Intensive Blood Pressure Management Preserves Functional Connectivity in Patients with Hypertension from the Systolic Blood Pressure Intervention Randomized Trial.

BACKGROUND AND PURPOSE: The Systolic Blood Pressure Intervention (SPRINT) randomized trial demonstrated that intensive blood pressure management resulted in slower progression of cerebral white matter hyperintensities, compared with standard therapy. We assessed longitudinal changes in brain functional connectivity to determine whether intensive treatment results in less decline in functional connectivity and how changes in brain functional connectivity relate to changes in brain structure. MATERIALS AND METHODS: Five hundred forty-eight participants completed longitudinal brain MR imaging, including resting-state fMRI, during a median follow-up of 3.84 years. Functional brain networks were identified using independent component analysis, and a mean connectivity score was calculated for each network. Longitudinal changes in mean connectivity score were compared between treatment groups using a 2-sample t test, followed by a voxelwise t test. In the full cohort, adjusted linear regression analysis was performed between changes in the mean connectivity score and changes in structural MR imaging metrics. RESULTS: Four hundred six participants had longitudinal imaging that passed quality control. The auditory-salience-language network demonstrated a significantly larger decline in the mean connectivity score in the standard treatment group relative to the intensive treatment group (P = .014), with regions of significant difference between treatment groups in the cingulate and right temporal/insular regions. There was no treatment group difference in other networks. Longitudinal changes in mean connectivity score of the default mode network but not the auditory-salience-language network demonstrated a significant correlation with longitudinal changes in white matter hyperintensities (P = .013). CONCLUSIONS: Intensive treatment was associated with preservation of functional connectivity of the auditory-salience-language network, while mean network connectivity in other networks was not significantly different between intensive and standard therapy. A longitudinal increase in the white matter hyperintensity burden is associated with a decline in mean connectivity of the default mode network.

Dual-energy CT for the evaluation of urinary calculi: image interpretation, pitfalls and stone mimics.

Urolithiasis is a common disease with a reported prevalence between 4% and 20% in developed countries. Determination of urinary calculi composition is a key factor in preoperative evaluation, treatment, and stone recurrence prevention. Prior to the introduction of dual-energy computed tomography (DECT), available methods for determining urinary stone composition were only available after stone extraction, and thereby unable to aid in optimized stone management prior to intervention. DECT utilizes the attenuation difference produced by two different x-ray energy spectra to quantify urinary calculi composition as uric acid or non-uric acid (with likely further classification in the future) while still providing the information attained with a conventional CT. Knowledge of DECT imaging pitfalls and stone mimics is important, as the added benefit of dual-energy analysis is the determination of stone composition, which in turn affects all aspects of stone management. This review briefly describes DECT principles, scanner types and acquisition protocols for the evaluation of urinary calculi as they relate to imaging pitfalls (inconsistent characterization of small stones, small dual-energy field of view, and mischaracterization from surrounding material) and stone mimics (drainage devices) that may adversely impact clinical decisions. We utilize our clinical experience from scanning over 1200 patients with this new imaging technique to present clinically relevant examples of imaging pitfalls and possible mechanisms for resolution.

Bereavement after caregiving or unexpected death: effects on elderly spouses.

Responses to bereavement have been shown to vary depending on whether death is expected or unexpected, and on the nature of family caregiving experiences, but little previous research has examined these factors simultaneously. To address these issues, we utilized prospective data on bereavement from 193 participants in the Changing Lives of Older Couples (CLOC) study, who were assessed both before their loss and at six and 18 months after the death. Participants who experienced either unexpected loss, or expected loss without caregiving, with low-stress caregiving, or with high-stress caregiving completed measures of psychological, social, and health functioning on each occasion. Results showed that unexpected death was associated with marked increases in depression, while the nature of caregiving did not affect the trajectory of any of the psychological well-being measures. All groups except highly stressed caregivers showed improvements in social activity and support after bereavement, suggesting that highly stressed caregivers may be at an increased risk for social isolation during bereavement. Thus experiencing an unexpected death may put bereaved spouses at risk for depression, while high-stress caregiving may lead to problems with social isolation.

Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study.

Although there has been considerable interest in racial differences in family caregiving for persons with dementia, most research to date has either ignored racial diversity or based conclusions on small numbers of caregivers drawn primarily from single site studies. The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of caregiving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers. Some results were specific to site, possibly due to differences in recruitment strategies, inclusion/exclusion criteria, and regional differences. Adjustment for covariates, including caregiver relationship to the care recipient, gender, age, socioeconomic status, and care recipient behavioral problems, altered few of these differences. Results are discussed in terms of their relevance to psychosocial intervention programs for ethnically diverse caregivers.

Well-being, appraisal, and coping in Latina and Caucasian female dementia caregivers: findings from the REACH study.

While there has been considerable interest in studying ethnically diverse family caregivers, few studies have investigated the influence of dementia caregiving on Latino families. The current study includes participants from two sites of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) project to compare well-being, appraisal, and religiosity by ethnicity, with specific attention to levels of acculturation. Latina (n = 191) and Caucasian female (n = 229) dementia family caregivers from two regions of the United States (Miami, Florida and Northern California) were compared at baseline on demographics, care recipient characteristics, mental and physical health, and psychosocial resources, including appraisal style and religiosity. Latina caregivers reported lower appraisals of stress, greater perceived benefits of caregiving, and greater use of religious coping than Caucasian caregivers. The relationship of these variables to level of acculturation for the Latina caregivers was also explored. Implications of these results for psychosocial interventions with Latino and Caucasian family caregivers are discussed.

Moderating effects of psychosocial attributes on the association between risk factors and disability in later life.

This study examined the roles of psychosocial attributes in the associations between potential risk factors (age, gender, marital status, education, and chronic conditions) and disability in later life, and in particular how neuroticism and social resources (social network, received support, and satisfaction with support) modify the linkages between risk factors and disability. The main and moderating effects were empirically tested using a sample of 444 community-dwelling older adults in Florida (MU age = 72.3) who were cognitively intact. The likelihood of disability increased with advancing age, more chronic conditions, higher levels of neuroticism, more received support, and less satisfaction w ith support. In addition to the main effects, neuroticism and received support interacted with age and chronic conditions, strengthening the associations between risk factors and disability. Results suggested that personality and social support deserve greater attention as factors that can alter the disability process.

Attitudes towards mental health care in younger and older adults: similarities and differences.

It is commonly assumed that older and younger adults have very different attitudes about seeking mental health services and that this is a major factor in reducing the use of mental health services by the elderly. However, little evidence exists to illustrate how elders actually perceive mental health care. Responses from a survey of 474 older adults age 65 and over were compared with data from a national survey of 1001 persons age 21-65. Results indicate similarities in many attitudes including likelihood of seeking treatment for severe mental disorders, importance of mental health care, and concerns about cost and coverage as barriers to care. Differences included use of services, perceptions about less severe disorders, referral sources, and preferred providers. Clinical, policy and public education implications are discussed.

Predictors of tolerance to chemotherapy in older cancer patients: a prospective pilot study.

Few data are available to help predict which older cancer patient is at risk of developing chemotherapy-related toxicity. This study was a pilot for a project designing a predictive risk score. Chemotherapy patients aged 70 years and older were prospectively enrolled. Chemotherapies were adjusted for their published toxicity. 60 patients were enrolled, 59 were evaluable. Mean dose-intensity was 90.3%, range 33.3-129.0%. 47% of the patients experienced grade 4 haematological and/or grade 3-4 non-haematological toxicity. Published toxicity (MAX2), diastolic blood pressure, marrow invasion and lactate dehydrogenase (LDH) were all associated with toxicity (P<0.1); Body Mass Index, previous chemotherapy, red blood cells, platelets, polymedication with dose-intensity; and polymedication with FACT-G change. After adjustment for the published toxicity, the variables retained their significance, except for LDH and polymedication (for dose-intensity). Although the size of this pilot study imposes a cautious interpretation, patient-related and chemotherapy-related variables correlated independently with toxicity. Designing a composite predictive score to use in assessing the toxicity of multiple chemotherapy regimens therefore appears to be a valid undertaking.

