Evidence of autonomic dysregulation in otherwise healthy cancer caregivers: A possible link with health hazard

A Systematic Review of Intervention Trials Utilizing Biomarkers Among Informal Caregivers of People with Alzheimer's Disease & Related Dementias

Informal caregivers of people with Alzheimer's Disease and Related Dementias (ADRD) experience unique stressors, reduced quality of life, and report poorer health, compared to non-caregivers. Throughout the last thirty years, researchers have developed and tested various psychosocial interventions and their ability to improve caregiver health. Due to an exclusive focus on self-report methods, however, no existing systematic literature reviews specifically examine intervention studies employing biomarkers; this systematic review aims to address this gap in the literature. In each database (PubMed and Web of Science, respectively), a title search was conducted with the following keywords: "alzheimer*" OR "dementia" AND "caregiv*" AND "intervention", followed by a second search using identical keywords except "intervention" was replaced with "program." Study or intervention protocol articles, exclusively qualitative studies, cultural applicability papers, dissemination studies, descriptive articles or program reports, acceptability/feasibility studies, studies utilizing formal caregiving samples, commentaries, review papers, and meta-analyses, erratums/corrections, measure development articles, factor analyses, and case reports were excluded from the final pool of studies. In this systematic review, the findings of 14 studies are summarized, and are organized based on specific types of biomarkers: neuroendocrine, immune, and autonomic physiological. Overall, the review yielded mixed results, which may, in part, be due to differences in the types of interventions tested, as well as differing biomarker measurement, methodology, and analysis. More biobehavioral intervention trials are needed among ADRD caregivers. Including biological parameters as pre- and post-measures can shed insight into the extent to which interventions may help caregivers heal from the stress of caregiving.

Design and validation of an electrophysiological based tool to assess chronic stress. Case study: burnout syndrome in caregivers

Caregiver burnout syndrome is an increasingly seen condition, although the subjective nature of self-administered psychometric tests and the lack of a consensual diagnostic tool might hinder a proper diagnosis. The availability of objective psychosomatic measures of stress might facilitate the early diagnosis and clinical management of these patients. For this reason, the aim of this work was to develop a quantitative tool to evaluate the stress level of caregivers in a noninvasive and repeatable manner. An observational, controlled, matched study was designed including a group of 38 principal caregivers of chronic patients and a control group of 38 non-caregivers. Psychometric, biochemical, and electrophysiological data were analyzed along with sociodemographic data. A quantitative chronic stress reference scale (CSRs) was constructed based on the weighted contribution of several psychometric and biochemical variables and afterwards, a predictive psychosomatic model (ESBSm) correlated with CSRs was elaborated from extracted variables of several electrophysiological signals monitored for 10 min. The resulting CSR scale shows a high power to discriminate caregivers from the control group while the ESBSm shows a 79% correlation with the CSR scale validated through a 5-fold process. Therefore, the results demonstrate that the ESBS model is an objective and validated tool to diagnose the degree of stress linked to burnout in caregivers of chronic patients from a 10-min session of noninvasive monitoring with a reliability equivalent to the questionnaires currently used to quantify stress in caregivers.

Trait mindfulness and the mental and physical health of caregivers for individuals with cancer

BACKGROUND

Mindfulness plays a role in moderating the negative mental and physical health outcomes associated with caregiving. The aims of this study were to examine the relationship between trait mindfulness and the (1) psychological functioning, (2) health behaviors, (3) and physical health of caregivers for individuals diagnosed with cancer.

METHODS

Caregivers completed a battery of questionnaires and examinations assessing sociodemographic characteristics, trait mindfulness, depression, perceived stress, caregiver stress, sleep, diet, physical activity, tobacco use, alcohol use, blood pressure, and BMI. Demographics and cancer diagnostics were collected for the individuals whom caregivers supported. Linear regression, multivariate analyses, and moderator analyses were performed.

RESULTS

Of the 78 caregivers, the mean age was 63.9 (S.D.=13.1); 59% identified as female; 97% identified as White. Regression analyses indicated that caregivers who reported higher levels of trait mindfulness reported significantly less perceived stress (b= -4.38, SE= 0.88, p <.001), lower levels of depression (b= -3.74, SE= 1.10, p = .001), greater caregiver quality of life (b= -9.05, SE=2.12, p < .001), better sleep quality (b= -0.98, SE=0.44, p = 0.03), and lower rates of tobacco use (b= -10.12, SE= 3.43, p =.003). Trait mindfulness was not significantly related to diet, alcohol use, blood pressure, or BMI.

