Longitudinal trajectories of cognitive decline and cerebral blood flow abnormalities in octogenarian men with normal global cognition.

Aims: Cognitive and perfusion changes have been previously observed in older men with Mini Mental State Examination scores>24 points. We aimed to investigate time change in cognitive domains in a cohort of non-demented men between age 68 and 82, and how they are expressed in regional defects estimated by Cerebral Blood Flow (rCBF). Methods: 103 men at age 81 with MMSE scores >24 (mean 28.4 ± 1.7), no dementia or stroke, were examined with the same cognitive test battery at age 68 and age 81: Synonyms (SRB-1), Block design (SRB-3), Paired Associates, Digit Symbol Substitution and Benton Visual Retention test. rCBF was estimated using 99mTc-HMPAO SPECT at age 82. Results: Between ages 68 and 82 we observed a relative decline (Δ%) of cognitive test scores: SRB-3 and Benton tests, -33.7 % (SD 16,8) and -25.8 % (SD 23.9) respectively, followed by Digit Symbol test: -22,6 % (SD 15,6). The cluster of men (46 %) could be detected, grouped on the largest test score decline and highest overall test predictors' importance in decreasing order: Δ% SRB-3, Δ% Paired Associates, Δ% Digit Symbol, Δ% Benton VR and Δ% SRB-1. Compared to the cluster with stable cognitive functions, it expressed lower rCBF in frontal and parietal lobes, and in subcortical areas. Conclusion: Nearly half of the studied, community-dwelling cohort of non-demented, octogenarian men with MMSE > 24, had a combination of decreasing visuospatial ability and episodic memory during preceding years, expressed by widespread rCBF changes in fronto-subcortical areas.

Cognitive abnormalities and cerebral perfusion defects in a community-dwelling cohort of elderly men with MMSE within the normal range.

OBJECTIVES: Mini Mental State Examination's (MMSE's) sensitivity in its upper level is questioned, hence we investigated cognitive abnormalities and defects in regional cerebral blood flow (rCBF) in elderly with MMSE scores ≥24. METHODS: One hundred and four men at age 81 with MMSE scores ≥24 (mean 28.4 ± 1.7), no dementia or stroke, were examined with neuropsychological test battery, and their rCBF was estimated using 99mTc-HMPAO SPECT. RESULTS: MMSE was very sparsely correlated with rCBF. Instead, visuo-spatial tests were correlated with rCBF in parietal and occipital lobe, verbal tests with rCBF in frontal and temporal-parietal lobes, and most of all between Digit Symbol and all rCBF regions, especially in subcortical gray and white matter. In a cluster of low achievers, test of Synonyms, followed by Digit Symbol and Benton test, had highest discriminatory importance. Low achievers had generalized rCBF changes especially in subcortical areas. Only lower scores on two MMSE items, figure drawing and calculation, could discriminate the clusters. CONCLUSION: A substantial number of octogenarian men with MMSE ≥ 24p have widespread rCBF changes corresponding to a decreased speeded performance and verbal capacity.

Personality factors and depression as predictors of hospital-based health care utilization following acute myocardial infarction.

BACKGROUND: Whether personality factors and depressive traits affect patients' utilization of health care following an acute myocardial infarction is relatively unknown. The aim of this study was to examine whether hospital-based health care utilization after a myocardial infarction was correlated with patients' personality factors and depressive symptoms. METHODS: We studied 366 myocardial infarction patients admitted to Malmö University Hospital between 2002 and 2005 who subsequently participated in a cardiac rehabilitation programme. The patients were followed for two years after their index event. We investigated whether personality factors and depressive traits were correlated with the participants' health care utilization, defined as a) out-patient Cardiology visits and phone calls to a physician, nurse or a social worker, and b) acute visits or admissions to the Emergency or Cardiology Departments, using negative binominal regression analysis. RESULTS: In unadjusted comparisons neuroticism predicted more out-patient contacts. This significance remained after adjusting for age, sex, smoking, alcohol consumption and size of the myocardial infarction (measured as max level on troponin-I and left ventricular ejection fraction). There were no significant correlations between other personality factors or depression and out-patient contacts. None of the personality factors or depression predicted acute admissions. CONCLUSION: Apart from neuroticism, personality factors did not explain utilization of health care in terms of Cardiology out-patient contacts or acute admissions in myocardial infarction patients participating in a cardiac rehabilitation programme. Neither did depressive symptoms predict more health care utilization. This might indicate a robust cardiac rehabilitation programme offered to the study subjects, minimizing the need for additional health care contacts.

