Chronic stress in caregivers of dementia patients is associated with reduced lymphocyte sensitivity to glucocorticoids

Stress and the risk of Alzheimer dementia: Can deconstructed engrams be rebuilt?

The exact neuropathological mechanism by which the dementia process unfolds is under intense scrutiny. The disease affects about 38 million people worldwide, 70% of which are clinically diagnosed with Alzheimer's disease (AD). If the destruction of synapses essential for learning, planning and decision-making is part of the problem, must the restoration of previously lost synapses be part of the solution? It is plausible that neuronal capacity to restitute information corresponds with the adaptive capacity of its connectivity reserve. A challenge will be to promote the functional connectivity that can compensate for the lost one. This will require better clarification of the remodeling of functional connectivity during the progression of AD dementia and its reversal upon experimental treatment. A major difficulty is to promote the neural pathways that are atrophied in AD dementia while suppressing others that are bolstered. Therapeutic strategies should aim at scaling functional connectivity to a just balance between the atrophic and hypertrophic systems. However, the exact factors that can help reach this objective are still unclear. Similarities between the effects of chronic stress and some neuropathological mechanisms underlying AD dementia support the idea that common components deserve prime attention as therapeutic targets.

Excessive Noise in Neonatal Units and the Occupational Stress Experienced by Healthcare Professionals: An Assessment of Burnout and Measurement of Cortisol Levels

Excessive noise in the work environment has been associated with extra-auditory symptoms, which can have harmful long-term effects on individuals. The purpose of this study was to identify noise levels in neonatal intensive care units and investigate their impact on the occurrence of stress among healthcare professionals, using cortisol levels as a biomarker for Burnout Syndrome. This descriptive, observational, and cross-sectional study was conducted in four public teaching hospitals in Fortaleza, Ceará, Brazil. Sound pressure levels in the environment were measured, and questionnaires were administered to collect sociodemographic data and assess perceptions of the work environment and Burnout symptoms. Saliva samples were collected at the beginning and end of work shifts for cortisol quantification. The average sound pressure ranged from 59.9 to 66.4 dB(A), exceeding the recommended levels set by Brazilian and international legislation. Among the 256 participants, the average age was 39.4 years, with 95% being female. The majority (70.9%) were nurses, and 22.7% were physicians. There was no significant association found between noise and Burnout Syndrome, nor with changes in cortisol levels. However, a significant association was observed between the perception of excessive noise and the sensation of a stressful work shift (p = 0.012). All evaluated professionals displayed symptoms of Burnout. The high sound pressure levels indicated that the assessed environments did not meet the recommended standards for acoustic comfort, and this was associated with the participants' perception of stressful work shifts. While Burnout symptoms were evident in our participants, it was not possible to confirm a correlation with high noise levels.

Effects of a Home-Based Exercise Program on Health-Related Quality of Life and Physical Fitness in Dementia Caregivers: A Randomized Controlled Trial

Regular exercise can be an effective health-promotion strategy to improve the physical and mental health of informal caregivers. A randomized controlled trial study was designed to evaluate the effects of a 9-month home-based exercise intervention on health-related quality of life (HRQoL) and physical fitness in female family caregivers of persons with dementia. Fifty-four female caregivers were randomly assigned to two groups for the 9-month study period. Participants of the intervention group (n = 25) performed two 60-min exercise sessions per week at home, under the direct supervision of a personal trainer. Participants in the control group (n = 23) continued their habitual leisure-time activities. HRQoL was assessed using the SF-36 questionnaire, and physical fitness was measured using a battery of appropriate fitness tests. After 9 months, significant improvements were observed in general health, social function, vitality, hand and leg strength, trunk flexor and extensor endurance, and aerobic endurance in the intervention group. The present intervention was highly adherent and safe for the participants, with no dropout related to the intervention. As a home-based exercise program conducted by a personal trainer face to face, it can be considered as a feasible and appropriate method to improve the most deficient HRQoL dimensions and contribute to preserving the functional capacity of female family caregivers of persons with dementia.

Psychobiological Evaluation of Day Clinic Treatment for People Living With Dementia – Feasibility and Pilot Analyses

Background

Hospitalization is often stressful and burdensome for people living with dementia (PwD) and their informal caregivers (ICs). Day clinic treatment may provide a suitable alternative, but is often precluded by a diagnosis of dementia. Furthermore, it is often caregiver-based ratings that measure treatment success as the validity of self-reports in PwD is critically discussed. We therefore set out to examine the feasibility of psychobiological stress measures in PwD and ICs and to evaluate treatment trajectories considering both the day clinic context and the daily life of the dyads.

Method

A total of 40 dyads of PwD (mean age: 78.15 ± 6.80) and their ICs (mean age: 63.85 ± 13.09) completed paper-and-pencil questionnaires (covering stress, depressive symptoms, and caregiver burden among others) in addition to the measurement of hair cortisol concentrations (HCC) at admission, discharge, and follow-up 6 months after day clinic treatment. As part of an ambulatory assessment, for 2 days at the beginning and 2 days at the end of the day clinic treatment, PwD and ICs collected six saliva samples per day for the analysis of salivary cortisol (sCort) and alpha-amylase (sAA).

Results

Paper-and-pencil questionnaires and HCC assessments were more feasible than the ambulatory assessment. We found discrepancies between subjective and physiological markers of stress in PwD. Whereas HCC decreased over time, self-reported stress increased. Child–parent dyads reported decreases in neuropsychiatric symptoms, associated burden, and self-reported stress from admission to follow-up. In daily life, both PwD and ICs showed characteristic diurnal profiles of sAA and sCort, however, we found no differences in summary indicators of salivary stress markers over time.

Discussion

The psychobiological evaluation was feasible and added informative value, underlining the potential of physiological stress markers to complement self-reports on stress in PwD and to objectively evaluate treatment trajectories. In this sample, HCC was more feasible and acceptable as biological marker of stress compared to saliva samples. Concerning treatment trajectories, differential effects on the dyads were found, with child–parent dyads benefiting more from day clinic treatment compared to spousal dyads.

Spousal caregiving, widowhood, and cognition: A systematic review and a biopsychosocial framework for understanding the relationship between interpersonal losses and dementia risk in older adulthood

Accumulating research suggests that stressful life events, especially those that threaten close intimate bonds, are associated with an increased risk of dementia. Grieving the loss of a spouse, whether in the form of caregiving or after the death, ranks among 'life's most significant stressors', evoking intense psychological and physiological distress. Despite numerous studies reporting elevated dementia risk or poorer cognition among spousal caregivers and widow(er)s compared to controls, no review has summarized findings across cognitive outcomes (i.e., dementia incidence, cognitive impairment rates, cognitive performance) or proposed a theoretical model for understanding the links between partner loss and abnormal cognitive decline. The current systematic review summarizes findings across 64 empirical studies. Overall, both cross-sectional and longitudinal studies revealed an adverse association between partner loss and cognitive outcomes. In turn, we propose a biopsychosocial model of cognitive decline that explains how caregiving and bereavement may position some to develop cognitive impairment or Alzheimer's disease and related dementias. More longitudinal studies that focus on the biopsychosocial context of caregivers and widow(er)s are needed.

Prevalence and determinants of stress of informal caregiving: A cross-sectional study among informal caregivers of hospitalised patients in a tertiary hospital in Nigeria

Background

Caring for patients in the hospital can cause a lot of stress for the caregivers, especially those who are involved with informal caregiving such as family members. Little is known in Nigeria on the stress of informal caregiving in the hospital environment. This study assessed the informal caregivers' stress level and their determinants in a tertiary hospital in Ilorin, Nigeria.