CONCLUSIONS

Higher levels of trait mindfulness are associated with positive mental and physical health measure for caregivers. Future research would benefit from further examining mindfulness-based interventions and their impacts in mitigating the negative toll of caregiving in the context of cancer.

Cardiovascular Disease Incidence and Risk in Family Caregivers of Adults With Chronic Conditions: A Systematic Review

BACKGROUND

Family caregivers experience psychological distress or physical strain that may lead to an increased risk of cardiovascular disease (CVD) morbidity and mortality.

OBJECTIVE

This systematic review aimed to describe the current evidence and gaps in the literature on measures used to assess CVD outcomes in family caregivers, the association of caregiving with CVD incidence/risk outcomes, and associated factors in family caregivers of patients with chronic disease.

METHODS

Medline, PubMed, CINAHL, Web of Science, and Google Scholar were searched for English-language, peer-reviewed studies published from 2008 to 2020 that examined CVD incidence and risk among family caregivers of adults with chronic conditions.

RESULTS

Forty-one studies were included in this review. The measures used to assess CVD risk were categorized into biochemical, subclinical markers, components of metabolic syndrome, and global risk scores. Compared with noncaregivers, caregivers were more likely to have higher CVD incidence rates and objectively measured risk. Cardiovascular disease risks were also increased by their caregiving experience, including hours/duration of caregiving, caregivers' poor sleep status, psychological symptoms, poor engagement in physical/leisure activities, and care recipient's disease severity.

CONCLUSIONS

Although there were limited longitudinal studies in caregivers of patients with diverse health conditions, we found evidence that caregivers are at high risk of CVD. Further research for various caregiver groups using robust methods of measuring CVD risk is needed. Caregiver factors should be considered in developing interventions aimed at reducing CVD risk for caregivers.

The impact of informal cancer caregiving: A literature review on psychophysiological studies

Caregiving can be experienced as a stressful process, which can cause psychological and physical consequences. The combination of prolonged stress and the physical demands of caregiving may impair the physiological functioning of caregivers and increase the risk of health problems creating considerable stress in the life of caregivers regarding emotional, physical, social and financial areas. This literature review explored studies that used measures of the autonomic nervous system in caregivers of oncology patients such as electrodermal and cardiovascular (re)activity. The results revealed that caregivers had elevated stress levels and a serious autonomic imbalance that may, in the long term, trigger negative health consequences such as infectious diseases, cancer progression, cardiovascular disease and even premature death. The results showed the need to carry out preventive strategies in this population, in order to improve the autonomic profile of caregivers of cancer patients.

The impact of coping strategies of cancer caregivers on psychophysiological outcomes: an integrative review

Purpose

A growing number of studies have explored the psychosocial burden experienced by cancer caregivers, but less attention has been given to the psychophysiological impact of caregiving and the impact of caregivers’ coping strategies on this association. This paper reviews existing research on the processes underlying distress experienced by cancer caregivers, with a specific focus on the role of coping strategies on psychophysiological correlates of burden.

Methods

A broad literature search was conducted in health-related databases namely MEDLINE, Science Citations Index Expanded, Scopus, and PsycINFO, using relevant search terms. All types of studies published in English were considered for inclusion.

Results

We found that cancer caregiving was related to increased blood pressure, dysregulation of autonomic nervous system, hypothalamic–pituitary–axis dysregulation, immune changes, and poor health-related behaviors. We also found that problem-focused coping was associated with decreased caregiver burden, decreased depression, and better adjustment, while emotion-focused coping was related to higher levels of posttraumatic growth and psychological distress. The way coping impacts psychophysiological correlates of burden, however, remains unexplored.

Conclusion

A better understanding of the psychophysiological elements of caregiver burden is needed. We propose a model that attends specifically to factors that may impact psychophysiological correlates of burden among cancer caregivers. Based on the proposed model, psychosocial interventions that specifically target caregivers’ coping and emotion regulation skills, family functioning, and self-care are endemic to the preservation of the health and well-being of this vulnerable population.

