Spouse caregivers of Alzheimer patients: problem responses to caregiver burden.

This paper reports on comparisons of patterns of responses by 199 spouses of Alzheimer disease patients to stresses of functioning as caregivers. Focusing on gender and age of spouses, we examine effects of the total burden of caregiving and perceived patient problems on a set of emotional and social responses of caregivers. We also examine ways in which depressive symptoms and anxiety of spouse caregivers were associated with patterns of their responses to caregiving stresses. Total patient problem burden was most strongly associated positively with caregiver anger-resentment toward the patient, followed by caregiver concerns about personal time restriction and limitation of social life. Among individual areas of patient problems, emotional lability of the patient rather than cognitive impairment appeared strongest by far in affecting caregiver response measures. Negative impact of caregiving on their social life and associations appeared to have particularly marked effects on effects on caregiver depressive symptoms and anxiety scores. Spouse caregivers did not differ by age in clinically significant ways in their patterns of reaction to stresses of caregiving. The study suggests the importance of considering potential spouse caregiver reactions in such areas as anger and aggressive response to patients, the impact of feelings of social deprivation and personal sacrifice, as well as the implications of caregiving stresses for patient care and maintenance of family cohesion and quality of life.

Vulnerability of husband and wife caregivers of Alzheimer disease patients to caregiving stressors.

This study assessed relationships between problem behaviors in 199 Alzheimer Disease patients and vulnerability factors in the well being and emotional health of their spouse caregivers. Among caregiver wives and the younger caregiver husbands (64 years old and under) the volume of patient problem behavior was significantly negatively associated with total scores on a summary well being measure. The association was not found within the older husband caregiver group. Considering five subdimensions of the summary well being scale (Anxiety, Depressive Symptoms, Positive Well Being, Vitality and General Health), correlational analyses showed that the total patient problems measure appeared to have impact primarily among wife caregivers, particularly those 64 years old and under. Multiple regression analyses showed that one patient problem behavior category, Emotional Lability, was the single strongest predictor of impaired well being of the caregiver among all five subdimensions of the caregiver well being measure. Although Destructive Behavior of the patient was not significant by itself, an Age by Destructive Behavior interaction showed that high levels of patient Destructive Behavior predicted high levels of Depression, Anxiety, and low levels of Positive Well Being more among younger caregivers. Husband caregivers had significantly higher Anxiety scores than wife caregivers. These findings document how particular patient problem behaviors can affect caregivers. They point up as well how both gender and age may help target which caregivers are most vulnerable to the stress of specific Alzheimer patient behavior problems. They also suggest the utility of examining specific dimensions of well being rather than a total score alone for purposes of understanding the relationship of particular patient behavior problems to caregiver emotional and physical health.

Pain perception, coping strategies, and stress management among periodontal patients with repeated surgeries.

The relationships between coping strategies, stress response during periodontal surgery, and perceived pain after each of two surgical procedures were studied in 42 adult women between the ages of 28 and 67 years. The presurgical use of coping by indirect action was positively correlated with decreased stress behavior during each surgery. The use of attention-coping strategies was significantly correlated with pain measures after each surgery, while avoidance-coping strategies were not. Age and patients' rating of pain were the best predictors of the use of attention coping. These findings suggest that preoperative preparation which includes information on enhancing attention-coping may assist some patients with postsurgical pain and discomfort.

Pre-surgery psychological characteristics, pain response, and activities impairment in female patients with repeated periodontal surgery.

This study assessed relationships between pre-surgery psychological characteristics and post-surgery pain response and impairment of life activities following each of two sessions of periodontal surgery. Forty-two female periodontal patients between the ages 26 and 67 participated. None had experienced previous peridontal surgery. Pre-surgery scores on dental anxiety, fatigue, and depression were positively associated with measures of post-surgery pain after the first surgery, and were negatively associated with positive well-being scores. A similar, though weaker pattern of associations was evident after the second surgery. Younger women reported significantly greater impairment of life activities during recovery than did the older women after both surgery episodes. The study points to the relevance of pre-surgery well-being and psychological stability as predictors of post-surgery pain and degree of impairment of life activities, as seen in the time sequence of repeated surgeries.

Pain response after psychological preparation for repeated periodontal surgery.