Methodology

This was a hospital-based cross-sectional study. Between September and October 2019, using a simple random sampling method, data were collected from 400 informal caregivers of patients in University of Ilorin Teaching Hospital with interviewer-administered questionnaire which included socio-demographic characteristics, Caregivers Strain index (CSI) and caregivers' stress from institution and other factors index (CSIOI). Analysis was performed, and prevalence and determinants of stress of informal caregiving were presented using descriptive statistics and logistic regressions. P < 0.05 was considered statistically significant.

Results

The majority, 381 (95.2%) of the informal caregivers, reported great stress levels using CSI, while 227 (56.7%) experienced a great level of stress with the CSIOI. Predictors of caregiver stress were perception that staying around was stressful (odds ratio [OR] - 17.5, P < 0.001), felt their patients will not be well cared for if not around (OR - 6.1, P < 0.001), staying at the hospital for >30 days (OR - 2.6, P = 0.001).

Conclusion

The informal caregivers experienced a great level of stress taking care of their patients on admission in the hospital. It is, therefore, expedient that issues surrounding the comfort of the informal caregivers as they care for their patients should be included in hospital policies.

Home health aide perceived information needs for dementia-specific care plans

Home health aides (HHAs) are a vital workforce essential to meet the complex care needs of the persons living with dementia (PLWD) who remain at home. Care plans for PLWD in the home healthcare setting should incorporate HHAs perspectives. We sought to understand HHAs' perspectives about their information needs in caring for PLWD, from June to August 2020, semi-structured interviews telephone interviews (n = 25) with English and Spanish-speaking HHAs with limited English proficiency in the New York metropolitan area. Interviews were audio-recorded, transcribed verbatim and transcripts were analyzed using conventional content analysis. Four key themes emerged reflective of information needs of HHAs caring for PLWD: (1) ambiguities of scope of HHA tasks related to medication management; (2) clinical information needs of HHAs; (3) dementia-related concerns; and (4) going above and beyond. Findings from this research can guide efforts to develop dementia-specific care plans, and training to support the HHA workforce caring for the growing population of PLWD.

Glucocorticoid resistance and β2-adrenergic receptor signaling pathways promote peripheral pro-inflammatory conditions associated with chronic psychological stress: A systematic review across species

Activation of the HPA-axis and SNS are widely accepted to link chronic stress with elevated levels of peripheral pro-inflammatory markers in blood. Yet, empirical evidence showing that peripheral levels of glucocorticoids and/or catecholamines mediate this effect is equivocal. Recent attention has turned to the possibility that cellular sensitivity to these ligands may contribute to inflammatory mediators that accompany chronic stress. We review current evidence for the association of chronic stress with glucocorticoid receptor (GR) and β-adrenergic receptor (β-AR) signaling sensitivity. Across 15 mouse, 7 primate, and 19 human studies, we found that chronic stress reliably associates with downregulation in cellular GR sensitivity, alterations in intracellular β-AR signaling, and upregulation in pro-inflammatory biomarkers in peripheral blood. We also present evidence that alterations in GR and β-AR signaling may be specific to myeloid progenitor cells such that stress-related signaling promotes release of cells that are inherently less sensitive to glucocorticoids and differentially sensitive to catecholamines. Our findings have broad implications for understanding mechanisms by which chronic stress may contribute to pro-inflammatory phenotypes.

Stigma associated with parental depression or cancer: Impact on spouse and offspring's cortisol levels and socioemotional functioning

Stress associated with caring for a mentally ill spouse can adversely affect the health status of caregivers and their children. Adding to the stress of caregiving is the stigma often placed against spouses and children of people with mental illness. Contrary to mental illness, many physical disorders such as cancer may be less stigmatized (expect pulmonary cancer). In this study, we measured externalized and internalized stigma, as well as psychological (depressive symptoms and stressful life events) and physiological (basal salivary cortisol levels) markers of stress in 115 spouses and 154 children of parents suffering from major depressive disorder, cancer, or no illness (control group). The results show that spouses and children from families with parental depression present significantly more externalized stigma than spouses and children from families with parental cancer or no illness, although we find no group differences on internalized stigma. The analysis did not show a significant group difference either for spouses or their children on depressive symptomatology, although spouses from the parental depression group reported greater work/family stress. Finally, we found that although for both spouses children the awakening cortisol response was greater on weekdays than on weekend days, salivary cortisol levels did not differ between groups. Bayes factor calculated on the null result for cortisol levels was greater than 100, providing strong evidence for the null hypothesis H0. Altogether, these results suggest an impact of stigma toward mental health disorder on psychological markers of stress but no impact of stigma on physiological markers of stress. We suggest that these results may be due to the characteristics of the families who participated in the present study.

Biomarking Trait Resilience With Salivary Cortisol in Chinese Undergraduates

This study aimed to examine the relationship between trait resilience and salivary cortisol in a group of Chinese undergraduates. The Chinese versions of the Brief Resilience Scale and a measure of optimism, the revised Life Orientation Test were administered to 49 Chinese undergraduates who provided self-collected saliva samples six times per day (immediately after waking; 0.5, 3, 6, and 12 h thereafter; and at bedtime) over 3 consecutive weekdays. The cortisol data were aggregated across the 3 days to examine the association between resilience and components of the diurnal rhythm of cortisol using multiple regression. The results showed that higher resilience was associated with a stronger cortisol response to awakening and a steeper diurnal decline in cortisol from waking to bedtime. Resilience was positively associated with cortisol output over the course of the day but this relationship was not significant (p = 0.065). This pattern of diurnal rhythm is consistent with that typically observed in better adjusted individuals. Generated by an intensive protocol with compliance objectively monitored, these findings clearly indicate the important role of the hypothalamic-pituitary-adrenocortical axis in health and adjustment and contribute to the growing literature on resilience and cortisol in humans.

Anticipatory plastic response of the cellular immune system in the face of future injury: chronic high perceived predation risk induces lymphocytosis in a cichlid fish

Vertebrate cellular immunity displays substantial variation among taxa and environments. Hematological parameters such as white blood-cell counts have emerged as a valuable tool to understand this variation by assessing the immunological status of individuals. These tools have long revealed that vertebrate cellular immune systems are highly plastic and respond to injury and infection. However, cellular immune systems may also be able to anticipate a high risk of injury from environmental cues (e.g., predation-related cues) and respond plastically ahead of time. We studied white blood-cell (leukocyte) profiles in African cichlids Pelvicachromis taeniatus that were raised for 4 years under different levels of perceived predation risk. In a split-clutch design, we raised fish from hatching onwards under chronic exposure to either conspecific alarm cues (communicating high predation risk) or a distilled water control treatment. Differential blood analysis revealed that alarm cue-exposed fish had twice as many lymphocytes in peripheral blood as did controls, a condition called lymphocytosis. The presence of a higher number of lymphocytes makes the cellular immune response more potent, which accelerates the removal of invading foreign antigens from the bloodstream, and, therefore, may be putatively beneficial in the face of injury. This observed lymphocytosis after long-term exposure to conspecific alarm cues constitutes first evidence for an anticipatory and adaptive plastic response of the cellular immune system to future immunological challenges.