Informal caregiving and metabolic markers in the UK Household Longitudinal Study

OBJECTIVES

Informal caregiving is associated with poorer mental and physical health. Little research has yet focused on objectively measured health risk factors, such as metabolic markers. The aim of this study was to investigate whether informal caregiving was associated with markers of metabolism in a large, representative UK longitudinal study. We also investigated whether more intensive caregiving, as indicated by more caregiving hours, was associated with a less favourable metabolic profile.

STUDY DESIGN/OUTCOME MEASURES

Using data on 9408 participants aged 16+ from the UK Household Longitudinal Study, we explored the relationship between caregiving and metabolic markers (blood pressure, total and high density lipoprotein cholesterol, glycated haemoglobin and triglycerides). We additionally investigated the importance of caregiving intensity (number of hours spent caregiving per week). Associations between caregiving/caregiving intensity and metabolic markers were tested using gender-stratified linear regression models adjusted for age, household income, education, social class, chronic illness, number of dependent children in the household, body mass index and partnership status.

RESULTS

Men who were informal caregivers had higher total cholesterol levels than non-caregivers (3.25% higher, 95% CI: 0.07, 6.53). Women caregivers also had higher total cholesterol levels and women providing intensive care (over 20 h per week) had higher triglyceride levels (19.91% higher, 95% CI: 7.22, 34.10) and lower levels of high density lipoprotein cholesterol (8.46% lower, 95% CI: 14.51, 1.99); however, associations for women were attenuated in our final models.

CONCLUSIONS

Informal caregiving is associated with less favourable lipid profiles. This may be one mechanism through which informal caregiving is associated with increased disease risk. The health of informal caregivers should be a priority for public health.

Interrelationships Between Health Behaviors and Coping Strategies Among Informal Caregivers of Cancer Survivors

BACKGROUND

Recent research among cancer survivors suggests that health behaviors and coping are intertwined, with important implications for positive behavior change and health. Informal caregivers may have poor health behaviors, and caregivers' health behaviors have been linked to those of survivors.

AIMS

This hypothesis generating study assessed the correlations among health behaviors and coping strategies in a population of lung and colorectal cancer caregivers.

METHOD

This cross-sectional study used data from the Cancer Care Outcomes Research & Surveillance Consortium. Caregivers ( n = 1,482) reported their health behaviors, coping, and sociodemographic and caregiving characteristics. Descriptive statistics assessed the distribution of caregivers' health and coping behaviors, and multivariable linear regressions assessed the associations between health behaviors and coping styles.

RESULTS

Many informal caregivers reported regular exercise (47%) and adequate sleep (37%); few reported smoking (19%) or binge drinking (7%). Problem-focused coping was associated with greater physical activity and less adequate sleep (effect sizes [ESs] up to 0.21, p < .05). Those with some physical activity scored higher on emotion-focused coping, while binge drinkers scored lower (ES = 0.16 and 0.27, p < .05). Caregivers who reported moderate daily activity, current smoking, binge drinking, and feeling less well rested scored higher on dysfunctional coping (ES up to 0.49, p < .05).

DISCUSSION

Health behaviors and coping strategies were interrelated among informal cancer caregivers. The relationships suggest avenues for future research, including whether targeting both factors concurrently may be particularly efficacious at improving informal caregiver self-care.

CONCLUSION

Understanding the link between health behaviors and coping strategies may inform health behavior research and practice.

Long-term caregiving is associated with impaired cardiovagal baroreflex

OBJECTIVE

Caregiving stress is associated with increased risk of cardiovascular disease (CVD). Inability to adequately regulate blood pressure is a possible underlying mechanism explaining this risk. We examined the relationship between length of caregiving and cardiovagal baroreflex sensitivity (cBRS) to better understand the link between caregiving and CVD risk.

METHODS

A total of 146 elderly individuals (≥55years) participated in this study, of whom 96 were providing in-home care to a spouse with dementia and 50 were healthy controls married to a non-demented spouse (i.e., non-caregivers). Among the caregivers, 56 were short-term caregivers (caring<4years) and 40 were long-term caregivers (caring≥4years). A multiple linear regression model, with contrast codes comparing short and long-term caregivers with non-caregivers was used to understand relationships between chronic caregiving and cBRS.

RESULTS

After controlling for relevant demographic and health characteristics, mean±SE log transformed cBRS for non-caregivers was 0.971±0.029. Relative to non-caregivers, the long-term caregivers had significantly impaired cBRS (0.860±0.033; p=0.013). However, mean cBRS for short-term caregivers did not significant differ from non-caregivers (0.911±0.028; p=0.144).