Smoking Cessation After Acute Myocardial Infarction in Relation to Depression and Personality Factors.

BACKGROUND: Smoking is an important cardiovascular risk factor and smoking cessation should be a primary target in secondary prevention after a myocardial infarction (MI). PURPOSE: The purpose of this study was to examine whether personality, coping and depression were related to smoking cessation after an MI. METHOD: MI patients ≤70 years (n = 323, 73 % men, 58.7 ± 8.3 years), participating in the Secondary Prevention and Compliance following Acute Myocardial Infarction study in Malmö, Sweden, between 2002 and 2005, were interviewed by a psychologist to assess coping strategies and completed Beck Depression and NEO Personality Inventories, in close proximity to the acute event. Correlation between smoking status (current, former and never), personality factors, coping and depression was assessed at baseline and 24 months after the MI using logistic regression and in a multivariate analysis, adjusting for age and sex. RESULTS: Of the participating patients, 46 % were current smokers. Two years after the event, 44 % of these were still smoking. At baseline, current smokers scored higher on the depression and neuroticism scales and had lower agreeableness scores. Patients who continued to smoke after 2 years had higher scores on being confrontational (i.e. confrontative coping style) compared to those who had managed to quit. Patients who continued to smoke had significantly lower agreeableness and were more often living alone. CONCLUSION: Personality, coping strategies and psychosocial circumstances are associated with smoking cessation rates in patients with MI. Considering personality factors and coping strategies to better individualise smoking cessation programs in MI patients might be of importance.

Depressive symptoms, atherosclerotic burden and cerebral blood flow disturbances in a cohort of octogenarian men from a general population.

BACKGROUND: The aim of this study was to examine in elderly men a relationship between depressive symptoms, peripheral vascular disease and cerebral blood flow (CBF). METHODS: Population-based cohort study started with an examination of 809 men at age 55, followed by the first (age 68ys) and second follow up (age 82ys). 128 survivors were examined at age 82 with 99mTc-HMPAO-SPECT to estimate CBF, Zung-Self-Rating-Depression Scale (ZSDS), and Ankle-Brachial Index (ABI). Analysis was performed on men free from stroke and dementia which defined the final study population to 120 subjects. RESULTS: ZSDS in the whole cohort ranged from 0.26 to 0.71 (reference 0.25-1.0). As the frequency of depressive symptoms was low, the case group (n = 31) was defined by ZSDS index above 75th percentile (≥0.48), comprising 9 subjects with mild depression (ZSDS 0.55-0.71) and 22 subjects at 88th percentile and above of the normal range (ZSDS index 0.48-0.54). Cases were more often current smokers at age 68 (44% vs. 24%; p = .02) and had lower systolic blood presure (SBP), lower social and physical activity, and suffered from fatigue, nausea, freezing and leg edema at age 82. Within the case group, ZSDS-index correlated negatively with CBF in subcortical area (r = -.42*), left and right thalamus (r = -.40*, r = -.46**), and right basal nuclei (r = -.35*). ZSDS-index correlated also with ABI at age 82 (right leg r = -.40*; left leg r = -.37*), and with Δ between ABI at age 82 and 68 (right r = -.36*; left r = -.46**). Despite decreasing SBP from age 68 to 82, adjusted multiple regression analysis showed in the case group that higher SBP determined CBF changes in the frontal and parietal areas, independently of ZSDS index, Δ ABI, and smoking. CONCLUSION: In this population-based cohort of octogenarian men free from stroke or dementia, a proportion of subjects with depressive symptoms was low. Still, men with borderline or mild depression scores had lower social and physical activity, persistent smoking habit, worse peripheral circulation in legs, and cerebral perfusion changes in basal nuclei, thalamus and subcortical white matter. Regional CBF decline could be partly mediated by higher SBP.