Telomerase and telomeres in aging theory and chronographic aging theory (Review)

The current review focuses on the connection of telomerase and telomeres with aging. In this review, we describe the changes in telomerase and telomere length (TEL) during development, their role in carcinogenesis processes, and the consequences of reduced telomerase activity. More specifically, the connection of TEL in peripheral blood cells with the development of aging‑associated diseases is discussed. The review provides systematic data on the role of telomerase in mitochondria, the biology of telomeres in stem cells, as well as the consequences of the forced expression of telomerase (telomerization) in human cells. Additionally, it presents the effects of chronic stress exposure on telomerase activity, the effect of TEL on fertility, and the effect of nutraceutical supplements on TEL. Finally, a comparative review of the chronographic theory of aging, presented by Olovnikov is provided based on currently available scientific research on telomere, telomerase activity, and the nature of aging by multicellular organisms.

Minimally-invasive methods for examining biological changes in response to chronic stress: A scoping review

BACKGROUND

Nurse researchers are increasingly interested in incorporating biological indicators related to chronic stress, or repeated or constant exposure to psychological stressors. Minimally invasive collection methods may improve access to vulnerable populations.

OBJECTIVE

To map biological indicators measured through minimally invasive methods investigating biological changes in response to chronic stress.

DESIGN, DATA SOURCES, AND METHODS

The paper seeks to answer two questions: What are the characteristics of the minimally-invasive methods used to measure the biological correlates of chronic stress? What are the limitations regarding the use of the minimally-invasive methods and/or biological indicators identified above? Authors completed a scoping review following guidelines from the Joanna Briggs Institute Manual and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews. A literature search was completed in PubMed, PsycINFO, and Scopus. 2518 articles were screened and 145 studies were included. Data were extracted using a standardized extraction tool, compiled, and coded.

RESULTS

Studies included minimally-invasive methods to measure the hypothalamic-adrenal-pituitary axis (N = 173), immune and inflammatory markers (N = 118), and adult neurogenesis (N = 6). Cortisol was most frequently measured (N = 136), usually in saliva (N = 86). Studies included a variety of limitations for the methods and indicators, including concerns about timing and accuracy of collection, frequency of sampling, and controlling for acute stressors.

CONCLUSIONS

Nurse researchers have access to many minimally-invasive methods to measure altered biological processes related to chronic stress. A gap identified by this review is the paucity of minimally-invasive methods for investigating neurogenesis; the measurement of brain derived neurotrophic factor in plasma is a distal proxy and further research is needed to test the response of peripheral levels to psychosocial stress interventions. Additionally, while this scoping review allows nurse researchers to consider possible biological indicators to include in their research, future research is still needed on some of the basic premises of stress research, including agreement on the conceptualization of chronic stress.

Caregiver Psychological Distress: Longitudinal Relationships With Physical Activity and Diet

Given limited longitudinal research with caregivers (CGs, n = 122) of spouses with Alzheimer disease, and demographically matched noncaregivers (NCGs, n = 117), we compared these groups on psychological distress (anxiety, depression), burden, and health behaviors over 2 years. Analyses examined group differences in relationships of micronutrient recommended daily allowances (RDAs) and physical activity considering hours of care, psychological distress, and burden. Participants were measured and assessed on whether they met micronutrient intake and physical activity totaled over an average week. Regression analyses showed a total effect whereby NCGs had greater increases in meeting micronutrient allowances (RDAs) than CGs (b = 10.91, standard error [SE] = 4.74, 95% confidence interval [CI]: 1.56-20.26). Additionally, over time, NCGs had greater increases in physical activity, which was mediated by hours of care (b = 0.149, SE = 0.060, 95% CI: 0.034-0.270). These results suggest CGs may lack proper nutrients, and care hours may influence their health behaviors.

The Biology of Social Adversity Applied to Oral Health

Biological embodiment is a concept derived from Engel's biopsychosocial model to health, theorized as the process by which adverse social exposures trigger neuroendocrine and immune responses, leading to disease and/or increased disease susceptibility. This critical review discusses the biopsychosocial model as applied to oral health and its relevance to oral health policy while deciphering some of the pathobiological processes underlying social adversity. In periodontal disease, for example, such processes can occur via the activation of the hypothalamic-pituitary-adrenal axis and the consequent release of the chronic stress hormone cortisol. The latter contributes to a proinflammatory immune state that increases the risk for periodontal inflammation. Recent research shows that cortisol relates to an elevated oral inflammatory load, demonstrated as hyperactive neutrophils that are pivotal to periodontal tissue damage. Consistent with the biopsychosocial model, this relationship is amplified in those of lower income and higher financial stress. Similarly, among children from lower socioeconomic backgrounds, cortisol is linked to a higher cariogenic bacterial load. Such findings implicate the stress pathway as key in the oral pathogenic process, particularly under social/socioeconomic adversity. Collectively, this work emphasizes the importance of addressing social factors in alleviating oral disease burden and reducing the social gaps therein.

Is Family Caregiving Associated With Inflammation or Compromised Immunity? A Meta-Analysis

BACKGROUND AND OBJECTIVES

Family caregiving stress has been widely reported to have negative effects on circulating biomarkers of immune system function and inflammation. Our goals were to systematically review this literature and conduct a meta-analysis on the extracted effects.

RESEARCH DESIGN AND METHODS

A systematic search of published studies comparing caregivers and noncaregivers on biomarkers measured from blood samples was conducted in the PubMed, Embase, and Cochrane databases. This search identified 2,582 articles and abstracts. After removing duplicative papers and studies not meeting inclusion criteria, 30 articles were identified that reported analyses on 86 relevant biomarkers from 1,848 caregivers and 3,640 noncaregivers.

RESULTS

Random-effects models revealed an overall effect size across all biomarkers of 0.164 SD units (d). A slightly larger overall effect (d = 0.188) was found for dementia caregivers only. Immune system comparisons yielded somewhat larger differences than inflammation comparisons. Most studies used small convenience samples, and effect sizes were larger for studies with moderate or high bias ratings than for studies with low bias ratings. No significant associations were found in studies that used population-based samples.

DISCUSSION AND IMPLICATIONS

Caregivers had small but significantly reduced immune system functioning and greater inflammation than noncaregivers, but associations were generally weak and of questionable clinical significance. The absence of clear associations from low bias studies and population-based studies underscores concerns with possible selection biases in many of the convenience samples. Population-based studies that assess biomarkers before and after the onset of caregiving might add much clarity to this literature.

The Relationship Between Circulating Interleukin-6 Levels and Future Health Service Use in Dementia Caregivers

OBJECTIVE

Older adults are among the most frequent users of emergency departments (EDs). Nonspecific symptoms, such as fatigue and widespread pain, are among the most common symptoms in patients admitted at the ED. Interleukin 6 (IL-6) and tumor necrosis factor α (TNF-α) are inflammation biomarkers associated with chronic stress (i.e., dementia caregiving) and nonspecific symptoms. This study aimed to determine whether IL-6 and TNF-α were prospectively associated with ED risk in dementia caregivers (CGs).

METHODS

Participants were 85 dementia CGs, who reported during three assessments (3, 9, and 15 months after enrollment) if they had visited an ED for any reason. Cox proportional hazards models were used to examine the relations between resting circulating levels of IL-6 and TNF-α obtained at enrollment and subsequent risk for an ED visit, adjusting for age, sex, use of ED 1 month before enrollment, physical and mental health well-being, body mass index, and CG demands.

RESULTS

(log) IL-6 significantly predicted ED visits during the 15-month follow-up (B = 1.96, SE = 0.82, p = .017). For every (log) picogram per milliliter increase in IL-6, the risk of visiting an ED was 7.10 times greater. TNF-α was not associated with subsequent ED visits. Exploratory analyses suggested that CGs with levels of IL-6 above the 80th percentile and experiencing high CG demands were at highest risk of an ED visit.