CONCLUSION

These results suggest that long-term caregiving stress is associated with an impaired cBRS. Accumulation of stress from years of caregiving could result in worse cBRS function, which could be a mechanistic explanation for the correlation between caregiving stress and the increased risk of CVD.

The Role of Biomarkers in Research on Caregivers for Cancer Patients: A Scoping Review

BACKGROUND

Biomarkers can be used as prognostic, predictive, or monitoring indicators of an associated outcome. The purpose of this review was to provide a comprehensive summary of the research examining the use of biomarkers as surrogate end points for clinical outcomes in family caregivers for cancer patients, identify gaps, and make recommendations for future research.

METHODS

A scoping review, a process of mapping the existing literature, was conducted. Studies comparing biomarkers across caregivers and controls and/or examining relationships between biomarkers and psychological health were reviewed.

RESULTS

The studies ( N = 18) of caregivers for cancer patients who were identified used biomarkers to predict outcomes ( n = 13) and to monitor the efficacy of interventions ( n = 6). Biomarkers were divided into two categories based on physiological systems involved: (1) neuroendocrine function (sympathetic-adrenal-medullary axis activity, hypothalamic-pituitary-adrenal axis activity) and (2) immune function. Predictive biomarkers were sensitive to differences between caregivers and controls. The biomarkers were used to evaluate outcomes frequently associated with stress, depression, and anxiety. Cortisol was the biomarker most commonly measured to monitor the efficacy of interventions.

DISCUSSION

Biomarkers are most commonly incorporated into caregiver studies to predict group membership and psychological health. Neuroendocrine biomarkers, specifically cortisol, are most frequently assessed. Future research should include biomarkers of other physiologic functions (e.g., cardiovascular function, cognitive dysfunction, and cell aging) and those that serve as multisystem indicators. Expanding the scientific study of biomarkers will contribute to our understanding of the mechanisms through which stress may influence caregiver health.

Caregiver Burden and the Nonmotor Symptoms of Parkinson's Disease

Parkinson's disease has traditionally been considered as primarily a motor disorder (Chaudhuri & Schapira, 2009). It is clear however that it is the burden of the nonmotor symptomatology which impacts significantly more highly on caregiver burden and quality of life (Benavides, Alberquerque, & Chana-Cuevas, 2013; Martinez-Martin, 2011). As Parkinson's disease advances there is an almost inevitable accrual of nonmotor symptoms alongside the motor aspects of the disease. Patients as their disease progresses require increasing support and this is not infrequently provided by an informal caregiver, most typically a spouse or family member (Martinez-Martin, Forjaz, Frades-Payo, et al., 2007). The role of the caregiver while being emotionally, physically, and psychosocially demanding is also costly and time intensive. The cost of care is typically borne by the family and one survey has estimated that the average caregiver spends an average of 22h per week fulfilling their role. The caregiver has a unique and privileged view of the patient's condition and often due to symptoms of apathy, cognitive impairment, and depression can provide a more accurate appraisal of symptoms and treatment effect. It is therefore imperative that the caregiver is involved, where possible in clinical appointments and treatment decisions. During this chapter the impact of nonmotor symptoms on the caregiver will be highlighted and the need for early and continued collaboration with the caregiver reiterated. The influence of certain key nonmotor symptoms on caregiver burden will be explored in more detail and the narrative will be punctuated with carer reflections as experienced by Jon Hiseman while caring for his wife Barbara, a world renowned saxophonist.

Reduced cardiovascular activation following chronic stress in caregivers of people with anorexia nervosa

Caring for offspring diagnosed with eating disorders (EDs) puts caregivers under high levels of chronic stress, which have negative consequences for their health. Unfortunately, caregivers have received little attention from mental health professionals. Chronic stress experienced by informal caregivers has been associated with the alteration of body homeostasis, and therefore, the functioning of various physiological systems. This could be the basis of health problems in informal caregivers of people with EDs. The main objective of this study was to analyze physiological response, in terms of heart rate (HR) and heart rate variability (HRV), to an acute laboratory stressor in a sample of informal caregivers of individuals with anorexia nervosa (n = 24) compared to a sample of noncaregivers (n = 26). In addition, the relationship between depressive mood and the aforementioned cardiovascular response parameters was analyzed in the group of caregivers. Caregivers had higher high-frequency (HF) power HRV, and lower HR, low-frequency (LF) power HRV and LF/HF ratio values than noncaregivers, which suggests lower cardiovascular reactivity to the acute stressor than noncaregivers. Moreover, a blunted HR response to stress was associated with high depressive mood scores in caregivers. Hence, it seems that the worse the mood the lower the cardiovascular reactivity to stressful events in this population. Developing and implementing psychotherapeutic interventions focused on stress management would help caregivers to reduce their stress levels and cope more effectively with stressors.