Association of life events and psychological distress in family caregivers of dementia patients.

Relationships between life events and psychological distress were investigated for 197 dementia caregivers and 218 non-caregivers. Participants indicated which events on the Louisville Older Persons Events Scale they had experienced over the past six months. Life events were then classified as associated or unassociated with care-giving using differences in incidence rates between caregivers and non-caregivers. Primary care-giving stressors and associated life events were most predictive of psychological distress among caregivers. Among non-caregivers, unassociated negative life events were the strongest predictors of depression and life satisfaction. Implications for the assessment of life events and caregiver interventions are discussed.

Twenty-four hour ambulatory blood pressure in the Hypertension Optimal Treatment (HOT) study.

BACKGROUND AND AIMS: The Hypertension Optimal Treatment (HOT) study showed that when antihypertensive treatment reduces diastolic blood pressure well below 90 mmHg, there can be a further reduction of cardiovascular events, particularly myocardial infarction, with no evidence of a J-shaped curve at lower pressures. Office measurement, however, gives no information about blood pressure outside the office. This paper describes a HOT substudy in which patients underwent both office measurement and 24 h ambulatory blood pressure monitoring. METHODS: The mean age of the substudy population was 62 +/- 7 years. Substudy patients were treated for a median period of 2 years. All received the dihydropyridine calcium antagonist felodipine, while some also received an ACE-inhibitor, a beta-blocker or a diuretic. Average 24 h, day and night ambulatory blood pressure values were computed at baseline (n = 277) and during treatment (n = 347): 112 patients had been randomized to a target office diastolic blood pressure

Latent growth models of the longitudinal effects of dementia caregiving: a comparison of African American and White family caregivers.

Self-report measures of depression, physical health symptoms, and life satisfaction were collected over a 2-year period from 197 family caregivers of dementia patients and 218 noncaregivers (controls). Latent growth models were used to compare changes across time for African American and White caregivers, with gender, age, and socioeconomic status serving as covariates. Results indicated that White caregivers sustained higher levels of elevated depression and decreasing life satisfaction over time compared with African American caregivers. Both groups of caregivers reported increases in physical symptoms over time. These results indicate worsening difficulties over time for many White caregivers. African American caregivers show more resilience on measures of depression and life satisfaction but are still vulnerable to increases in physical symptoms over time. Implications for additional research and clinical intervention are discussed.

Cross-cultural comparability of the Geriatric Depression Scale: comparison between older Koreans and older Americans.

It is becoming increasingly clear that, in order to better understand the implications of global aging, more cross-cultural research is needed. In the present study, the structure and validity of the Geriatric Depression Scale-Short Form (GDS-SF) was examined in Korean and US samples of older adults. The participants included 153 older adults living in Korea (mean age=65.9 years) and 459 older adults from Florida (mean age=72.4 years). All participants completed the original or translated versions of the GDS-SF, as well as additional demographic and health-related measures. The results indicated that the GDS-SF exhibited good reliability in both samples. However, the results of a principal components analysis indicated that the structure was not well replicated across the two samples. In general, the present study suggests that, despite great efforts to make the questionnaires equivalent in the two cultures, the concept of depression for older adults may vary greatly in Korea and the USA. Possible explanations for cross-cultural differences are discussed, as well as implications.

Effect of regression of left ventricular hypertrophy from systemic hypertension on systolic function assessed by midwall shortening (HOT echocardiographic study).