CONCLUSIONS

IL-6 levels and CG demands may be useful for predicting vulnerability for future ED visits. Although further studies should be conducted to replicate and extend these findings, interventions that successfully modify inflammation markers, including the underlying pathophysiology related to stress and/or comorbid illnesses, may be useful in preventing costly and detrimental outcomes in this population.

Daily hassles, loneliness, and diurnal salivary cortisol in emerging adults

This study used an intensive protocol to examine the effects of daily hassles and loneliness on diurnal salivary cortisol levels. Fifty Chinese undergraduates (28 females) provided six saliva samples each day for two consecutive days (at 0, 0.5, 3, 6, and 12 h after waking and at bedtime) and completed a questionnaire that included scales to measure daily hassles experienced over the previous month, trait loneliness, and depression. Cortisol data were aggregated over two days and used in subsequent analyses, focusing on the cortisol awakening response, diurnal slope, and overall cortisol output operationalized as the area under the curve with reference to the ground (AUC_G). Multiple regression analysis showed that an increase in loneliness had a significant association with an increase in the AUC_G and with a steeper diurnal slope. Loneliness also showed a significant interaction with daily hassles in that the positive association between daily hassles and AUC_G was accentuated in the participants who reported a greater degree of loneliness. Our findings demonstrate for the first time the importance of trait loneliness in modulating the association between daily hassles and diurnal cortisol levels, which has significant clinical implications. Interventions to reduce loneliness should help college students to better cope with daily stressors. Increased attention should also be paid to the health implications of an elevated cortisol level in this relatively young and healthy population.

Years of caregiving for chronically ill and disabled family members is not associated with telomere length in the Philippines

BACKGROUND

Caring for chronically disabled family members is a stressful experience. In turn, psychosocial stress is linked to premature aging. Telomere length (TL) is a plastic genetic trait that is a biomarker of aging, and a possible mechanism linking psychosocial stress and accelerated aging.

METHODS

TL was measured using qPCR method from blood samples in 1233 Filipino adults from Cebu, Philippines. Caregiving was measured as chronicity of care, or the sum total number of years an individual was the primary caregiver for any household member with a chronic illness or disability. Linear regression models were used to test for associations between chronicity of care and TL. Interaction terms were used to test whether or not the association between chronicity of care and TL differed by sex, age, and relationship to the caregiver. Specific statistical designs were publicly pre-registered before analysis began.

RESULTS

Chronicity of care was not associated with TL. Neither did we find any evidence for caregiving varying in its effect on TL by caregiver sex, age, or relationship to the chronically ill/disabled.

CONCLUSIONS

We found no evidence of an association between chronicity of care and TL. This result coupled with a recent study of a similarly sized cohort suggests that previous significant results linking caregiving and TL may be due to very particular types of caregiving populations or are possibly artifacts of small sample sizes.

Depressive symptoms in caregivers immediately after stroke

BACKGROUND

Caregivers of stroke survivors often suffer depressive symptoms that interfere with their own health. Early recognition may lead to attenuation of symptoms and better health and well-being for caregivers.

OBJECTIVE

We examined characteristics of caregivers and stroke survivors associated with caregivers' depressive symptoms in the early poststroke period.

METHODS

We conducted a prospective, longitudinal exploratory observational study with a convenience sample of 63 caregivers of older adult (≥ 65 years) stroke survivors recruited from urban acute-care settings. We enrolled caregivers by 2 weeks poststroke (T1) and revisited them 4 weeks later (T2). Depressive symptoms were measured using the Patient Health Questionnaire-9. A separate unadjusted linear mixed model was computed to explore significant associations between each caregiver or stroke-survivor characteristic and depressive symptoms.

RESULTS

Caregivers, on average, reported mild depressive symptoms at T1 and T2. Each of the following characteristics was independently associated with caregiver depressive symptoms over the first 6 weeks poststroke: caregiver uncertainty (p < 0.001), perceived stress (p < 0.001) but not cortisol levels (p = 0.858 on waking, p = 0.231 evening), coping (p < 0.001), social support (p = 0.006), race (p = 0.022), income (p = 0.001), time spent on care (p = 0.039), and stroke-survivor race (p = 0.033) and functional status (p = 0.003). At T2, caregiver depressive symptoms were correlated with evening cortisol level (p = 0.001).

CONCLUSIONS

Caregiver and stroke-survivor characteristics may help identify caregivers at highest risk for early depressive symptoms and guide interventions aimed at their resolution.

Biomedical health profiles of unpaid family carers in an urban population in South Australia

OBJECTIVES

To compare the biomedical health profile and morbidity of adult carers with non-carers.

METHODS

The North West Adelaide Health Study (NWAHS) is a representative population-based longitudinal biomedical cohort study of 4056 participants aged 18 years and over at Stage One. Informal (unpaid) carers were identified in Stage 3 of the project (2008-2010). Risk factors, chronic medical conditions and biomedical, health and demographic characteristics using self-report and blood measured variables were assessed. Data were collected through clinic visits, telephone interviews and self-completed questionnaires. Risk factors included blood pressure, cholesterol/lipids, body mass index (BMI), smoking and alcohol intake. Chronic medical conditions included cardiovascular and respiratory diseases, diabetes, and musculoskeletal conditions. Blood measured variables were routine haematology, biochemistry, Vitamin D, and the inflammatory biomarkers high sensitivity C-Reactive Protein (hs-CRP), Tumor Necrosis Factor alpha (TNFα) and Interleukin-6 (Il-6).

RESULTS

The prevalence of carers aged 40 years and over was 10.7%, n = 191. Carers aged 40 years and over were more likely to assess their health status as fair/poor and report having diabetes, arthritis, anxiety and depression. They also reported insufficient exercise and were found to have higher BMI compared with non-carers. Significant findings from blood measured variables were lower serum Vitamin D and haemoglobin. Male carers had raised diastolic blood pressure, higher blood glucose, lower haemoglobin and albumin levels and slightly elevated levels of the inflammatory biomarkers TNFα and hs-CRP.

DISCUSSION AND CONCLUSIONS

This study confirms informal carers had different biomedical profiles to non-carers that included some chronic physical illnesses. It identifies that both female and male carers showed a number of risk factors which need to be considered in future caregiver research, clinical guidelines and policy development regarding carer morbidity.

Stress and immunosenescence: The role of telomerase

Chronic stress is associated with the accelerated aging of the immune system and represents a potent risk factor for the development and progression of a wide range of physical and mental disorders. The elucidation of molecular pathways and mechanisms underlying the link between stress and cellular aging is an area of considerable interest and investigation. In this context, telomere biology has emerged as a particularly attractive candidate mechanism. Several studies have linked immune cell telomere length with stress-related conditions and states, and also with several physical and mental disorders. Because the cellular reverse transcriptase enzyme telomerase is the primary regulator of telomere length (by adding telomeric DNA to telomeres and thereby attenuating telomere shortening), the understanding of its regulation and regulatory functions constitutes a prime target for developing strategies to prevent, attenuate or reverse the adverse consequences of immune system aging (immunosenescence). In this review we provide an overview of the mechanistic pathways linking telomerase with stress and cellular aging, with an emphasis on the immune system. We summarize and synthesize the current state of the literature on immune cell telomerase in different stress- and aging-related disease states and provide recommendations for future research directions.

