Psychological Distress and Hypertension: Results from the National Health Interview Survey for 2004-2013.

BACKGROUND/AIMS: Psychological conditions are increasingly linked with cardiovascular disorders. We aimed to examine the association between psychological distress and hypertension. METHODS: We used data from the National Health Interview Survey for 2004-2013. Hypertension was self-reported and the 6-item Kessler Psychological Distress Scale was used to assess psychological distress (a score ≥13 indicated distress). We used a logistic regression model to test the assumption that hypertension was associated with psychological distress. RESULTS: Among the study participants completing the survey (n = 288,784), 51% were female; the overall mean age (±SEM) was 35.3 ± 0.02 years and the mean body mass index was 27.5 ± 0.01. In the entire sample, the prevalence of psychological distress was 3.2%. The adjusted odds of reporting hypertension in psychologically distressed individuals was 1.53 (95% CI = 1.31-1.80, p = 0.01). CONCLUSION: The findings suggest that psychological distress is associated with higher odds of hypertension after adjusting for other risk factors for high blood pressure. Further studies are needed to confirm these findings and to elucidate the mechanisms by which stress increases hypertension risk.

Uncontrolled blood pressure and risk of sleep apnea among blacks: findings from the Metabolic Syndrome Outcome (MetSO) study.

Uncontrolled blood pressure (BP) is linked to increased risk of obstructive sleep apnea (OSA). However, few studies have assessed the impact of this relationship among blacks with metabolic syndrome (MetS). Data for this study were collected from 1035 blacks (mean age=62±13 years) enrolled in the Metabolic Syndrome Outcome study. Patients with a score ⩾6 on the Apnea Risk Evaluation System were considered at risk for OSA. Of the sample, 77.1% were low-to-high OSA risk and 92.3% were hypertensive, of which 16.8% had uncontrolled BP levels. Analysis also showed that 60.4% were diabetic, 8.9% had a stroke history, 74.3% had dyslipidemia, 69.8% were obese and 30.9% had a history of heart disease. Logistic regression analyses were employed to investigate associations between uncontrolled BP and OSA risk, while adjusting for known covariates. Findings showed that uncontrolled BP independently increased the odds of OSA risk twofold (odds ratio=2.02, 95% confidence interval=1.18-3.48, P<0.05). In conclusion, our findings show that uncontrolled BP was associated with a twofold greater risk of OSA among blacks, suggesting that those with MetS and who have uncontrolled BP should be screened for the presence of OSA.

Anxiety and cardiovascular risk: Review of Epidemiological and Clinical Evidence.

An increasing body of evidence suggests that anxiety is an independent predictor of adverse cardiovascular (CV) events. Individuals with high levels of anxiety are at increased risk of coronary heart disease, congestive heart failure, stroke, fatal ventricular arrhythmias, and sudden cardiac death. Anxiety following a major cardiac event can impede recovery, and is associated with a higher morbidity and mortality. This linkage between anxiety and CV disease is further corroborated by evidence suggesting that treatment of anxiety may improve cardiac symptoms. However, the mechanisms underlying the observed associations are not entirely delineated. Several intermediary mechanisms have been suggested, including sympathetic activation, impaired vagal control, reduced heart rate variability, stimulation of the hypothalamic-pituitary axis, hyperventilation-induced coronary spasm, oxidative stress, increased inflammatory mediators, and unhealthy lifestyle. There is a need for several clinical trials to explicate the complex associations between anxiety and CV disease, which may be compounded by the involvement of other psychosocial factors. In this review, we examine the epidemiological evidence for the association between anxiety and CV disease, and discuss the proposed mechanisms that may be responsible for this association.

Resistant hypertension and obstructive sleep apnea in the primary-care setting.

We ascertained the prevalence of resistant hypertension (RH) among blacks and determined whether RH patients are at greater risk for obstructive sleep apnea (OSA) than hypertensives. Method. Data emanated from Metabolic Syndrome Outcome Study (MetSO), a study investigating metabolic syndrome among blacks in the primary-care setting. Sample of 200 patients (mean age = 63 ± 13 years; female = 61%) with a diagnosis of hypertension provided subjective and clinical data. RH was defined using the JNC 7and European Society guidelines. We assessed OSA risk using the Apnea Risk Evaluation System ARES), defining high risk as a total ARES score ≥6. Results. Overall, 26% met criteria for RH and 40% were at high OSA risk. Logistic regression analysis, adjusting for effects of age, gender, and medical co morbidities, showed that patients with RH were nearly 2.5 times more likely to be at high OSA risk, relative to those with hypertension (OR = 2.46, 95% CI: 1.03-5.88, P < .05). Conclusion. Our findings show that the prevalence of RH among blacks fell within the range of RH for the general hypertensive population (3-29%). However, patients with RH were at significantly greater risk of OSA compared to patients with hypertension.