The effects of pre-surgery intervention messages on postsurgical pain and recovery in 42 female patients were compared. Each participant was scheduled for at least two periodontal surgeries and exposed to one of four messages before each surgery. Auditory and visual messages classified as "control enhancement" were associated with reduction of pain after the second surgery with no effect after the first surgery.

Unmedicated blood pressure levels and quality of life in elderly hypertensive women.

We examined the associations between unmedicated systolic and diastolic blood pressure (BP) levels and measures of quality of life (QOL). Women (N = 315) ranging in age from 60 to 80 with diagnoses of mild to moderate hypertension were removed from antihypertensive medications and placed on placebo medication in the context of a clinical drug trial. Unmedicated BP levels were measured at the QOL interview, which followed a 4- to 8-week placebo run-in period, and at the preceding visit 1 week earlier. Indices representing five QOL dimensions were obtained in the QOL interview. The QOL dimensions assessed were: 1) sense of general well-being; 2) cognitive functioning; 3) affective status; 4) physical health status; and 5) level and enjoyment of social activity. QOL indices were regressed on unmedicated systolic and diastolic BP levels and on duration of hypertension in separate models. Each regression model included age, education, cigarette smoking, alcohol intake, and body mass index as covariables. We found that unmedicated BP levels were inversely related to QOL measures of cognitive functioning and social activity level. Although duration of hypertension was not related to cognitive functioning or social activity level, duration was associated with indices representing other dimensions of QOL. Specifically, duration of hypertension was inversely related to sense of general well-being and positively related to measures of physical health status, i.e., physical symptom incidence and sleep dysfunction.

Effects of antihypertensive medications on quality of life in elderly hypertensive women.

The impact of antihypertensive medications on the quality of life of elderly hypertensive women has rarely been systematically evaluated in large clinical trials using drugs from the new generations of pharmaceutic preparations. We carried out a multicenter, randomized double-blind clinical trial with 309 hypertensive women aged 60 to 80 years to assess effects of atenolol, enalapril, and isradipine on measures of quality of life over a 22-week period. The patients had mild to moderate hypertension. Hydrochlorothiazide was added to treatment if monotherapy was inadequate in lowering blood pressure. At the conclusion of the trial the three drug groups did not differ in degree of reduction of diastolic blood pressure or in supplementation with hydrochlorothiazide. Over the 22-week trial, linear trend analysis showed no differences between the treatment groups in change from baseline on quality of life measures of well-being, physical status, emotional status, cognitive functioning, and social role participation. Regarding each of 33 physical side effects over the 22 weeks, we found no general difference between atenolol, enalapril, and isradipine groups on measures of change in distress over symptoms except for enalapril patients who worsened in distress over cough (P = .001) and atenolol patients who worsened in distress over dry mouth (P = .014). Centering on three medications that are relatively new additions to the armamentarium for blood pressure control, the findings underline the increasing opportunities for the physician to select drugs that can control blood pressure while maintaining the quality of life of elderly hypertensive women.

The sexual functioning of elderly hypertensive women.

To assess the sexual interest and behavior of a large cohort of 60-80-year-old women with mild to moderate hypertension, data from a large multicenter study were analyzed. Of the 142 hypertensive women with partners, 87 (61%) were sexually active and 55 (39%) were sexually abstinent. The sexually active women were somewhat younger, had higher household incomes, and reported higher ratings of subjective sexual interest than did the abstinent women. For sexually abstinent women, two major factor appeared to determine the level of sexual activity: their partner's level of sexual desire and his health. Of particular note is the finding that the majority of women in both groups indicated moderate or high satisfaction with their sexual life. When the sample was divided into "younger" elderly (age 69 or below) and "older" elderly (70 or above), the percentage of women displaying moderate or high sexual interest was quite similar (76% and 65%, respectively). Difficulty achieving orgasm and lack of vaginal lubrication were the two most common sexual complaints. Scores on quality of life measures did not differ significantly between the sexual abstinent and active women at baseline.

Relation of hostility to medication adherence, symptom complaints, and blood pressure reduction in a clinical field trial of antihypertensive medication.