Characterization in humans of in vitro leucocyte maximal telomerase activity capacity and association with stress

The goal of this study was to develop and validate a measure of maximal telomerase activity capacity (mTAC) for use in human studies of telomere biology, and to determine its association with measures of stress and stress responsivity. The study was conducted in a population of 28 healthy young women and men who were assessed serially across two separate days, at multiple time points, and in response to a standardized laboratory stressor. Venous blood was collected at each of these multiple assessments, and an in vitro mitogen challenge (phytohaemagglutinin supplemented with interleukin-2) was used to stimulate telomerase activity in leucocytes. After first establishing the optimal post-stimulation time course to characterize mTAC, we determined the within-subject stability and the between-subject variability of mTAC. The major findings of our study are as follows: (i) the optimal time point to quantify human leucocyte mTAC appears to be at 72 h after mitogen stimulation; (ii) mTAC exhibits substantial within-subject stability (correlations were in the range of r 0.68-0.82) and between-subject variability, with a high intra-class coefficient (0.70), indicating greater between-subject relative to within-subject variability; (iii) mTAC is not influenced by situational factors including time of day, cortisol, acute stress exposure and immune cell distribution in the pre-stimulation blood sample; and (iv) a significant proportion of the between-subject variability in mTAC is associated with measures of stress and stress responsivity (mTAC is lower in subjects reporting higher levels of perceived (chronic) stress and exhibiting higher psychophysiological stress reactivity). Based collectively on these findings, it appears that mTAC, as proposed and operationalized, empirically meets the key criteria to represent a potentially useful individual difference measure of telomerase activity capacity of human leucocytes.This article is part of the theme issue 'Understanding diversity in telomere dynamics'.

Acute Stress and Anxiety in Medical Residents on the Emergency Department Duty

The objectives of this longitudinal study were to compare salivary cortisol release patterns in medical residents and their self-perceived anxiety levels between a regular working day and a day when on call in the emergency department (ED-duty day) and to determine any differences in cortisol release pattern as a function of years of residency or sex. The study included 35 residents (physicians-in-training) of the Granada University Hospital, Granada, Spain. Acute stress was measured on a regular working day and an ED-duty day, evaluating anxiety-state with the Spanish version of the State-Trait Anxiety Inventory. Physiological stress assessment was based on salivary cortisol levels. Cortisol release concentrations were higher on an ED-duty day than on a regular working day, with a significantly increased area under the curve (AUC) (p < 0.006). This difference slightly attenuated with longer residency experience. No gender difference in anxiety levels was observed (p < 0.001). According to these findings, the hypothalamic-pituitary-adrenal axis activity and anxiety levels of medical residents are higher on an ED-duty day than on a regular working day.

Development of glucocorticoid resistance over one year among mothers of children newly diagnosed with cancer

Chronic distress associates with peripheral release of cortisol and a parallel upregulation of innate inflammation. Typically, cortisol functions to down-regulate inflammatory processes. However, in the context of chronic stress, it is hypothesized that glucocorticoid receptors within immune cells become less sensitive to the anti-inflammatory effects of cortisol, resulting in increased systemic inflammation. Caring for a child newly diagnosed with cancer is a particularly provocative chronic stressor. Here, we examine evidence for the development of cellular resistance to glucocorticoids among 120 mothers (Aged 18-56 years; 86% Caucasian) across the 12 months following their child's new diagnosis with cancer. Measures of psychological distress, interleukin (IL)-6, and glucocorticoid resistance (GCR) were assessed 1, 6, and 12 months after the diagnosis. A latent factor for distress was derived from the covariation among symptoms of anxiety, depression, and post-traumatic stress. Latent change score models revealed a significant positive association between change in distress and change in GCR from 0 to 6 months, and 6 months-1 year. This finding provides initial evidence for a longitudinal association between change in maternal distress and change in GCR from the onset of a chronic stressor through one year. Although levels of IL-6 increased during the first six months after the child's diagnosis, the magnitude of this change was not related to change in distress or change in GCR. Given the possible health consequences of reduced immune sensitivity to glucocorticoids, future work should further explore this stress response and its clinical significance.

Testing the stress-buffering hypothesis of social support in couples coping with early-stage dementia

Purpose

To test whether the negative relationship between perceived stress and quality of life (Hypothesis 1) can be buffered by perceived social support in patients with dementia as well as in caregivers individually (Hypothesis 2: actor effects) and across partners (Hypothesis 3: partner effects and actor-partner effects).

Method

A total of 108 couples (N = 216 individuals) comprised of one individual with early-stage dementia and one caregiving partner were assessed at baseline and one month apart. Moderation effects were investigated by applying linear mixed models and actor-partner interdependence models.

Results

Although the stress-quality of life association was more pronounced in caregivers (β = -.63, p<.001) compared to patients (β = -.31, p<.001), this association was equally moderated by social support in patients (β = .14, p<.05) and in the caregivers (β = .13, p<.05). From one partner to his or her counterpart, the partner buffering and actor-partner-buffering effect were not present.

Conclusion

The stress-buffering effect has been replicated in individuals with dementia and caregivers but not across partners. Interventions to improve quality of life through perceived social support should not only focus on caregivers, but should incorporate both partners.

Psychometric properties of the Perceived Stress Scale in a sample of German dementia patients and their caregivers

BACKGROUND

The aim of the present study was to investigate the psychometric characteristics of the Perceived Stress Scale (PSS) in a sample of dementia patients and their spousal caregivers.

METHODS

We investigated the reliability and validity of the 14-item PSS in a sample of 80 couples, each including one spouse who had been diagnosed with mild to moderate dementia (mean age 75.55, SD = 5.85, 38.7% female) and one spousal caregiver (mean age 73.06, SD = 6.75, 61.3% female). We also examined the factor structure and sensitivity of the scale with regard to gender differences.

RESULTS

Exploratory factor analysis of the PSS revealed a two-factor solution for the scale; the first factor reflected general stress while the second factor consisted of items reflecting the perceived ability to cope with stressors. A confirmatory factor analysis verified that the data were a better fit for the two-factor model than a one-factor model. The two factors of the PSS showed good reliability for patients as well as for caregivers ranging between α = 0.73 and α = 0.82. Perceived stress was significantly positively correlated with depressive symptomatology in both caregivers and patients. Mean PSS scores did not significantly differ between male and female patients nor did they differ between male and female caregivers.

CONCLUSION

The present data indicate that the PSS provides a reliable and valid measure of perceived stress in dementia patients and their caregivers.

Associations between spontaneous parental perspective-taking and stimulated cytokine responses in children with asthma

OBJECTIVES

Cognitive empathy in parents-reflecting the extent to which one considers the perspectives and emotions of others-is hypothesized to contribute to family social environments in ways that affect youths' physical health. Using a novel assessment technique for cognitive empathy, the current study examined associations between spontaneous parental perspective-taking and key inflammatory processes implicated in pediatric asthma.

METHOD

One hundred thirty children (ages 9-17) with physician-diagnosed asthma, along with 1 parent, participated in the current study. Parents completed an interview from which statements of perspective-taking were coded and youths provided blood samples.

RESULTS

Youths whose parents demonstrated greater spontaneous perspective-taking during the interview had cells that mounted smaller inflammatory responses to stimulation by nonspecific, asthma-specific, and viral analogue ligands, as well as cells that showed greater sensitivity to the anti-inflammatory effects of glucocorticoids. These results were not accounted for by parental warmth or parent or youth depressive symptoms, nor by covariates of race, age, gender, parental education level, use of asthma medications over the past week, or asthma severity.

CONCLUSIONS

These findings suggest that parental perspective-taking may have implications for biological processes relevant to childhood asthma. (PsycINFO Database Record

Psychological status and quality of life among primary caregivers of individuals with mental illness: a hospital based study

Background

This study aimed to explore the psychological status and quality of life among primary caregivers of individuals suffering from various mental illnesses including early psychosis, chronic schizophrenia, depressive disorders, anxiety disorders and dementia.

