Quality of life issues in hypertension: consequences of diagnosis and considerations in management

Epidemiology of Hypertension in Older Adults

The exact definition of hypertension in older adults has changed over the decades, but the benefits of strict blood pressure control across the life span are being increasingly recognized by professional societies and guideline committees. This article discusses the prevalence of hypertension in older adults and describes the associations between hypertension and both clinical and nonclinical morbidity in that population.

Screening for thyroid dysfunction and treatment of screen-detected thyroid dysfunction in asymptomatic, community-dwelling adults: a systematic review

BACKGROUND

This systematic review was conducted to inform the Canadian Task Force on Preventive Health Care recommendations on screening for thyroid dysfunction (TD). The review sought to answer key questions on the benefits and harms of screening for TD, patients' values and preferences for screening, and the benefits and harms of treating screen-detected TD.

METHODS

This review followed Canadian Task Force on Preventive Health Care methods, which include the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The search strategy used for benefits and harms of screening and treatment was an update to the 2014 review by the US Preventive Services Task Force and searched MEDLINE and the Cochrane Library. MEDLINE, Embase, ProQuest Public Health, and SCOPUS were searched for patients' values and preferences for screening. Outcomes of interest included all-cause mortality, deaths due to cardiovascular diseases, fatal and non-fatal cardiovascular events, atrial fibrillation, fractures, quality of life, cognitive function, and harms due to TD treatment. Two reviewers independently screened abstracts and full texts according to pre-determined inclusion criteria and assessed the risk of bias for each study included. Strength and quality of the evidence was assessed for each outcome. A narrative synthesis was conducted due to heterogeneity of the included studies.

RESULTS

No studies were found on screening for TD, treatment of subclinical hyperthyroidism, or patients' values and preferences for screening for TD. Twenty-two studies (from 24 publications) on the treatment of TD in patients with screen-detected subclinical hypothyroidism were included. Results from the included randomized controlled trials suggested no benefit of treatment for subclinical hypothyroidism for the large majority of outcomes. We found very low-quality evidence (from two cohort studies) for a small reduction in all-cause mortality among adults < 65 or 40-70 years who were treated for TD compared to those who were not.

CONCLUSIONS

This review found moderate to very low-quality evidence on the benefits and harms of treatment for subclinical hypothyroidism, with most of the evidence showing no benefit of treatment.

Thyroid hormone status and health-related quality of life in the LifeLines Cohort Study

BACKGROUND

Thyroid disorders are prevalent in Western society, yet many subjects experience limited symptoms at diagnosis, especially in hypothyroidism. We hypothesize that health-related quality of life (HR-QOL) is more severely impaired in subjects with more abnormal thyroid hormone function tests.

METHODS

This is a cross-sectional study of Dutch adults participating in the LifeLines Cohort Study between December 2009 and August 2010. In 9491 Western European participants (median age 45 years; 3993 men and 5498 women), without current or former use of thyroid medication, we compared HR-QOL using the RAND 36-Item Health Survey between subjects with normal thyrotropin (TSH) values and subjects with disturbed thyroid hormone status (serum TSH, free thyroxine, and free triiodothyronine). The influence of possible confounders (age, smoking, co-morbidity) on HR-QOL was evaluated as well.

RESULTS

Suppressed TSH values (TSH < 0.5 mU/L) were found in 114 (1.2%), while 8334 (88.8%) had TSH within the normal range, 973 participants (10.3%) had TSH between 4 and 10 mU/L, and 70 (0.7%) had TSH > 10 mU/L. Men had a higher HR-QOL than women (70-92 vs. 65-89; p < 0.001), except for the domain "general health" (72 vs. 72; p = 0.692). Men with suppressed or elevated TSH values did not score significantly lower than euthyroid men for any of nine domains of the RAND 36-Item Health Survey. Compared with euthyroid women, women with suppressed TSH scored significantly lower in the domains "physical functioning" (84 vs. 89, p = 0.013) and "general health" (67 vs. 72, p = 0.036). Women with markedly elevated TSH (> 10 mU/L) had a score in all HR-QOL domains that was similar to that of women with normal TSH values. There were no differences in the physical component score and the mental component score between any of the TSH groups. Physical component score and mental component score were mainly determined by smoking status, co-morbidity, and body mass index or waist circumference.

CONCLUSIONS

In this population-based study, HR-QOL scores of subjects with suppressed TSH values or markedly elevated TSH values were generally not significantly lower than those of subjects with normal or mildly elevated TSH values.

Symptoms of fatigue in chronic heart failure patients: Clinical and psychological predictors

OBJECTIVE

To examine the role of clinical and psychological characteristics as predictors of fatigue in CHF.

