associated with stress-related increases in circulating IL-1β. (2) Acute stress-induced decreases in POS and increases in IL-1β reactivity will predict increases in depressive symptoms 1 year later. Thirty-five post-menopausal women were exposed to acute stress with the Trier Social Stress Task (TSST) and provided blood samples under resting conditions and 30 min after the conclusion of the TSST, which were assayed for IL-1β. IL-1β reactivity was quantified as post minus pre-TSST. Failure to maintain POS was quantified as the decrease in POS during the TSST. Change in depressive symptoms from the study baseline to the following year was determined. Greater acute stress-induced declines in POS were significantly associated with increased IL-1β reactivity (p≤.02), which significantly predicted increases in depressive symptoms over the following year (p<.01), controlling for age, body mass index, chronic stress, antidepressant use and baseline depressive symptoms. IL-1β reactivity was a significant mediator of the relationship between POS decline and future increases in depressive symptoms (p=.04). Difficulty maintaining positivity under stress and heightened pro-inflammatory reactivity may be markers and/or mechanisms of risk for future increases in depressive symptoms.

Effects of Gender and Dementia Severity on Alzheimer's Disease Caregivers' Sleep and Biomarkers of Coagulation and Inflammation

BACKGROUND Being a caregiver for a spouse with Alzheimers disease is associated with increased risk for cardiovascular illness, particularly for males. This study examined the effects of caregiver gender and severity of the spouses dementia on sleep, coagulation, and inflammation in the caregiver. METHODS Eighty-one male and female spousal caregivers and 41 non-caregivers participated (mean age of all participants 70.2 years). Full-night polysomnography (PSG) was recorded in each participants home. Severity of the Alzheimers disease patients dementia was determined by the Clinical Dementia Rating (CDR) scale. The Role Overload scale was completed as an assessment of caregiving stress. Blood was drawn to assess circulating levels of D-dimer and Interleukin-6 (IL-6). RESULTS Male caregivers who were caring for a spouse with moderate to severe dementia spent significantly more time awake after sleep onset than female caregivers caring for spouses with moderate to severe dementia (p=.011), who spent a similar amount of time awake after sleep onset to caregivers of low dementia spouses and to non-caregivers. Similarly, male caregivers caring for spouses with worse dementia had significantly higher circulating levels of D-dimer (p=.034) than females caring for spouses with worse dementia. In multiple regression analysis (adjusted R(2)=.270, p<.001), elevated D-dimer levels were predicted by a combination of the CDR rating of the patient (p=.047) as well as greater time awake after sleep onset (p=.046). DISCUSSION The findings suggest that males caring for spouses with more severe dementia experience more disturbed sleep and have greater coagulation, the latter being associated with the disturbed sleep. These findings may provide insight into why male caregivers of spouses with Alzheimers disease are at increased risk for illness, particularly cardiovascular disease.

Coping Processes and Hemostatic Reactivity to Acute Stress in Dementia Caregivers

Background: A hypercoagulable stress response might contribute to the increased cardiovascular risk in Alzheimer’s caregivers. Objectives: (1) To evaluate whether coping processes affect hemostatic reactivity to acute psychological stress and (2) whether these effects differ substantially between caregivers and noncaregivers. Methods: Sixty elderly community-dwelling spousal caregivers of patients with Alzheimer’s disease and 33 noncaregiving controls completed the revised Ways of Coping Questionnaire to assess approach/problem-solving versus avoidant coping processes. Participants were administered an acute stress test that required them to deliver a 3-minute speech challenge to the interviewer on an assigned topic. The hypercoagulability marker D-dimer was measured at three time points: baseline, immediately postspeech, and during recovery (15 minutes postspeech). Results: Multivariate analysis of covariance revealed that subjects who endorsed greater levels of approach coping had decreased levels of D-dimer at all time points (p = .048). A significant three-way interaction between planful problem solving, caregiver status, and the temporal pattern of D-dimer was found (p = .004), indicating that caregivers with low levels of planful problem solving exhibited greater increases in D-dimer from baseline to speech and recovery time points relative to controls. No relationship between avoidant coping and D-dimer was found. Conclusions: These findings suggest the possibility that approach and problem-solving coping processes buffer the impact of acute psychological stressors on procoagulant activity. It remains to be seen whether interventions that increase approach/problem-solving processes might produce salutary effects among caregiving populations. APP = approach coping; AVD = avoidant coping; BMI = body mass index; CGS = caregiver status; DD = D-dimer; HAM-D = Hamilton Rating Scale for Depression; HARS = Hamilton Anxiety Rating Scale; MANCOVA = multivariate analysis of covariance; PPS = planful problem solving; WOC = Ways of Coping; UCSD = University of California San Diego; HLM = hierarchical linear modeling.

Effects of faith/assurance on cortisol levels are enhanced by a spiritual mantram intervention in adults with HIV : A randomized trial

OBJECTIVES Previous research among HIV-infected individuals suggests that spiritual well-being is inversely related to psychological distress and rates of disease progression. Use of a mantram, a spiritual word or phrase repeated frequently and silently throughout the day, has been associated with decreased psychological distress and increased spiritual well-being. This study compared the effects of 2 interventions-a spiritually-based mantram intervention versus an attention-matched control group-on faith/assurance and average salivary cortisol levels among HIV-infected individuals. METHODS Using a randomized design, HIV-infected adults were assigned to the intervention (n = 36) or control condition (n = 35). Faith scores and saliva (collected at 7 a.m., 11 a.m., 4 p.m., and 9 p.m.) were assessed at preintervention, postintervention, and 5-week follow-up. Path analyses tested competing models that specify both concurrent and sequential relationships between faith and average daily cortisol levels while comparing groups. RESULTS Faith levels increased among mantram participants from pre- to postintervention. Greater faith at preintervention was significantly associated with lower average cortisol at postintervention in the mantram group but not in the controls. The associations between faith at postintervention and cortisol levels at 5-week follow-up were significant among both groups but weaker than the pre- to postintervention association identified in the mantram group. CONCLUSIONS These results suggest the presence of lagged or antecedent consequent relationships between faith and cortisol, which may be enhanced by mantram use. Decreased cortisol could potentially benefit immune functioning among HIV-infected individuals.