Methods

A total of 350 primary caregivers with relatives seeking treatment at a tertiary psychiatric hospital were recruited for this study. Socio-demographic data was obtained and the brief version of the World Health Organisation Quality of Life instrument was used to assess caregiver’s quality of life (QOL). Psychological status among primary caregivers was assessed using the General Anxiety Disorder - 7 item (GAD-7) and Patient Health Questionnaire - 9 item (PHQ-9) scales. Family Interview Schedule (FIS) was used to assess the impact of caregiving relating to social problems, interpersonal strain among family members, work related problems and financial difficulties as a result of their relative’s illness. The socio-demographic and clinical correlates of QOL, PHQ-9 and GAD-7 were examined using multiple linear and logistic regression analyses. Associations between QOL domains and psychological status was examined using multiple linear regression analyses.

Results

The mean age of the primary caregivers was 49.7 years (SD = 13.2), ranging from 21 to 82 years, with a preponderance of females (67.6%), aged 50–64 years old (45.7%). Majority were of Chinese ethnicity (57.5%), had secondary level education (43.1%), were married (65.2%), and employed (64.9%). 18.3% of primary caregivers had symptoms of depression (based on PHQ-9 cut-off point of 10 or greater) while 12.7% had symptoms of anxiety (based on GAD-7 cut-off point of 10 or greater). Multiple linear and logistic regression analyses revealed that primary caregivers aged between 35-49 years and 50–64 years, unemployed, living with others, providing care to those diagnosed with dementia and who had higher FIS scores were significantly more likely to report symptoms of depression whilst those who cared for their son/daughter were less likely to be associated with symptoms of depression. Primary caregivers who had lower education, were living with others, were single or divorced/separated, were unemployed and with higher FIS scores were associated with lower QOL domain scores. Those with symptoms of depression were significantly associated with low QOL across all four domains, whilst those with symptoms of anxiety were significantly associated with low QOL in the social relationships domain.

Conclusion

Psychological status of caregivers in the current study was associated with the various domains of QOL. In particular, caregivers’ symptoms of depression were significantly associated with lower QOL across all four domains of QOL whereas symptoms of anxiety were associated with lower scores in the social relationships domain. The study suggests a need to provide caregivers with social support and psycho-education to improve the QOL as well as aid in developing healthy coping strategies.

Competence, Compassion, and Care of the Self: Family Caregiving Needs and Concerns in Heart Failure

BACKGROUND

Family caregivers are essential to the well-being of patients with chronic heart failure (HF) because they provide care in managing complex medication regimens, dietary sodium restrictions, and symptoms.

OBJECTIVE

The purpose of this qualitative study was to gain a deeper understanding of the HF caregiving experience and describe the needs and concerns expressed by caregivers.

METHODS

Qualitative descriptive methodology was conducted using data from responses to open-ended questions asked as part of a larger longitudinal study. The sample was 63 patients with HF and 63 family caregivers.

RESULTS

Using basic content analysis, the 3 main themes of needs and concerns that emerged were competence concerns, compassion maintenance, and care of the self. Subthemes of competence concerns were doing things right, making a serious mistake, and uncertainty.

CONCLUSIONS

Family caregivers of patients with HF had many needs and concerns about their competence in performing tasks, their compassion, and caring for themselves. Data can be used to design testable interventions to improve the HF caregiving experience for patients and caregivers.

Immune Function Is Impaired With a Mini Nutritional Assessment Score Indicative of Malnutrition in Nursing Home Elders With Pressure Ulcers

BACKGROUND

Malnutrition is prevalent in elders with pressure ulcers and is associated with increased morbidity and mortality. This study compared nutritional status, assessed by the Mini Nutrition Assessment (MNA), to immune function in nursing home elders with pressure ulcers.

METHODS

Nutritional status was assessed in nursing home residents (>65 years) with a stage II or more severe pressure ulcer. Subjects were classified as well nourished, at risk of malnutrition, or malnourished according to MNA score. Blood was drawn to assess whole blood mitogen-induced lymphocyte proliferation and neutrophil respiratory burst. Delayed-type hypersensitivity to 3 antigens was measured. MNA status was compared with immune parameters using the Kruskall-Wallis test.

RESULTS

Of the 24 subjects (23 men, 1 woman) who completed the study protocol, only 4 (17%) were classified as well nourished, whereas 7 (29%) were at risk and 13 (54%) were malnourished according to MNA score. Whole blood lymphocyte proliferation was significantly lower in the malnourished vs at risk subjects with both pokeweed (median [25th, 75th percentile], 0.6 [0.3, 0.9] vs 1.8 [1.2, 2.1] disintegrations per minute [dpm]/cell, p < .05); and concanavalin A (1.7 [0.9, 2.0] vs 2.8 [2.6, 3.9] dpm/cell, p < .05) mitogens. Neutrophil respiratory burst normalized to a young control was significantly lower in malnourished subjects vs well-nourished subjects (0.8 [0.5, 0.9] vs 1.4 [1.0, 1.7], p < .05). Total induration to 3 skin-test antigens was 13.4 +/- 4.6, 3.5 +/- 2.6, and 3.8 +/- 1.8 (mean +/- SEM) for well-nourished, at risk, and malnourished, respectively (p = .059).

CONCLUSIONS

Immune function is impaired with an MNA score indicative of malnutrition in nursing home elders with pressure ulcers.

A systematic review of the psychobiological burden of informal caregiving for patients with dementia: Focus on cognitive and biological markers of chronic stress

As the physiological impact of chronic stress is difficult to study in humans, naturalistic stressors are invaluable sources of information in this area. This review systematically evaluates the research literature examining biomarkers of chronic stress, including neurocognition, in informal dementia caregivers. We identified 151 papers for inclusion in the final review, including papers examining differences between caregivers and controls as well as interventions aimed at counteracting the biological burden of chronic caregiving stress. Results indicate that cortisol was increased in caregivers in a majority of studies examining this biomarker. There was mixed evidence for differences in epinephrine, norepinephrine and other cardiovascular markers. There was a high level of heterogeneity in immune system measures. Caregivers performed more poorly on attention and executive functioning tests. There was mixed evidence for memory performance. Interventions to reduce stress improved cognition but had mixed effects on cortisol. Risk of bias was generally low to moderate. Given the rising need for family caregivers worldwide, the implications of these findings can no longer be neglected.

Stress, Cortisol, and Periodontitis in a Population Aged 50 Years and Over

Periodontitis and its relationship with psycho-neuro-immunological variables, such as psychological stress and cortisol, have been little explored. The objective of this study was to evaluate the extent and severity of chronic periodontitis and its association with the levels of salivary cortisol and the scores obtained with a stress questionnaire in a population aged 50 years and over. We studied 235 individuals in a cross-sectional study. They answered the Lipp’s Inventory of Stress Symptoms for Adults, were instructed to collect three saliva samples for cortisol analysis, and were examined for evaluation for periodontitis. Based on logistic regression, cortisol levels were positively associated with the following outcomes: means of clinical attachment level (CAL) > = 4 mm [OR = 5.1, 95%CI (1.2, 20.7)]; 30% of sites with CAL > = 5 mm [OR = 6.9, 95%CI (1.7, 27.1)]; and 26% of sites with probing depth > = 4 mm [OR = 10.7, 95%CI (1.9, 54.1)] after adjustment for confounding variables. The results suggest that cortisol levels were positively associated with the extent and severity of periodontitis.