The Perceptions of Important Elements of Caregiving for a Left Ventricular Assist Device Patient: A Qualitative Meta-Synthesis

BACKGROUND

The use of a left ventricular assist device (LVAD) is becoming increasingly common in patients with end-stage heart failure. Many LVAD programs require patients to have a caregiver before receiving a device. There are few studies exploring the experience, burden, and impacts on caregivers of patients with LVADs.

OBJECTIVES

The aim of this study was to synthesize the qualitative literature regarding caregiver's perceptions about caring for an adult LVAD patient.

METHODS

We searched MEDLINE, CINAHL, PsychInfo, and Web of Science to find English articles on the topic of LVAD caregiver's perceptions. The articles were then synthesized using a formal process of qualitative meta-synthesis.

RESULTS

Eight articles met criteria for inclusion. The meta-synthesis across the articles resulted in 8 themes categorized under 3 domains. Many of the articles suggested a longitudinal process of caregiving with perceptions largely dependent upon the time of interview in relation to the LVAD. The first domain of caregiving is the "early" stage, covering the life before the LVAD through the procedure. This phase is characterized by the pre-LVAD "emotional rollercoaster," the decision seen as "no option," and the thought of "leave it [the LVAD] at the hospital." The second domain is the "middle" stage, covering the time frame after discharge from the hospital. This phase is characterized by fragility of the patient, recognition of a need to adapt, and a transformed life. The final domain is "late LVAD" and describes how late in the LVAD process the LVAD indication (bridge to transplant or destination therapy) brings in to focus what is important to caregivers.

CONCLUSIONS

Existing literature indicates that the LVAD caregiver experience is intense as well as burdensome and entails the need to adapt to a new life. Given the burdens caregivers experience, clinicians and future research should explore strategies to support these important individuals.

Documenting stress in caregivers of transplantation patients: initial evidence of HPA dysregulation

There is growing evidence linking caregiver stress with an increased risk for morbidity and mortality. While the emotional and practical burden experienced by caregivers is well established, the physiological changes that may affect the caregiver's health are less understood. This study sought to compare self-reported stress, anxiety and depression along with neuroendocrine and immune markers of stress among adult caregivers of allogeneic hematopoietic stem cell transplantation patients during the acute transplant recovery period to matched non-caregivers controls. Biomarkers and self-reported data were collected at three points during the patient's HSCT: (1) before transplant, (2) after initial transplantation discharge (±7 days) and (3) 6 weeks after initial transplantation discharge. Mixed linear modeling was used to examine differences by group and time. Twenty-one caregivers and 20 controls completed all study procedures. The majority of caregivers were female (57% or 57.1%) and married (95.2%), with a mean age of 52 ± 11.4 years. Caregiver perceived stress, anxiety and depression scores were significantly higher than controls (p < 0.001) with effect sizes (ES) ranging from 1.37 to 1.80 and they did not change over time (p > 0.05) for either group. Caregivers had significantly lower serum cortisol levels than controls at both discharge (p = 0.013; ES = 0.81) and 6 weeks after discharge (p = 0.028; ES = 0.72) but exhibited no significant relationship between self-reported stress and serum cortisol. In addition, caregivers showed a significant inverse relationship between stress and epinephrine levels (r(s)=-0.654, p = 0.021). These findings support the evidence of the caregiving experience being stressful. The counter-intuitive relationship between cortisol and epinephrine might suggest dysregulation of the HPA axis and central nervous system but additional research on the physiological impact of caregiving is warranted.

Autonomic nervous system dysregulation in irritable bowel syndrome

BACKGROUND

Autonomic nervous system (ANS) regulation may be altered in functional diseases, including irritable bowel syndrome (IBS), but published data are not clear to date. The aim of the study was to analyze ANS function in IBS subjects classified by Rome III criteria and healthy controls using standardized technique.