The impact of hostility was examined in relation to the conduct and results of a clinical field trial. Data were derived from a multi-center randomized double-blind study of the comparative effects of antihypertensive therapy (captopril, methyldopa and propranolol) on the quality of life of 620 hypertensive men. Hostility levels were higher in subjects reporting skipping medication dosages compared to those reporting they always complied with the medication schedule. Reporting of symptoms often associated with antihypertensive drug regimens was positively related to hostility scores throughout the study, even during the blinded placebo period. Persons with high hostility scores showed the greatest decline in blood pressure independent of type of antihypertensive medication. However, there was some limited evidence that hostility levels were significantly reduced by one antihypertensive medication. Overall, the present findings suggest that double-blind pharmacologic clinical trials may benefit from using reliable measures of hostility as covariates in the evaluation of symptom reports and amount of blood pressure reduction.

Hypertensive black men and women. Quality of life and effects of antihypertensive medications. Black Hypertension Quality of Life Multicenter Trial Group.

A multicenter, randomized double-blind clinical trial was conducted among 306 black men and women with mild to moderate hypertension to determine effects of atenolol, captopril, and verapamil SR on measures of quality of life. Patients were randomly assigned to a stable or forced-dose titration sequence. After an 8-week treatment period, the rate of withdrawal from treatment because of adverse effects was low and did not differ by drug treatment group or titration level. Patients taking verapamil SR showed a significantly greater reduction in mean blood pressures than patients treated with atenolol or captopril. Along with absence of worsening on any quality of life total scale scores examined over the treatment period, we found either improvement or no change in the total scale scores for all three treatment groups. Among both male and female patients, comparisons between drug treatment groups showed no differences in degree of change on the total scale scores. In comparisons within each treatment group, improvement in scores of male patients after 8 weeks appeared among those taking atenolol in general well-being and physical symptoms reduction; among male patients taking captopril in general well-being, physical symptoms, and sexual performance; and among male patients receiving verapamil SR in scores in irritability, sleep, and the Digit Span test. Improvement in scores among female patients taking atenolol was found in scores on general well-being, physical symptoms, and sleep; among women taking captopril on general well-being, physical symptoms, and irritability; and among women taking verapamil SR on general well-being. Patients in all treatment groups improved on measures of visuomotor functioning. The research shows that with the three newer generation antihypertensive medications studied, blood pressure control was achieved during the treatment period without negative effects on quality of life scales, along with findings of improvement on some measures. Given the special clinical features of hypertension in black patients, the study underlines as well the potential and utility of systematic tracking of measures of quality of life, while monitoring blood pressures in this patient population.

Self-reported side effects from antihypertensive drugs. A clinical trial. Quality of Life Research Group.

We report on the distress associated with physical symptoms in 761 male hypertensive patients enrolled in a clinical trial of the effects of captopril, methyldopa or propranolol on quality of life. Educational level at entry into the trial showed a negative association with a series of physical symptom distress items among patients not previously treated with antihypertensive medications but no association with symptoms among the previously treated. Over the 24 weeks of therapy captopril as monotherapy was associated with no change from baseline in distress in all symptoms examined. In contrast, distress increased in the methyldopa treated patients for dry mouth and blurred vision. Propranolol treated patients had increased "trouble getting breath," bradycardia, shortness of breath or wheezing, and blurred vision. Between group comparisons revealed significant differences favorably comparing captopril to both methyldopa and propranolol in regard to fatigue, and blurred vision, as well as to methyldopa alone for dry mouth and "feeling worn out." There were significant differences as well between captopril and propranolol with patients on propranolol worsening in bradycardia. Other comparisons of patients on propranolol and methyldopa monotherapy showed propranolol patients worsening in bradycardia and loss of taste, but methyldopa patients reported more dry mouth and feeling worn out than those on propranolol. The addition of hydrochlorothiazide to therapy worsened total physical symptom distress scores for methyldopa and propranolol patients. This study confirms the value of methods which assess the degree of distress associated with symptoms commonly reported by hypertensive patients receiving antihypertensive medications. This approach can be useful in establishing a treatment regimen least likely to cause distress and can be of value in preserving quality of life, preventing noncompliance, and withdrawal from treatment.

Sexual symptoms in hypertensive patients. A clinical trial of antihypertensive medications.