Pilot Study of Parent Psychophysiologic Outcomes in Pediatric Hematopoietic Stem Cell Transplantation

BACKGROUND

Parents of children undergoing hematopoietic stem cell transplantation (HSCT) are at risk for psychological distress. This distress may result in aberrant immune, inflammatory, or endocrine effects. These physiologic outcomes have not been reported previously.

MAIN OBJECTIVE

The aim of this study is to examine the feasibility of longitudinal testing of psychophysiological parameters of stress in parents of children undergoing HSCT.

METHODS

This pilot study was conducted at a large children's hospital in the Midwest and included parents of children who received autologous or allogeneic HSCT. Time points included before the start of HSCT conditioning and day +30, +60, and +100. Outcome variables included parent-perceived stress, lymphocyte subsets, C-reactive protein (CRP), proinflammatory cytokines, salivary cortisol, and salivary amylase. Effect sizes were calculated for each outcome.

RESULTS

Twelve parent-child dyads were enrolled (10 mothers, 2 fathers). Missing data were minimal. Parent-perceived stress significantly increased from pre-HSCT through day +100, and parent CD3+ T-lymphocyte counts decreased from pre-HSCT through day +100. No significant effects were observed for salivary studies, CRP, or proinflammatory cytokines. Effect sizes ranged from 1.23 (perceived stress) to 0.07 (CRP).

CONCLUSION

The results of this study suggest that it is feasible longitudinally measure parent psychophysiologic outcomes in the pediatric HSCT setting. In addition, parent-perceived stress increased linearly from start of conditioning through day +100, whereas parent T-lymphocyte counts decreased concurrently.

IMPLICATIONS FOR PRACTICE

Routine psychological and physical health screening of parents of children undergoing HSCT is needed. Multidisciplinary psychosocial support services should be offered to parents at regular intervals during their child's HSCT.

The Effects of Mindfulness-Based Stress Reduction for Family Caregivers: Systematic Review

Caring for patients with various conditions is demanding and stressful and can have a negative impact on both physical and psychological health. This paper reports a systematic review and critical appraisal of the evidence on the effectiveness of mindfulness-based stress reduction for the family caregivers of patients with various conditions. There were improvements in the self-rated psychological symptoms, such as stress, depression, anxiety and mindfulness. To conclude, mindfulness-based stress reduction, as a safe and transportable approach, has potential to improve the psychological symptoms in the caregivers of patients with various conditions.

Feasibility of 24-Hr Urine Collection for Measurement of Biomarkers in Community-Dwelling Older Adults

Biologic markers are becoming a key part of gerontological research, including their measurement at multiple intervals to detect changes over time. This report examined the feasibility and quality of 24-hr urine collection to measure neuroendocrine biomarkers in a community-based sample of older caregivers and non-caregivers. At each interview, participants were instructed on the correct method to collect and store the sample. As incentives, participants selected a day for urine collection within 5 days of the interview, received a reimbursement, and study staff travelled to their home to retrieve the specimen. Between 2008 and 2013, 256 participants were enrolled; all but two participants (99%) provided a baseline urine specimen, of which 93% were considered adequate. Urine collection and quality remained high over three annual follow-up interviews and did not vary by caregiver status or perceived stress level. Our results indicate that 24-hr urine collection is feasible in active, community-dwelling older adults.

Implications of Stroke for Caregiver Outcomes: Findings from the ASPIRE-S Study

Background

Informal caregivers are vital to the long-term care and rehabilitation of stroke survivors worldwide. However, caregiving has been associated with negative psychological outcomes such as anxiety and depression, which leads to concerns about caregiver as well as stroke survivor well-being. Furthermore, caregivers may not receive the support and service provision they require from the hospitals and community.

Aims

This study examines caregiver psychological well-being and satisfaction with service provision in the context of stroke.

Methods

Caregiver data were collected as part of the ASPIRE-S study, a prospective study of secondary prevention and rehabilitation which assessed stroke patients and their carers at six-months post stroke. Carer assessment included measurement of demographics, satisfaction with care (UK Healthcare Commission National Patient Survey of Stroke Care), psychological distress (Hospital Anxiety and Depression Scale), and vulnerability (Vulnerable Elders Scale). Logistic regression analyses and chi-squared tests were performed using STATA version 12.

Results

Analyses from 162 carers showed substantial levels of dissatisfaction (37·9%) with community and hospital services, as well as notable levels of anxiety (31·3%) and depressive symptoms (18·8%) among caregivers. Caregiver anxiety was predicted by stroke survivor anxiety (OR = 3·47, 95% CI 1·35–8·93), depression (OR = 5·17, 95% CI 1·83–14·58), and stroke survivor cognitive impairment (OR 2·35, 95% CI 1·00–5·31). Caregiver depression was predicted by stroke survivor anxiety (OR = 4·41, 95% CI 1·53–12·72) and stroke survivor depression (OR = 6·91, 95% CI 2·26–21·17).

Conclusion

Findings indicate that caregiver and stroke survivor well-being are interdependent. Thus, early interventions, including increased training and support programs that include caregivers, are likely to reduce the risk of negative emotional outcomes.

Systematic review and meta-analysis of the impact of carer stress on subsequent institutionalisation of community-dwelling older people

BACKGROUND

In the caregiving literature there is a common assertion that a higher level of carer stress is a critical determinant of premature ending of homecare. However, this contention has not been systematically assessed. We therefore systematically reviewed and meta-analysed the prospective association between various forms of carer stress and subsequent institutionalisation of community-dwelling older people.

METHODS

Systematic literature search of prospective studies measuring carer stress at baseline and institutionalisation at follow-up. Given substantial interchangeability in the measurement of carer stress, we included a wide number of exposure measures, namely: carer stress, burden, depression, distress, anxiety, burnout, and strain. Institutionalisation included both acute and long-term care utilisation. The standardised mean difference between stressed and non-stressed carers was the primary measure of effect. We assessed study quality with the Crowe Critical Appraisal Tool (CCAT). Pre-planned sensitivity analysis included examination of estimates according to study size; decade published; study quality according to quartiles of CCAT scores; population; follow-up period; study design and impact of adjusted or unadjusted estimates.

RESULTS

The search yielded 6,963 articles. After exclusions, we analysed data from 54 datasets. The meta-analysis found that while carer stress has a significant effect on subsequent institutionalisation of care recipients, the overall effect size was negligible (SMD = 0 · 05, 95% CI = 0 · 04-0 · 07). Sensitivity analyses found that, the effect size was higher for measurements of stress than for other measures, though still relatively small (SMD = 0 · 23, 95% CI = 0 · 09-0 · 38). Thus, whether analysing the association between carer stress, burden, distress, or depression with either acute or long-term care, the effect size remains small to negligible. Concurrently, we found estimates reduce over time and were smaller with larger studies and those of higher quality, according to the CCAT scores.

CONCLUSION

Despite strong statements to the contrary, it appears that the effect of carer stress on subsequent care recipient institutionalisation is small to negligible. The current findings point to a biased literature, with significant small study effects. The results suggest a need to re-evaluate the degree to which carer stress predicts premature ending of home care. Concurrently, other factors may be more crucial in institutional placement than carer stress and should be investigated.

Injustice at work and leukocyte glucocorticoid sensitivity: findings from a cross-sectional study

OBJECTIVE

Organizational justice refers to perceived fairness at the workplace. Low organizational justice has been identified as a major source of distress and a predictor of poor health. Impaired regulation of immunological and inflammatory pathways may, in part, underlie these health effects. The present study investigated the association of organizational justice with leukocyte glucocorticoid sensitivity in vivo.