Depressed midwall shortening has been shown to be an independent predictor of cardiovascular morbid events in hypertensive patients with left ventricular (LV) hypertrophy despite normal endocardial fractional shortening. The effects of LV mass changes in hypertensive patients on midwall shortening are unclear. To determine the impact of LV hypertrophy regression on LV systolic function assessed at the endocardium and the midwall level, 508 patients (58% men, 57% Caucasians, mean age 60 +/- 7 years) participating in the Hypertension Optimal Treatment study were prospectively studied by serial echocardiography at baseline, year 1, year 2, and at the end of the study. The Hypertension Optimal Treatment study was designed to challenge the existence of the J-curve phenomenon in hypertension. This study enrolled men and women between 50 and 80 years of age with mild to moderate hypertension. Patients were treated with a regimen based on felodipine with the addition of other antihypertensive drug classes as needed to reduce the diastolic blood pressure to a predefined target of < or =80, < or =85, or < or =90 mm Hg. From baseline to year 1, year 2, and end of the study, body mass index was unchanged (30.4, 30.1, 30.2, and 30.5 kg/m(2)); however, diastolic blood pressure was significantly reduced (99, 83, 80, and 80 mm Hg, p <0.0001), as was systolic blood pressure (161, 139, 137, and 134 mm Hg, p <0.0001) and LV mass index (117, 119, 107, and 106 g/m(2), p <0.0001). Over the same period of observation the endocardial fractional shortening did not change significantly (40%, 42%, 43%, and 44%); however, shortening at the midwall level showed improvement (20%, 21%, 22%, and 30%, p <0.001). In conclusion, midwall shortening is a more sensitive index of systolic function in subjects with pressure-overload hypertrophy, and it identifies high-risk patients who may benefit from a more aggressive antihypertensive program. The disparity between midwall and endocardial shortening suggests reduced myofibril function in patients with hypertension-induced hypertrophy.

Diagnostic attributions versus labeling: impact of Alzheimer's disease and major depression diagnoses on emotions, beliefs, and helping intentions of family members.

Labeling theory suggests that applying disease labels to behavior may serve to medicalize deviance and produce stigma. In contrast, attribution theory suggests that this practice may evoke sympathetic responses. Female undergraduates (N = 221) read vignettes describing an older parent exhibiting inappropriate behavior in a social situation, with diagnostic label (Alzheimer's disease, major depression, no label), personal congruence of the behavior (congruent, incongruent, no information), and parent gender manipulated across participants. Participants rated their emotional responses, attributions, and willingness to help. The Alzheimer's disease label, and to a lesser extent the major depression label, produced more sympathy toward the parent, less blame, and greater willingness to help, indicating that the provision of these labels may facilitate compassionate attitudes and enhanced caregiving toward older adults. However, participants reported greater anger and higher personality attributions toward fathers than mothers, suggesting that the influence of parent gender on potential caregivers' reactions warrants further attention.

End of life care and reactions to death in African-American and white family caregivers of relatives with Alzheimer's disease.

Family caregivers for relatives with Alzheimer's Disease (AD) often experience significant stress-related problems in mental and physical health. Patients with AD often survive for protracted periods of time, placing an extensive burden of care on the caregiver prior to the patient's death. The present study addresses ethnic differences in the experience of AD caregivers around the time of their loved one's death, including life-sustaining treatment decisions and reactions to death. The results showed that, in our sample, more patients died in their homes than has been reported for deaths in the United States. African-American and White caregivers differed substantially in their reports of end of life care and subjective reactions to the death. Compared with White caregivers, African-American caregivers were less likely to make a decision to withhold treatment at the time of death, less likely to have their relative die in a nursing home, and reported less acceptance of the relative's death and greater perceived loss. Results suggest that death after AD caregiving deserves further study, and that ethnic differences in end of life care and bereavement may be of particular importance.

The structure of self-rated health among community-dwelling older adults with stroke.

OBJECTIVE: To examine whether depressive symptomatology is a third fundamental component of the structure of self-rated health, in addition to two other components (physical disease and functional disability) among community-dwelling older adults with stroke. DATA SOURCES AND STUDY SETTING: A total of 591 community-dwelling older adults with stroke were identified from the 1993 Asset and Health Dynamics among the Oldest-Old (AHEAD) national survey of community-dwelling older adults. STUDY DESIGN: A cross-sectional study. Structural equation modeling was applied to compare a widely used two-factor model of self-rated health with a model adding depression as a third possible factor. PRINCIPLE FINDINGS: The hypothesized three-factor model explained additional 21% more variance of self-rated health of older adults with stroke (R2 = 79%, NNFI = 0.95, CFI = 0.96, RMSEA = 0.04) as compared with the two-factor biomedical model (R2 = 58%, NNFI = 0.95, CFI = 0.98, RMSEA = 0.05). The three-factor model was statistically different from the two-factor model. CONCLUSIONS: Greater attention should be given to the theoretical structure of self-rated health of older adults with stroke, particularly, the significant impact of depression on their self-rated health.