Decreasing blood pressure over time is the strongest predictor of depressive symptoms in octogenarian men.

OBJECTIVE: The aim of this study was to examine the longitudinal impact of blood pressure variations and vascular risk factors on depressive symptoms in the elderly. DESIGN: Longitudinal and cross-sectional cohort study. SETTING: Urban population of elderly men, city of Malmö, Sweden. PARTICIPANTS: A total of 809 randomly included men took part in a prospective cohort study, "Men born in 1914", and 171 survivors reached the age of 81 years. MEASUREMENTS: Depressive symptoms were estimated at the age of 81 using the Zung Self-Rating Depression Scale (ZSDS). Vascular risk factors were identified at both 68 and 81 years of age. RESULTS: At the age of 68, diagnosis of hypertension and on-going antihypertensive therapy were more frequent in subjects with high than low ZSDS scores. In contrast, at age 81, the highest ZSDS scores correlated with low systolic blood pressure (SBP). Declining SBP between the ages of 68 and 81 was more frequent in high-scoring than in low-scoring groups. Subjects with high ZSDS scores took more drugs and had more clinical diagnoses at age 81. Those taking hypnotics and sedatives had higher ZSDS scores, lower SBP at 81, and showed more frequent decrease in SBP during the observation period. CONCLUSION: Depressive symptoms in octogenarian men could be predicted by hypertension earlier in life, and were strongly associated with decreasing SBP during the last decade.

Behavior in a stressful situation, personality factors, and disease severity in patients with acute myocardial infarction: baseline findings from the prospective cohort study SECAMI (the Secondary Prevention and Compliance following Acute Myocardial Infarction study).

BACKGROUND: Psychosocial stress has been identified as a risk factor in association with cardiovascular disease but less attention has been paid to heterogeneity in vulnerability to stress. The serial Color Word Test (CWT) measures adaptation to a stressful situation and it can be used to identify individuals that are vulnerable to stress. Prospective studies have shown that individuals with a maladaptive behavior in this test are exposed to an increased risk of future cardiovascular events. The aim of the present study was to investigate whether maladaptive behavior in the serial CWT alone or in combination with any specific personality dimension was associated with severity of myocardial infarction (MI). METHODS: MI-patients (n = 147) completed the test and filled in a personality questionnaire in close proximity to the acute event. The results were analyzed in association with four indicators of severity: maximum levels above median of the cardiac biomarkers troponin I and creatine kinase-MB (CKMB), Q-wave infarctions, and a left ventricular ejection fraction (LVEF) ≤ 50%. RESULTS: Maladaptive behavior in the serial CWT together with low scores on extraversion were associated with maximum levels above median of cardiac troponin I (OR 2.97, CI 1.08-8.20, p = 0.04) and CKMB (OR 3.33, CI 1.12-9.93, p = 0.03). No associations were found between the combination maladaptive behavior and low scores on extraversion and Q-wave infarctions or a decreased LVEF. CONCLUSIONS: Maladaptive behavior in combination with low scores on extraversion is associated with higher cardiac biomarker levels following an MI. The serial CWT and personality questionnaires could be used to identify individuals vulnerable to the hazardous effects of stress and thereby are exposed to an increased risk of a more severe infarction.

The impact of personality factors on delay in seeking treatment of acute myocardial infarction.

BACKGROUND: Early hospital arrival and rapid intervention for acute myocardial infarction is essential for a successful outcome. Several studies have been unable to identify explanatory factors that slowed decision time. The present study examines whether personality, psychosocial factors, and coping strategies might explain differences in time delay from onset of symptoms of acute myocardial infarction to arrival at a hospital emergency room. METHODS: Questionnaires on coping strategies, personality dimensions, and depression were completed by 323 patients ages 26 to 70 who had suffered an acute myocardial infarction. Tests measuring stress adaptation were completed by 180 of them. The patients were then categorised into three groups, based on time from onset of symptoms until arrival at hospital, and compared using logistic regression analysis and general linear models. RESULTS: No correlation could be established between personality factors (i.e., extraversion, neuroticism, openness, agreeableness, conscientiousness) or depressive symptoms and time between onset of symptoms and arrival at hospital. Nor was there any significant relationship between self-reported patient coping strategies and time delay. CONCLUSIONS: We found no significant relationship between personality factors, coping strategies, or depression and time delays in seeking hospital after an acute myocardial infraction.