METHODS

Organizational justice was assessed among 541 male factory workers (mean [standard deviation] age = 46 [9] years) by questionnaire. Cortisol release was measured at three time points before blood collection and summed as the area under the curve. Blood was used to assess leukocyte (white blood cell [WBC] count) subsets (neutrophils [%WBC], lymphocytes [%WBC], and the neutrophil/lymphocyte ratio). Glucocorticoid sensitivity was operationalized as the correlation between cortisol release and these hematologic parameters. Associations were adjusted for demographics, work characteristics, and life-style variables.

RESULTS

A dose-response relationship between organizational justice and glucocorticoid sensitivity was found. Cortisol and hematologic parameters showed the expected significant association among individuals reporting high (all β values ≥ |.26|; all p values ≤.001) or medium organizational justice (all β values ≥ |.15|; all p values ≤.050), but not among those reporting low organizational justice (all β values ≤ |.04|; all p values > .10). These regression slopes differed significantly between organizational justice groups (p values for interaction < .050).

CONCLUSIONS

Low justice at work is associated with an impaired ability of endogenous cortisol to regulate leukocyte distribution in vivo. These findings identify a novel biological pathway by which organizational justice may affect health.

Cognitive-behavioural group therapy improves a psychophysiological marker of stress in caregivers of patients with Alzheimer's disease

BACKGROUND

Family caregivers of patients with dementia frequently experience psychological stress, depression and disturbed psychophysiological activity, with increased levels of diurnal cortisol secretion.

OBJECTIVES

To compare the effects of a cognitive-behavioural group therapy (CBT) to a psychoeducation group programme (EDUC) on cortisol secretion in caregivers of patients with moderate Alzheimer's disease (AD).

METHOD

Caregivers of AD outpatients were semi-randomly allocated to one of two intervention programmes (CBT or EDUC) consisting of eight weekly sessions. Twenty-six participants completed the study. Before and after intervention, salivary cortisol was collected at four different times of the day. Effects of the interventions were evaluated with self-report psychological scales and questionnaires related to functional abilities and neuropsychiatric symptoms of the AD relative.

RESULTS

Only in the CBT group did salivary cortisol levels significantly decrease after intervention, with a large effect size and high achieved power. Both groups reported a reduction of neuropsychiatric symptoms of their AD relative after intervention.

CONCLUSION

Psychoeducation for caregivers may contribute to a reduction of neuropsychiatric symptoms of AD patients while CBT additionally attenuates psychophysiological responses to stressful situations in caregivers, by reducing diurnal cortisol levels. This may lead to a positive impact in the general health of the caregiver, eventually resulting in better care of the AD patient.

Stress, ageing and their influence on functional, cellular and molecular aspects of the immune system

The immune response is essential for keeping an organism healthy and for defending it from different types of pathogens. It is a complex system that consists of a large number of components performing different functions. The adequate and controlled interaction between these components is necessary for a robust and strong immune response. There are, however, many factors that interfere with the way the immune response functions. Stress and ageing now consistently appear in the literature as factors that act upon the immune system in the way that is often damaging. This review focuses on the role of stress and ageing in altering the robustness of the immune response first separately, and then simultaneously, discussing the effects that emerge from their interplay. The special focus is on the psychological stress and the impact that it has at different levels, from the whole system to the individual molecules, resulting in consequences for physical health.

Impulse control disorders in Parkinson's disease: an overview from neurobiology to treatment

Parkinson's disease (PD) is the second most common neurodegenerative brain disorder and is characterized by motor symptoms such as tremor, bradykinesia, rigidity and postural instability. A majority of the patients also develop non-motor symptoms. Impulse control disorders (ICD) are behavioural changes that often fail to be detected in clinical practice. The prevalence of ICD in PD varies widely from 6.1 to 31.2 % and treatment with dopaminergic medication is considered to be the greatest risk factor. Management consists mainly of reducing dopaminergic medication. In our experience, ICD has a tremendous impact on the quality of life of the patients and their families and should therefore not be disregarded. Studies addressing the role of ICD in PD caregiver strain are imperative. We attempt to give a comprehensive overview of the literature on the complicated neurobiology of ICD and discuss risk factors, genetic susceptibility, screening modalities and management.

Filial Caregiving is Associated with Greater Neuroendocrine Dysfunction: Evidence from the 2005 National Survey of Midlife in the U.S

Objectives:

This study examined associations between providing caregiving for a biological or adoptive parent and clinically assessed biological risk factors (allostatic load and its three subscales—inflammatory dysfunction, metabolic dysfunction, and neuroendocrine dysfunction), as well as moderation of these associations by gender.

Methods:

Regression models were estimated using telephone and self-report data from 962 men and women who participated in the National Survey of Midlife in the United States in 2005.

Results:

Filial caregivers demonstrated higher levels of neuroendocrine dysfunction. No gender difference in biological risks was found.

Discussion:

Filial caregiving is the most prevalent form of family caregiving, and results indicating the presence of greater neuroendocrine dysfunction among filial caregivers in contrast to noncaregivers suggest an important public health concern. Future research needs to continue to examine different relationship types of caregivers and include a range of biological risk measurement to further the understanding of how family caregiving is linked to biological health risks.

The impact of early dementia diagnosis and intervention on informal caregivers

In the absence of disease modifying therapies for dementia, the question rises what the benefits are of an early dementia diagnosis for patients and their caregivers. This paper reviews the caregiver perspective in dementia and addresses the question what the consequences are of promoting earlier dementia diagnosis. An early diagnosis offers caregivers the opportunity to advance the process of adaptation to the caregiver role. Caregivers that are better able to adapt to the changes that characterize dementia, feel more competent to care and experience less psychological problems. However, drawbacks of an early diagnosis may outweigh the benefits if people are left with a diagnosis but little support. There is convincing evidence that multicomponent caregiver interventions in the mild to moderate dementia stages are effective to improve caregiver well-being and delay institutionalization. However, there still exist a gap between the improved possibilities to diagnose people in the predementia stage versus the scarce knowledge on intervention effects in this very early stage. This stresses the urgent need for more research on early caregiver interventions that enhance role adaptation and that include long-term follow-up and cost-effectiveness evaluation. Early interventions may help caregivers in anticipating and accepting the future care role and transitions, with the increased possibility that caregivers can still involve the patient in the decision making process. As levels of stress and burden are still low in the predementia stage it provides excellent opportunities to empower the resources of caregivers.

Chronic exposure to stress predisposes to higher autoimmune susceptibility in C57BL/6 mice: glucocorticoids as a double-edged sword

Stress activates the hypothalamic-pituitary-adrenocortical axis to promote the release of corticosterone (CORT), which consequently suppresses pathogenic stimulation of the immune system. Paradoxically, however, stress often promotes autoimmunity through yet unknown mechanisms. Here we investigated how chronic variable stress (CVS), and the associated alterations in CORT levels, affect the susceptibility to experimental autoimmune encephalomyelitis (EAE) in female and male C57BL/6 mice. Under baseline (nonstressed) conditions, females exhibited substantially higher CORT levels and an attenuated EAE with less mortality than males. However, CVS induced a significantly worsened EAE in females, which was prevented if CORT signaling was blocked. In addition, females under CVS conditions showed a shift toward proinflammatory Th1/Th17 versus Th2 responses and a decreased proportion of CD4(+) CD25(+) Treg cells. This demonstrates that whereas C57BL/6 female mice generally exhibit higher CORT levels and an attenuated form of EAE than males, they become less responsive to the immunosuppressive effects of CORT under chronic stress and thereby prone to a higher risk of destructive autoimmunity.