Sleep apnea and diabetes: insights into the emerging epidemic.

The rampant diabetes pandemic over the past few decades has been associated with an increased rise in cardiovascular events and deaths. Risk factors such as obesity, family history of diabetes, decreased physical activity, and aging are among the most common in the development of diabetes. Emerging evidence in the past 10 years has suggested that sleep apnea is a novel risk factor in the development of diabetes. Associations between diabetes and sleep apnea are supported by both epidemiologic and clinical sleep apnea studies. In this report, we discuss epidemiologic and clinical evidence suggesting that sleep apnea is involved in the pathogenesis of altered glucose metabolism. In light of current evidence, sleep apnea treatment should be incorporated into existing pharmacotherapeutic regimens for optimal management of diabetes among diabetic patients with sleep apnea to reduce associated cardiovascular risk. Suggestions to improve practice guidelines in the management of diabetic patients with sleep apnea are provided.

Perceived insomnia, anxiety, and depression among older Russian immigrants.

There are few data on the relationships of anxiety and depression to insomnia among immigrants in the United States. Observations of high rates of symptoms of these associated conditions among older Russians indicate the need to focus clinical attention on this population. Relationships of self-reported depression and anxiety to insomnia complaints were investigated in a community-based sample of older Russian immigrants. Volunteers (N=307) were urban community-residing Russians (ages 50 to 95 years; 54% women). Surveys were conducted in a semistructured environment by bilingual educators in various community centers. 93% reported a major health problem, 83% experienced pain, and 62% had problems engaging in daily activities. Of the sample, 61% reported an insomnia complaint, and 43% considered depression and/or anxiety to be a major impairment. Logistic regression analysis showed that insomnia was the most important predictor of perceived anxiety and depression; the corresponding multivariate-adjusted odds ratio was 4.37. Insomnia complaints and perceptions of depression and anxiety among older Russians may have a synergistic effect. Both patients and primary-care physicians should be better educated regarding the recognition of barriers limiting access to adequate health care among older Russians.

Anxiety and cardiovascular symptoms: the modulating role of insomnia.

BACKGROUND: Anxiety and insomnia are associated with cardiovascular (CV) symptoms. We assessed whether the relation between anxiety and CV symptoms is modulated by insomnia. METHODS: Independently living women (n = 1,440; mean age = 59.36 +/- 6.53 years) were recruited by cluster sampling technique. We obtained data on demographic characteristics, health beliefs, access to health care, CV symptoms, sleep, stress and anxiety levels. RESULTS: Overall, 56% of the sample reported insomnia; 46% reported CV symptoms, and 54% were highly anxious. There was a greater likelihood for highly anxious women and those experiencing insomnia to report CV symptoms (r(s) = 0.31* and r(s) = 0.32*, respectively). In logistic regression analysis, the adjusted odds ratios for reporting CV symptoms were 1.39 for patients with insomnia and 2.79 for those with anxiety. With control for insomnia, we observed a 3-fold reduction in the magnitude of the association between anxiety and CV symptoms (r(p) = 0.09*). Stepwise adjustments for sociodemographic factors, CV risk markers, and factors anchoring health beliefs and access to health care showed lesser impact on the relationships. With simultaneous control for those covariates, the correlation was r(p) = 0.13*; * p < 0.01. CONCLUSION: The association of CV symptoms with anxiety is partly accounted for by insomnia.

Obstructive sleep apnea and cardiovascular disease: evidence and underlying mechanisms.

A body of epidemiologic and clinical evidence dating back to the early 1960s establishes the relationships between sleep apnea and cardiovascular disease (CVD). Individuals with obstructive sleep apnea, the most common type of sleep-disordered breathing, are at increased risk for coronary artery disease, congestive heart failure, and stroke. Evidence that treatment of sleep apnea with continuous positive airway pressure reduces blood pressure, improves left ventricular systolic function, and diminishes platelet activation further supports linkage between obstructive sleep apnea and CVD. Notwithstanding, complex associations between these two conditions remain largely unexplained due to dearth of systematic experimental studies. Arguably, several intermediary mechanisms including sustained sympathetic activation, intrathoracic pressure changes, and oxidative stress might be involved. Other abnormalities such as dysfunctions in coagulation factors, endothelial damage, platelet activation, and increased systemic inflammation might also play a fundamental role. This review examines evidence for the associations between obstructive sleep apnea and CVD and suggested underlying anatomical and physiological mechanisms. Specific issues pertaining to definition, prevalence, diagnosis, and treatment of sleep apnea are also discussed. Consistent with rising interest in the potential role of the metabolic syndrome, this review explores the hypothesized mediating effects of each of the components of the metabolic syndrome.