Family caregiving in hospice: effects on psychological and health functioning among spousal caregivers of hospice patients with lung cancer or dementia.

INTRODUCTION: Caregiving stress has been found to lead to depression and poor health among caregivers compared with age-matched non-caregiving controls. However, most of these studies have focused on dementia caregivers, and have not included hospice caregivers. The aim of this project was to assess the impact of caregiving stress on psychological and health functioning among spousal caregivers of hospice patients, in contrast to demographically matched non-caregiving controls. A secondary aim was to compare the caregiving stressors and psychological and health functioning between spousal caregivers of hospice patients with dementia versus lung cancer. METHODS: Forty spousal caregivers of hospice patients with dementia, and 40 spousal caregivers of hospice patients with lung cancer, were compared on admission to hospice, using measures of caregiving stressors, depression, life satisfaction, and physical health, with a sample of 40 demographically equated control subjects. RESULTS: Both groups of caregivers showed higher depression, lower life satisfaction and poorer physical health (p < .05) compared with non-caregivers. Over half of all caregivers evidenced clinically significant levels of depression, with rates of depression about three times the prevalence found in community samples of older adults. CONCLUSIONS: While family caregivers of hospice patients with dementia and lung cancer face very different objective stressors, the negative psychological and health impacts on the caregiver are marked and comparable across diagnosis. Hospice family caregivers are at high risk for both psychological and physical health disorders, and caregiver depression and health problems should be systematically assessed and treated by the hospice team.

Amlodipine besylate induced acute interstitial nephritis.

Adverse effects of amlodipine besylate, a widely used antihypertensive medication, include peripheral edema, flushing, headache, pruritus, and rash. An adverse renal effect attributable to the medication has hitherto not been reported in the literature. We herein report a case of amlodipine besylate induced acute interstitial nephritis.

Longitudinal course of behavioral problems during Alzheimer's disease: linear versus curvilinear patterns of decline.

BACKGROUND: Patients with Alzheimer's Disease (AD) are commonly assumed to experience a linear decline in behavioral functioning that parallels progressive cognitive decline. However, some researchers have suggested that specific behavioral problems either decline at different rates or improve in late dementia. METHODS: The present analyses examined 150 AD patients at an initial assessment, 61 of whom were also evaluated annually on two additional occasions. Measures of cognitive impairment and behavioral problems were obtained. RESULTS: Cross-sectional results indicated curvilinear associations between dementia severity and certain behavioral problems (forgetful behaviors, and emotional and impulsive behaviors). Longitudinal analyses further indicated trends for curvilinear rates of behavioral disturbance across time, with some problem areas showing improvement as AD progresses through the most severe stages. CONCLUSIONS: Even though Alzheimer's disease is a progressive dementia characterized by increasing cognitive deterioration, it appears to be inaccurate to expect behavioral functioning to show the same linear decline across time.

The family caregiver of the older cancer patient.

Cancer care is becoming increasingly complex. The health care practices of the present day make it imperative that the family provide assistance in the day-to-day management of a patient's symptoms and in the implementation of home care. This increased responsibility for the family caregiver can come at great cost to the overall functioning of the family, because of role changes, changes in the family structure, and financial stressors, among others. Caregivers can experience adverse effects on their mental and physical health that can remain long after the caregiving role has ended. Although much of the research has focused on the negative elements of caregiving, it must be remembered that there are positive aspects to caregiving, which are now receiving attention in the research literature. Although other factors affect caregiving, the model of factors important in the caregiving experience presented in this article may provide the impetus for studying the relationships among these different factors. Results of these studies will allow the development of specific interventions to help caregivers be more effective in their caregiving role and, at the same time, address the overall impact of caregiving on the family.