BACKGROUND

Little is known about predictors of fatigue in CHF. Next to heart failure characteristics, depressive symptoms and type-D personality may explain individual differences in fatigue.

METHODS

At baseline, 136 CHF outpatients (age<or=80 years) completed a questionnaire to assess depressive symptoms, type-D personality and cardiac symptoms. At one-year follow-up, they completed the Dutch Exertion Fatigue Scale and the Fatigue Assessment Scale to assess symptoms of fatigue. Medical information was obtained from the patients' medical records.

RESULTS

Exertion fatigue and general fatigue were identified as different manifestations of fatigue. We found that exertion fatigue at 12-month follow-up was predicted by decreased exercise capacity (beta=-.35; p<.001), dyspnoea (beta=24; p=.002), hypertension (beta=.16; p=.03), and depressive symptoms (beta=.16; p=.05). In contrast, general fatigue at 12-month follow-up was predicted by dyspnoea (beta=.24; p=.003), depressive symptoms (beta=.27; p<.001), type-D personality (beta=17; p=.03), and sleep problems (beta=.20; p=.01). Together, these variables explained 32% and 37% of the variance, respectively.

CONCLUSION

The present study showed that fatigue was related to both clinical and psychological characteristics. The use of this knowledge may lead to a better understanding and treatment of the clinical manifestations of fatigue in CHF.

Psychological impact of chronic hepatitis C: Comparison with other stressful life events and chronic diseases

AIM: To examine the psychological impact of chronic hepatitis C (CHC) diagnosis in a large cohort of CHC patients as compared with other stressful life events and chronic diseases carrying a risk of life-threatening complications.

METHODS: One hundred and eighty-five outpatients with compensated CHC were asked to self-grade, using a 100-mm visual analogue scale (VAS), the degree of stress caused by the learning of CHC diagnosis and the perceived severity of their disease. Diagnosis-related stress was compared to four other stressful life events and perceived CHC severity was compared to four other common chronic diseases.

RESULTS: Learning of CHC diagnosis was considered a major stressful event (mean ± SD scores: 72 ± 25), significantly less than death of a loved-one (89 ± 13, P < 0.0001) and divorce (78 ± 23, P < 0.007), but more than job dismissal (68 ± 30, P < 0.04) and home removal (26 ± 24, P < 0.0001). CHC was considered a severe disease (74 ± 19), after AIDS (94 ± 08, P < 0.001) and cancer (91 ± 11, P < 0.001), but before diabetes (66 ± 23, P < 0.001) and hypertension (62 ± 20, P < 0.001). Perceived CHC severity was not related to the actual severity of liver disease, assessed according to Metavir fibrosis score. In multivariate analysis, diagnosis-related stress was related to perceived disease severity (P < 0.001), trait anxiety (P < 0.001) and infection through blood transfusion (P < 0.001).

CONCLUSION: Our results show the considerable psychological and emotional burden that a diagnosis of CHC represents, even in the absence of significant liver disease. They should be taken into account when announcing a diagnosis of CHC in order to reduce its negative effects.

Review article: psychosocial factors in the quality of life of patients with inflammatory bowel disease

Information on quality of life in inflammatory bowel disease is limited. Despite the clear importance of this topic to patients, quality of life measurement is seldom undertaken in day-to-day management of patients or included in clinical trials. Although previous reviews have dealt with quality of life, the area of psychosocial functioning has not been specifically addressed. The aim of this study was to review the psychosocial factors affecting quality of life in patients with inflammatory bowel disease, using an electronic search of MEDLINE, EMBASE, CINAHL and psycINFO. Of the 751 articles identified by the search, 107 were considered relevant and included in the review. A number of psychosocial factors appear to be important, including gender, socioeconomic status, ethnicity and perceived stress. To improve the quality of life in patients with inflammatory bowel disease, clinicians' attention needs to be drawn towards this subject, with an awareness of those patient groups more vulnerable to impaired quality of life. These identified variables also represent important factors, which should be adjusted for when conducting research into quality of life in these patients.

Health-related quality of life in patients with inflammatory bowel disease five years after the initial diagnosis

BACKGROUND

Health-related quality of life (HRQOL) has become an important tool in evaluating patient satisfaction in inflammatory bowel disease (IBD). So far, few prospective follow-up studies have been done to identify variables that influence HRQOL. We aimed to identify demographic and clinical variables that influence HRQOL 5 years after diagnosis in patients with ulcerative colitis (UC) or Crohn disease (CD) included in a prospective follow-up study from 1990 to 1994 (the IBSEN study).