Sleep-disordered breathing and hypertension among African Americans.

This study investigated differences in sleep-disordered breathing (SDB) between hypertensives without a family history of hypertension and hypertensives with a family history. Furthermore, it examined whether these two groups differed in the severity of SDB. Patients were African Americans (n=162, mean age=51.19+/-13.77 years; mean body mass index (BMI)=37.85+/-9.51 kg/m2, male=57%), who were referred to the clinic because of a sleep complaint. Sleep was recorded in the laboratory using standard physiological parameters; all parameters were analysed by a trained scorer. Altogether, 91% of the patients received an SDB diagnosis. Of these patients, 25% were hypertensives without a family history, 20% were hypertensives with a family history, and 55% were normotensives. We found a significant difference between these patient groups regarding the severity of SDB (F14,158=1.823, P<0.05), but no significant group difference was observed in the rate of SDB. Increasing weight was accompanied by increasing severity of SDB. The finding that hypertensive patients with or without a positive family history showed worse oxygenation and respiratory characteristics than did normotensives is consistent with previous research. Of note, hypertensives reporting a family history were characterized by a greater number of oxygen desaturations and apnoea hypopnoea index than those typified only by a current diagnosis of hypertension. Hypertensives with a family history are likely to show a profile of greater blood pressure, higher BMI, and more severe SDB, which by all accounts are more common among African Americans.

Associations of ambient illumination with mood: contribution of ophthalmic dysfunctions.

Evidence suggests that ocular pathology could reduce light-stimulated neuronal signaling to the suprachiasmatic nuclei. This study investigated associations of ambient illumination with moods, while considering the contribution of ophthalmic dysfunctions. Seventy Black (59%) and White (41%) Americans participated in the study. Their average age was 68.27+/-5.97 years; 73% were women. Baseline data included: physical health, mood, and sociodemographics. Ophthalmic factors including visual acuity, visual field defects, intraocular pressure, vertical and horizontal cup-to-disk ratios, and nerve-fiber-layer thickness were assessed at SUNY Downstate's eye clinic. The following week, participants wore the Actiwatch-L at home to monitor ambient illumination and sleep. Cosine analyses were performed on the logarithm of measured illumination, yielding the mesor and acrophase of daily illumination exposure. Sleep was estimated with an automatic scoring algorithm. Of the sample, 25% reported visual impairment and 85% reported good to excellent health; 27% were visually impaired according to American criteria. Partial correlation analyses showed an inverse correlation of daily illumination levels to depressed mood [r(p)=-0.33, P<0.05], when age, sex, ethnicity, income, BMI, diabetes, hypertension, respiratory disease, and habitual sleep duration were controlled. With further control for ophthalmic factors, the magnitude and significance of the correlation diminished [r(p)=-0.26, NS]. Individuals receiving daily illumination later in the day reported more depressed moods [r(p)=0.36, P<0.01]; of note, this correlation was not significant after control for the covariates [r(p)=0.18, NS]. Regression analysis indicated that the ophthalmic factors explained 13% of the variance in depression. Our results show that both the level and timing of ambient illumination are associated with mood. Furthermore, they suggest that visual impairment has a mediating effect on the associations of ambient illumination with depression, supporting the notion that ocular pathology lessens the efficacy of daily illumination in promoting positive moods.

Ethnic differences in self-reported sleep problems in older adults.