Social support at work and the risk of myocardial infarction and stroke in women and men.

It has been proposed that lack of social support in a work place characterized by high levels of stress, may increase the likelihood of future cardiovascular disease. The aim of this study was to analyze the prospective impact of social support at work in combination with self-reported work stress on incidence of myocardial infarction (MI) and stroke in a cohort of 4707 women (mean age: 54.2 years) and 3063 men (mean age: 55.5 years) in Malmö, Sweden. The results are based on self-reports of work-related stress and social support collected at baseline examinations between the years 1992 and 1996. Work-stress was operationalized according to the Karasek job strain model. Data on incidence of MI and stroke were obtained from national and regional registers. At the end of follow-up, December 31, 2001, 38 women had experienced an MI and 53 had had a stroke. Corresponding figures for men were 114 MIs and 81 strokes. The first finding was that social support at work was an independent predictor of an MI and stroke among women. The second finding was that there was no evidence to support the iso-strain model. The third finding was that low levels of social support at work together with a passive work situation indicated an increased risk of a future cardiovascular outcome (MI or stroke) during follow-up in the female group. In men, no association was found between any psychosocial work conditions and incidence of MI or stroke during the same follow-up period.

Social support and behavior in a stressful situation in relation to myocardial infarction and mortality: who is at risk? Results from prospective cohort study "Men born in 1914," Malmö, Sweden.

Coronary heart disease remains an important cause of morbidity and mortality. Much data support the view that social support is associated with coronary heart disease. Participants of the study "Men born in 1914," (414 men) were followed from a baseline measurement in 1982/83 until the end of 1996. At baseline, the men answered a questionnaire on social support and participated in a stressful test where their behavior was categorized as adaptive or maladaptive. This study examined whether social support had a prospective impact on the incidence of myocardial infarction and all-cause mortality when behavior in the stressful task was taken into consideration. The conclusion of the study was that unsatisfactory levels of social support is associated with an increased risk of incident myocardial infarction (HR 2.40, CI 1.36-4.25, p = .003) and premature death (HR 1.99, CI 1.32-3.00, p = .001) but only in men who had shown maladaptive behavior in the test.

Asymptomatic atherosclerosis and myocardial infarction: risk modified by ability to adapt to stressful situations. Results from prospective cohort study "Men born in 1914", Malmo, Sweden.

BACKGROUND: The purpose of this study was to investigate whether different behaviors in a stressful situation modify the risk of atherosclerosis in association with a myocardial infarction, cardiovascular mortality, and all-cause mortality. Many individuals have atherosclerotic changes in their arteries but may never experience any symptoms nor develop cardiovascular disease. A myocardial infarction is caused by a disruption of a vulnerable atherosclerotic plaque. The mechanisms that trigger these events are not fully understood, but among the proposed agents is psychological stress. A differential in risk exposure could be expected since individuals differ in their ability to cope with stressful situations. MATERIAL/METHODS: In the prospective cohort study "Men born in 1914", atherosclerosis was noninvasively studied in the peripheral, carotid, and coronary arteries at a baseline examination in 1982/83. The serial Color Word Test, which is a semi-experimental way to assess how individuals adapt in a stressful situation, was administered at the same examination. Participants were followed-up regarding incidence of myocardial infarction and mortality until December 31 1996. RESULTS: Atherosclerosis was associated with an increased risk of myocardial infarction (relative risk (RR) 2.96; 95% confidence interval (CI) 1.52 to 5.74) and cardiovascular mortality (RR 3.31; 95% CI 2.08 to 5.28) during follow-up only among the men who showed maladaptive behavior. No excess risk could be established in men with an adaptive behavior pattern. CONCLUSIONS: The serial Color Word Test can assist in identifying men at high cardiovascular risk.

Prognostic significance of ventricular arrhythmia modified by ability to adapt to stressful situations.