METHODS

ANS activity was evaluated by autoregressive spectral analysis of RR interval and systolic arterial pressure variabilities, to obtain indices of sympatho-vagal modulation of the heart and of spontaneous cardiac baroreflex (α index). A symptom list was used to score 18 somatic complaints (score 0-180) (4SQ). Fatigue and stress were assessed through the use of a global scoring index (0-10).

KEY RESULTS

We enrolled 41 IBS subjects (29 F, age 40 ± 2 years) and 42 healthy matched controls. Heart rate was higher in IBS than control subjects (69 ± 2 vs 61 ± 1; p < 0.001). The total variance of RR interval variability, and α index, were significantly lower in IBS compared to controls (1983.12 ± 384.64 ms(2) vs 4184.55 ± 649.59 ms(2) ; 18.1 ± 2 ms/mmHg vs 29 ± 3 ms/mmHg; p < 0.01). The α index results showed an inverse correlation with stress scores and somatic symptoms.

CONCLUSIONS & INFERENCES

IBS subjects display a significant reduction in α index, an established marker of cardiac baroreflex. ANS dysfunction appears to be involved in the pathophysiology of IBS and its assessment may open new perspectives for clinical management of patients suffering from IBS.

Effects of adverse life events on heart rate variability, cortisol, and C-reactive protein

OBJECTIVE

Our objective was to assess whether self-reported adverse life events during childhood or over the lifespan are associated with altered activity of the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal axis (HPA axis), and the immune system.

METHOD

This study was performed in a population-based cohort of 1094 adults aged 33-79 years, 46.3% male, average age 53 (SD 11.4). Two waves of data were collected at a 2-year interval, enabling replication of the analyses. Cumulative exposure to adverse life events was assessed by means of the List of Threatening Experiences. ANS function was assessed by spectral analysis of heart rate variability in the high-frequency band (HRV-HF). HPA axis function was assessed by 24-h urinary free cortisol (24-h UFC) excretion. Inflammation was assessed by high-sensitive C-reactive protein (hsCRP).

RESULTS

Multiple linear regression analyses did not reveal any significant associations, with the exception of one significant negative association between the lifetime score of adverse life events and HRV-HF β = -0.028; P = 0.037 at baseline, but not at follow up 2 years later.

CONCLUSION

In a large population-based cohort, adverse life events were not consistently associated with HRV-HF, 24-h UFC or (hsCRP).

A labor of love: the influence of cancer caregiving on health behaviors

BACKGROUND

Evidence suggests that emotional distress and objective demands of cancer caregiving are comparable to those of dementia caregiving, yet little research has focused on the physical health of cancer caregivers. Whether the stress leads directly to changes in health or whether the stress leads to changes in health behaviors, which in turn affect health, has not been systematically examined.

OBJECTIVE

The objective of this study was to review the research literature regarding changes in health behaviors associated with caring for an individual with cancer.

METHODS

Literature was reviewed from multiple databases including CINAHL (Cumulative Index to Nursing and Allied Health Literature), CINAHL Plus, PsycNET, PubMed, SCOPUS, EMBASE, and Web of Science. Key words included "health behavior," "health promotion," "caregivers/caregiving," "cancer/oncology," "diet/nutrition," "exercise/physical activity," "stress management," "smoking" and "alcohol." Studies were included if they involved informal adult caregivers and at least 1 behavior associated with a healthy lifestyle. Of the 866 studies identified, 8 met the criteria.

RESULTS

Studies revealed conflicting information, with some suggesting deleterious changes in behaviors, whereas others found the changes protective.

CONCLUSIONS

The lack of uniformity of terminology and conflicting findings make it difficult to conclude the impact of the caregiving experience on the health behaviors of cancer caregivers. Something is placing caregivers at risk for illness and early death, but the mechanisms behind the risk and the role of unhealthy behaviors are not clear.

IMPLICATIONS FOR PRACTICE

At a minimum, cancer caregivers should be screened for behavior changes and disease risk. Developing standardized measures for future research including controlled, longitudinal studies is needed.