METHODS

All patients completed the Inflammatory Bowel Disease Questionnaire (IBDQ), a disease-specific quality-of-life questionnaire translated into Norwegian and validated. We present data from 497 patients (328 UC patients and 169 CD patients, mean age 43.3 years, 48% female). The impact of age, gender, smoking, symptom severity, disease distribution, rheumatic symptoms and surgery on IBD patients' HRQOL was analysed.

RESULTS

Women had a reduction in IBDQ total score of 10 points compared to men, CD patients had a reduction of 7.5 compared to UC patients. The patients with moderate/severe symptoms had a 50 points lower score than the patients without symptoms. The patients with rheumatic symptoms had a 10 points lower total score than the patients without these symptoms. All differences were statistically significant. The multiple regression analysis showed that symptom severity, rheumatic symptoms and female gender were the strongest predictors of reduction in HRQOL for both diagnosis groups.

CONCLUSION

IBD symptoms, rheumatic symptoms and female gender have a significant influence on patients' HRQOL as measured by IBDQ. This was confirmed by the regression analysis.

The impact of diagnosis of hepatitis C virus on quality of life

The aim of this study was to examine the effects of diagnosis of hepatitis C virus (HCV) infection on quality of life in a cohort admitted to Fairfield Infectious Diseases Hospital with acute hepatitis from 1971 to 1975. Sera stored from the original admission were tested for antibody to HCV. Systematic approaches were used to locate anti-HCV-positive individuals and outcomes assessed by the Short Form 36 (SF-36) scale and a study-specific questionnaire as well as clinical review. Study subjects' SF-36 scores were compared with Australian population norms. Anti-HCV and HCV-RNA positive individuals (n = 15) aware of their serostatus rated significantly worse on 7 of 8 SF-36 scales compared with population norms. However, HCV-seropositive and RNA-positive individuals unaware of their HCV serostatus (n = 19) scored significantly worse in only 3 scales. Those aware of their serostatus did not differ sociodemographically, clinically, virologically, or serologically from those who were unaware, nor was there a link between quality of life (QOL) scores and objective measures of ill health. All subjects had injected drugs in the past. In conclusion, HCV-RNA and anti-HCV-positive individuals in our study have significantly poorer subjective health status 26 years after original infection compared with population norms. QOL measures were significantly worse for HCV-seropositive individuals aware of their serostatus compared with those unaware. We feel that the reduced QOL in the diagnosed group may be partially an effect of labeling and that the impact of the diagnostic process per se on QOL in individuals with HCV requires further evaluation.

Awareness of blood pressure: interoception or contextual judgement?

Most patients with mild to moderate hypertension are asymptomatic but some patients report symptoms and seem to be aware of their blood pressure. The research question is whether the estimation of blood pressure is primarily derived from interoception or is inferred by contextual judgement. A psychophysiological ambulatory assessment was conducted with 51 male hypertensive patients and 30 either normotensive or hypotensive student subjects employing (1) a multichannel recording system for blood pressure, heart rate and physical activity; and (2) a pocket computer for assessing estimated BP, setting variables and self-ratings of subjective state. Within-subject correlations revealed that there was no significant relationship between estimated BP and concurrently recorded systolic BP. Estimated BP is, however, related to self-ratings of feeling physically tense and self-ratings of physical activity. Blood pressure awareness appears to be a rather inconsistent and subjective phenomenon, based on contextual judgements and inferences instead of "perception", but it is a relevant methodological issue (and possible bias) in hypertension research.

Symbiotic relationships of quality of life, health services research and other health research

Clinical biomedical research, the traditional research orientation of quality of life (QOL) researchers, is chiefly concerned with disease processes and assessing the impact of therapeutic interventions on improving health status and QOL outcomes. This paper suggests, however, that the biomedical paradigm limits utility of QOL research findings in terms of its ability to shape health policy and improve health-related QOL in populations at risk. This paper proposes that health services research (HSR) and other health research paradigms can be used to assess QOL from multiple perspectives. HSR and QOL research can be mutually beneficial. The models for understanding health services utilized in HSR may assist in defining major determinants of QOL and the interaction of QOL with its environment. Conversely, QOL measures may be used to establish the relevance of HSR to people's well-being. The paper first defines the domain of HSR and the domain of quality of life. In order to understand their relationship, we consider what a model or paradigm for each might be, and how they would overlap. Finally, a merging of conceptual frameworks is proposed, linking QOL research to HSR and other health research. Ultimately, expanding the QOL paradigm beyond the biomedical model will promote two objectives. First, it will permit research findings to contribute more fully to shaping national health policy by considering the broader community and the delivery system factors which influence QOL. Second, researchers will be more aware of a broader range of factors affecting patients and will incorporate this in their research.

Cost of antihypertensive treatment: a point of view from India

In India, expenditure on the treatment of all patients with mild hypertension is not cost effective. Nonpharmacologic treatment is encouraged.