BACKGROUND: Ventricular arrhythmia is a risk factor for myocardial infarction and mortality but many individuals with this abnormality live long and healthy lives. The aim of this study is to analyse the prognostic significance of frequent and complex ventricular arrhythmia in men who differed regarding ability to adapt to a stressful situation. DESIGN: Prospective cohort study. METHODS: The serial Color Word Test is a semi-experimental way to assess how individuals behave in a stressful encounter. This test was included in the prospective cohort study 'Men born in 1914' together with 24-h ambulatory electrocardiographic recordings at a baseline examination in 1982/83. Behaviour in the test was categorized as either adaptive or maladaptive. Behaviour in the test and occurrence of ventricular arrhythmia at baseline were analyzed in relation to incidence of myocardial infarction and mortality during approximately 14 years of follow-up. RESULTS: Multivariate analyses showed that ventricular arrhythmia was not associated with the incidence of myocardial infarction or all-cause mortality in the presence of an adaptive behaviour. Ventricular arrhythmia together with a maladaptive behaviour was associated with the incidence of myocardial infarction [relative risk (RR) 2.43; 95% confidence interval (CI) 1.37 to 4.31] and with all-cause mortality (RR 1.56; 95% CI 1.01 to 2.41) during follow-up. CONCLUSIONS: A maladaptive behaviour in a stressful encounter makes men with electrocardiographically detected ventricular arrhythmias more vulnerable and thereby exposed to an increased risk of a future myocardial infarction and overall mortality.

Adaptive behavior in stressful situations in relation to postinfarction mortality results from prospective cohort study "Men Born in 1914" in Malmo, Sweden.

The serial Color Word Test, which is a semi-experimental way to differentiate adaptive behavior in stressful situations, was administered at baseline to men participating in the prospective cohort study "Men born in 1914". During follow-up, from 1982-1983 until December 31, 1996, 133 men experienced a myocardial infarction. Four patterns of adaptive behavior in 2 separate dimensions, the Variability and the Regression, can be discerned during testing. These patterns were compared regarding outcome following the myocardial infarction. The Cumulative-dissociative pattern of the Regression dimension was univariately associated with mortality within 28 days (OR 5.75, CI 1.85-17.88, p = .003). Dissociative (OR 3.87, CI 1.21-12.42, p = .023) and Cumulative-dissociative (OR 5.46, CI 1.66-17.96, p = .005) patterns, of the same dimension, were independently associated with mortality within one year. Specific difficulties in adaptation to stressful situations were associated with increased risk of death following a myocardial infarction. In this male sample, these difficulties could be identified with the serial Color Word Test.

Hypertension and changes of cognitive function in 81-year-old men: a 13-year follow-up of the population study "Men born in 1914", Sweden.

BACKGROUND: The relationship between blood pressure levels and decline of cognition has been discussed previously, but little is known about the confounding effect of lifestyle factors, antihypertensive treatment and disease in the elderly. OBJECTIVE: To examine the association between systolic (SBP) and diastolic (DBP) blood pressure, changes of DBP and SBP and hypertension (HT) on cognitive function, while controlling for confounding factors. DESIGN: A longitudinal cohort study of men born in 1914 and residing in the municipality of Malmö studied at age 68 and 81 years. SETTING: Probands invited to a university clinic. SUBJECTS: One hundred and eighty-six out of 281 invited men still alive in 1995/6 participated in the most recent follow-up. MAIN OUTCOME: Change of the cognitive performance in the verbal (Paired Associates and Synonyms), spatial (Block Design and Benton Visual Retention test) and speed (Digit Symbol Substitution) functions. RESULTS: DBP by tertiles at 68 years, but not HT, was inversely related to verbal, spatial and speed performance at 81 years. Only spatial function was related to SBP at 68 years. The association between DBP and SBP by tertiles, and spatial functions (Block Design and Benton Visual Retention test) remained after controlling for education, marital status, smoking, alcohol and physical activity, and intermediates such as arteriosclerotic manifestations (block design, beta = 0.17; = 0.029) in multiple regression models. A decrease in DBP was likewise related to spatial (beta = 0.16; = 0.049) and speed performance (beta = 0.17; = 0.039) in the same regression model. CONCLUSIONS: Evidence is found to support the hypothesis that hypertension, especially high DBP in late midlife, is associated with a decline in spatial performance of cognitive functions in elderly men.