Cardiovascular response to psychosocial repeated stress in caregivers of offspring with schizophrenia

Taking care of offspring suffering a long-term illness such as schizophrenia is one of the more stressful life experiences. Care conditions may act as a protective factor in the health of the caregiver. The present study assesses heart rate (HR), blood pressure (BP), and mood responses to psychosocial stress in 16 mothers receiving specialised support for the care of their offspring (CARE+) and in 11 mothers caring for their offspring without support (CARE-). The CARE- group take care of less functional and more symptomatic offspring; and display higher basal, but lower HR, responses after stress than the CARE+ group. No significant group effects were found for BP. For mood states, there were significant decreases in the anger subscale in the CARE- group that were not found in the CARE+ group. HR was related to active and passive coping styles, trait anxiety, and years spent providing care. In the total sample, other significant relationships between cardiovascular responses and life events and personality traits have been found. In sum, the data suggests that specialised support for patients may modulate cardiovascular responses to repeated stress in caregivers.

Post-traumatic disorder symptoms and blunted diurnal cortisol production in partners of prostate cancer patients

Prostate cancer (PC) is the most common cancer diagnosed in men, and research suggests that coping with this illness can cause significant distress in patients as well as their partners. This study examined the relationship of caregiving for a partner with PC with diurnal cortisol output in women between the ages of 42 and 75 years old. Participants were women whose partners had PC (n = 19) and women who were in relationships with men with no diagnosed medical illness (n = 26). Women provided saliva samples (4 times per day over 3 days) in their natural environment. The Structured Clinical Interview for DSM-IV Axis-I Disorders was also conducted to assess for the presence of post-traumatic stress disorder (PTSD) and major depression. Partners of men with PC had lower daily cortisol output across the three days than controls, F(1,444.08) = 20.72, p<.001). They were also more likely to report PTSD symptoms with 68.4% of PC partners fulfilling criteria for sub-threshold PTSD as compared to 23.1% of controls (χ(2) = 11.30, p = .01). Mixed model analyses revealed that the presence of sub-threshold PTSD symptoms significantly predicted cortisol production, F(1,419.64) = 5.10, p<.01). Regardless of caregiver status, women who reported at least sub-threshold PTSD symptoms had lower cortisol production than those with no PTSD symptoms. Major depression did not explain differences in cortisol production between partners of PC patients and controls. Although these findings are preliminary, they highlight the importance of developing interventions aimed at reducing risk of psychopathology in partners of men with PC.

From stress to functional syndromes: an internist's point of view

In this brief review we address schematically the relationship between two emerging issues in clinical medicine: stress and functional syndromes. It is becoming increasingly clear that they demand a multidimensional approach, considering simultaneously elements of behavioral therapy with traditional pharmacological treatment, guided by a better physiopathological understanding including autonomic assessment. New techniques, based on innovative analysis of continuous segments of electrocardiogram and non invasive arterial pressure recordings capable to extract hidden oscillations, provide quantitative indices of sympathetic and vagal modulation of the cardiovascular system. This more complete diagnostic process facilitates explanation of symptoms and reassurance of patients, based on functional evidence. The described clinical approach implies in addition an active collaboration of patients requiring the implementation of a creative alliance. Physical exercise, eating habits and muscular-mental relaxation are combined with pharmacological tools as needed.

A pilot study evaluating the effect of mindfulness-based stress reduction on psychological status, physical status, salivary cortisol, and interleukin-6 among advanced-stage cancer patients and their caregivers

PURPOSE

To investigate whether a mindfulness-based stress reduction program for cancer (MBSR-C) improved psychological and physical symptoms, quality of life (QOL), and stress markers among advanced-stage cancer patients and caregivers.

DESIGN

A pilot within-subject design was used.

METHOD

Patients previously diagnosed with advanced-stage breast, colon, lung, or prostate cancer and on treatment were recruited from the Moffitt Cancer Center and Research Institute. Twenty-six patient-caregiver dyads completed a modified 6-week, self-study MBSR-C program based on the Kabat-Zinn model. Psychological and physical symptoms and QOL were compared pre- and post-MBSR-C sessions. Salivary cortisol and interleukin-6 were assessed pre- and post-MBSR-C session at 1, 3, and 6 weeks.

FINDINGS

Following the 6-week MBSR program, patients showed improvements in stress and anxiety (p < .05); caregivers' psychological and QOL also improved but were not statistically significant. Both patients and caregivers had decreases in cortisol at Weeks 1 and 3 (p < .05) but not at Week 6. Similar to cortisol levels at Week 6, salivary interleukin-6 levels were lower overall (before/after an MBSR-C session), compared with Week 1 for patients and caregivers.