The effects of captopril, methyldopa, and propranolol hydrochloride on reported distress over sexual symptoms over a 24-week treatment period were examined as part of a multicenter, randomized, double-blind clinical trial in which 626 men with mild to moderate hypertension participated. On entry into the clinical trial, 58% of patients taking antihypertensive medications and 44% of men not receiving antihypertensive drugs reported distress over one or more sexual symptoms. Among 304 patients treated with monotherapy who completed the trial, total symptoms distress scores of treatment groups did not differ from each other in change from baseline to week 24, but in particular, problems of maintaining an erection were significantly worsened with propranolol therapy. Among 177 patients treated with monotherapy plus a diuretic, total sexual symptoms distress scores worsened among the groups taking methyldopa or propranolol, with significant worsening in all individual symptoms among patients taking propranolol, and problems in maintaining an erection and in ejaculation among patients receiving methyldopa. Among patients treated with captopril plus a diuretic, no change from baseline appeared in scores for any of the sexual symptoms. The findings underline the importance of taking an adequate sexual history and document that selection of antihypertensive drugs may significantly affect the incidence of sexual symptoms.

Effects of antihypertensive medications on vitality and well-being.

The effects of captopril, methyldopa, and propranolol were assessed for sense of well-being and vitality among 626 men with mild to moderate hypertension in a multicenter, randomized, double-blind clinical trial. After a 24-week treatment period, patients taking captopril, compared with patients taking methyldopa and propranolol, scored significantly higher on measures of well-being and vitality. In addition, patients on captopril had more favorable results in being able to keep up with their work and in not feeling tired or sleepy at work. The effects of each of the drugs manifested themselves at different periods. For example, the negative effects of methyldopa on vitality were evident by week 8, whereas the negative effects did not become manifest for propranolol until week 24. On the other hand, a steady progressive improvement in vitality scores was evident at week 8 and at week 24 for patients on captopril. The findings of the study also suggest that the effects of the treatment drugs were most marked in patients who had had previous antihypertensive medications and who were on single-drug therapy during the course of the clinical trial. Further, the differences between patients taking captopril and those on methyldopa and propranolol appear to be obscured by the addition of a diuretic. The findings of the study may guide the physician in orienting his or her patient and in planning and implementing a therapeutic regimen.

Impact of antihypertensive therapy on quality of life: effect of hydrochlorothiazide.

Six hundred and twenty-six male patients with mild to moderate hypertension were enrolled in a multicentre randomized double-blind clinical trial to determine the effect of methyldopa, captopril and propranolol on the quality of life of these patients. During the 6-month trial hydrochlorothiazide was added to the treatment programme of those patients whose blood pressure was not normalized. More individuals in the captopril group (33%) required hydrochlorothiazide than in the propranolol group (22%). As a group, those individuals who required a diuretic were heavier and had higher basal and end-of-study blood pressure than those individuals requiring only monotherapy. However, the basal quality-of-life indices were similar in the six treatment subgroups. The withdrawal rate from the study was twice as high for those patients treated with propranolol and methyldopa as for those treated with captopril, whether a diuretic was added or not. More individuals requiring a diuretic experienced sexual dysfunction and a substantial worsening of their general well-being and of physical symptom indices over the 24 weeks of the study (P less than 0.01), particularly in the captopril and propranolol treatment subgroups. In summary, the present results suggest that diuretic therapy may have a greater negative impact on the quality of life of hypertensive patients than captopril, propranolol or methyldopa alone.

Work performance, absenteeism and antihypertensive medications.

Relationships between antihypertensive medications and selected aspects of work performance and absenteeism were explored in a multicentre, randomized, double-blind, clinical trial with 626 male hypertensive patients assigned to regimens of captopril, methyldopa or propranolol, either alone or supplemented as needed by a diuretic for blood pressure control. Patients previously on antihypertensive therapy did not differ from new patients in work absenteeism, both before and throughout the clinical trial. After a 24-week treatment period patients on captopril alone improved significantly over baseline in work-performance measures of mental acuity and job satisfaction-morale, while significant worsening in the methyldopa group and no change in the propranolol group occurred among patients given these drugs alone. When 24-week changes between groups not on diuretic were compared, significant differences in the measures appeared in favour of captopril. However, patients also taking a diuretic did not differ from baseline either within or between the three groups. Withdrawal from the trial because of lethargy and fatigue was significantly greater among patients on methyldopa and propranolol than among those receiving captopril. Absenteeism did not differ between the drug groups. The study shows that there are measurable differences in the impact of the antihypertensive drugs on aspects of work performance, and it underlines the importance of considering this factor in assigning patients to therapy.