CONCLUSIONS

MBSR-C may be a beneficial intervention for reducing stress, anxiety, cortisol levels, and symptoms in advanced-stage cancer patients and may also benefit caregivers.

Caregiving burden, stress, and health effects among family caregivers of adult cancer patients

Unlike professional caregivers such as physicians and nurses, informal caregivers, typically family members or friends, provide care to individuals with a variety of conditions including advanced age, dementia, and cancer. This experience is commonly perceived as a chronic stressor, and caregivers often experience negative psychological, behavioral, and physiological effects on their daily lives and health. In this report, we describe the experience of a 53-year-old woman who is the sole caregiver for her husband, who has acute myelogenous leukemia and was undergoing allogeneic hematopoietic stem cell transplantation. During his intense and unpredictable course, the caregiver's burden is complex and complicated by multiple competing priorities. Because caregivers are often faced with multiple concurrent stressful events and extended, unrelenting stress, they may experience negative health effects, mediated in part by immune and autonomic dysregulation. Physicians and their interdisciplinary teams are presented daily with individuals providing such care and have opportunity to intervene. This report describes a case that exemplifies caregiving burden and discusses the importance of identifying caregivers at risk of negative health outcomes and intervening to attenuate the stress associated with the caregiving experience.

Blood pressure variability and closed-loop baroreflex assessment in adolescent chronic fatigue syndrome during supine rest and orthostatic stress

Hemodynamic abnormalities have been documented in the chronic fatigue syndrome (CFS), indicating functional disturbances of the autonomic nervous system responsible for cardiovascular regulation. The aim of this study was to explore blood pressure variability and closed-loop baroreflex function at rest and during mild orthostatic stress in adolescents with CFS. We included a consecutive sample of 14 adolescents 12–18 years old with CFS diagnosed according to a thorough and standardized set of investigations and 56 healthy control subjects of equal sex and age distribution. Heart rate and blood pressure were recorded continuously and non-invasively during supine rest and during lower body negative pressure (LBNP) of –20 mmHg to simulate mild orthostatic stress. Indices of blood pressure variability and baroreflex function (α-gain) were computed from monovariate and bivariate spectra in the low-frequency (LF) band (0.04–0.15 Hz) and the high–frequency (HF) band (0.15–0.50 Hz), using an autoregressive algorithm. Variability of systolic blood pressure in the HF range was lower among CFS patients as compared to controls both at rest and during LBNP. During LBNP, compared to controls, α-gain HF decreased more, and α-gain LF and the ratio of α-gain LF/α-gain HF increased more in CFS patients, all suggesting greater shift from parasympathetic to sympathetic baroreflex control. CFS in adolescents is characterized by reduced systolic blood pressure variability and a sympathetic predominance of baroreflex heart rate control during orthostatic stress. These findings may have implications for the pathophysiology of CFS in adolescents.

Hemodynamic, autonomic and baroreflex changes after one night sleep deprivation in healthy volunteers

BACKGROUND

Sleep disorders are associated to a number of cardiovascular disturbances that might increase cardiovascular risk. Sleep deprivation, in particular, might, by inducing autonomic dysregulation, raise arterial pressure and hypertensive risk. Available evidence however is contradictory.

METHODS

We tested the main hypothesis that one night sleep deprivation in 24 volunteers might alter hemodynamics (heart rate and Arterial Pressure - AP), autonomic regulation (mono and bivariate spectral analysis of RR and non invasive AP variability) and baroreflex control (spectral index alpha and spontaneous baroreflex slope), performance indices (reaction time) and subjective stress (questionnaires and salivary cortisol). Volunteers were studied in normal living conditions and while kept in isolation and confinement, to test the presence of possible bias related to environmental stress.

RESULTS

Results indicate that there were no differences between normal living conditions and isolation and confinement (Intraclass Correlation Coefficient >0.75 for most variables). Conversely, after one night sleep deprivation subjects felt tired (p<0.05), and performance deteriorated (p<0.05), while cortisol profile was substantially maintained, hemodynamic parameters did not change and HRV and index alpha increased slightly.

CONCLUSIONS

Findings support the contention that one night sleep deprivation, in absence of significant additional stress or disturbances, does not lead to increased arterial pressure values or to changes in autonomic or baroreflex profiles that could conceivably favor hypertension development, but induces the expected increase in tiredness and reduction in performance.