Angiotensin converting enzyme and memory: preclinical and clinical data.

Results from both preclinical and clinical studies described here suggest that ACE may have a role in the modulation of cognitive memory processes in the rat and in humans. The finding of improved cognitive performance among patients treated with captopril relative to those treated with propranolol or methyldopa is consistent with other clinical and prec-clinical data. Clinical data derive primarily from quality of life measures based on interviews with patients in the same clinical trial from which our other cognitive data are drawn. For example, mental acuity in the workplace was reported to have improved significantly from baseline to week 24 in patients on captopril (p less than 0.05), although it did not change in patients treated with propranolol and worsened in those receiving methyldopa (Croog et al, 1987). The difference between captopril and methyldopa was significant (p less than 0.01). Pre-clinical data come primarily from studies demonstrating that inhibitors of ACE delay CAE in rats when compared not only with methyldopa, but also with saline (Sudilovsky et al, 1984, 1986). A fundamental question is how could inhibition of ACE improve cognitive functioning independent of blood pressure control. It is known that captopril exerts its antihypertensive effects primarily through inhibition of the ACE and that this is present in the brain as well as in non-neuronal tissues elsewhere (Ganten et al, 1982; Strittmatter et al, 1983, 1984). The activity of the enzyme has been found to be significantly increased in the caudate nucleus, the frontal cortex, parahyppocampal gyrus, and medial hippocampus of patients dying with Alzheimer's disease when compared to age-matched controls (Arregui et al, 1982). In addition, AII has been shown to impair performance on various learning and memory paradigms in animals (Melo and Graeff, 1975; Morgan and Routtenberg, 1977). Raising the level of endogenous AII by intravenous administration of its precursor renin has similar effects, and these are prevented if captopril is administered previously (Koller et al, 1979). Also, chronic oral treatment with captopril produces changes of brain renin angiotensin system parameters which suggest inhibition of AII biosyntheses in the brain (Scholkens et al, 1983). It is conceivable therefore, that our findings with prolonged administration of captopril are exerted through reduced formation of AII. Other possible mechanisms through which captopril may affect cognition include peptide-protein systems (Ganten et al, 1982, Sudilovsky et al, 1988) or the modulation of cerebral blood flow autoregulation mechanisms.(ABSTRACT TRUNCATED AT 400 WORDS)

The effects of antihypertensive therapy on the quality of life.

We conducted a multicenter randomized double-blind clinical trial among 626 men with mild to moderate hypertension to determine the effects of captopril, methyldopa, and propranolol on their quality of life. Hydrochlorothiazide was added if needed to control blood pressure. After a 24-week treatment period, all three groups had similar blood-pressure control, although fewer patients taking propranolol required hydrochlorothiazide. Patients taking captopril alone or in combination with a diuretic were least likely to withdraw from treatment because of adverse effects (8 percent vs. 20 percent for methyldopa and 13 percent for propranolol). The treatment groups were similar in scores for sleep dysfunction, visual memory, and social participation. However, patients taking captopril, as compared with patients taking methyldopa, scored significantly higher (P less than 0.05 to less than 0.01) on measures of general well-being, had fewer side effects, and had better scores for work performance, visual-motor functioning, and measures of life satisfaction. Patients taking propranolol also reported better work performance than patients taking methyldopa. Patients taking captopril reported fewer side effects and less sexual dysfunction than those taking propranolol and had greater improvement (P less than 0.05 to less than 0.01) on measures of general well-being. Our findings show that antihypertensive agents have different effects on the quality of life and that these can be meaningfully assessed with available psychosocial measures.

Quality of life and the patient's response to treatment.

Quality of life resides mainly in an individual's satisfaction with his role at work, at home, and in his community. Illness and treatment affect quality of life to the extent that they damage an individual's ability to perform these roles to his own satisfaction. Clinicians will increasingly have to take account of quality of life in assessing the effect of an illness and of their treatment for it. This is particularly so in chronic diseases for which there is no "cure" and in asymptomatic conditions, such as hypertension.