STUDY OBJECTIVES: To date, conflicting observations have been made regarding ethnic differences in sleep patterns. Plausibly, differing sampling strategies and disparity in the cohorts investigated might help explain discrepant findings. To our knowledge population-based studies investigating ethnic differences in sleep complaints have not addressed within-group ethnic heterogeneity, although within-group health disparities have been documented. DESIGN: Volunteers (n =1118) in this study were community-residing older European Americans and African Americans residing in Brooklyn, New York, which were recruited by a stratified, cluster sampling technique. Trained interviewers of the same race as the respondents gathered data during face-to-face interviews conducted either in the respondent's home or another location of their choice. Data included demographic and health risk factors, physical health, social support, and emotional experience. Relationships of demographic and health risk factors to sleep disturbances were examined in multiple linear regression analyses. Within-group differences in sleep complaints were also explored. SETTING: N/A. PARTICIPANTS: N/A. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: Of the factors showing significant associations with sleep disturbance, European American ethnicity was the most significant predictor (r2 = 0.20). Worse sleep and greater reliance on sleep medicine were observed among European Americans. Caribbean Americans reported less sleep complaints than did U.S.-born African Americans, and immigrant European Americans reported greater complaints than did US-born European Americans. CONCLUSIONS: As expected several health risk factors were predictive of sleep disturbance among urban community-dwelling older adults, but ethnicity was the most significant predictor. The present data suggest both between-group and within-group ethnic differences in sleep complaints. Understanding of demographic and cultural differences between African Americans and European Americans may be critical in interpreting subjective health-related data.

Sleep estimation from wrist activity in patients with major depression.

Actigraphy has been used to monitor individuals' sleep and wakefulness patterns without laboratory confinement. To date, its validity in monitoring sleep and wakefulness among patients with major depressive episodes has not been systematically examined. The present study investigated whether the normative criteria of the Actigraph Data Analysis Software, initially optimized for healthy individuals, could score wrist-activity data accurately in a sample of depressed patients. Application of the normative algorithm yielded a correlation coefficient of 0.85 and an average error of 35 min, comparing actigraphic and polysomnographic sleep estimates. The algorithm optimized for this sample provided a correlation coefficient of 0.81 and an error of 6 minutes. For both algorithms, agreement for individual comparisons varied substantially. These findings suggest that scoring criteria optimized on wrist-activity data of healthy young adults may not produce optimal results for patients characterized with major depressive episodes.

Assessment of physical activity and sleep by actigraphy: examination of gender differences.

Research evidence suggests that actigraphy is a very important instrument in documenting sleep/wake patterns of people with a variety of sleep disorders or motor dysfunctions. The present actigraphic investigation examined physical activity and sleep profiles as a function of gender in volunteers monitored in their natural environment. Irrespective of age, women exhibited better sleep quality than did men. This was demonstrated by higher sleep efficiency index and lower frequency of transitions between sleep and wakefulness. Additionally, women slept more than men and had shorter sleep onset latency. However, no significant gender effect on daytime activity level and circadian activity amplitude was observed.

Actigraphic predictors of depressed mood in a cohort of non-psychiatric adults.

OBJECTIVE: Depressed mood is one of the essential features for the diagnosis of major depression. Evidence from the three-site Epidemiologic Catchment Area study (ECA, Baltimore, Durham and Los Angeles) suggests a prevalence of 4.4% of depressive symptoms in the community. In this study, we examined whether depressed mood, as coded in the Alzheimer's Disease Assessment Scale, would be correlated with actigraphic-derived daytime activity and sleep/wake parameters in a non-psychiatric sample. METHOD: Consenting volunteers were monitored at home for 5 days with a wrist actigraph. On the last day of the recording, they were given a neuropsychological battery including the Alzheimer's Disease Assessment Scale. RESULTS: Daytime activity level was the best predictor of depressed mood as indicated by a logistic regression analysis. The regression model further suggested that sleep onset latency, total time asleep, and time in bed were also significant predictors of depressed mood. CONCLUSION: This investigation demonstrates that daytime activity level could be used as an index of depressed mood even in a non-psychiatric sample. Further, the results support the notion that depression should be considered more as a continuum rather than as a set of rigid categories.

Actigraphic assessment of sleep in insomnia: application of the Actigraph Data Analysis Software (ADAS).

The usefulness of the actigraph methodology has been demonstrated in normal individuals. However, the validity of actigraphy has been questioned in insomnia patients because of the considerable measurement error that has been reported between actigraphy (ACT) and polysomnography (PSG). Two independent investigations have reported errors of 48 and 49 min in total sleep time between ACT and PSG. With a new scoring method called the Actigraph Data Analysis Software, a reanalysis of one of these studies was conducted. Based on this reanalysis, we have obtained a measurement error of only 25 min between the two methods. This finding may be an indication of the advantage of this new scoring method. A strong correlation coefficient (r = 0.82, p < 0.0001) was noted between ACT and PSG for total sleep time, thus suggesting a high degree of accuracy of the actigraph methodology in assessing the sleep/wake profile of insomniacs.

Predictors of subjective sleepiness induced by melatonin administration.

Researchers have found that melatonin substantially reduced both sleep onset latency and the number of nocturnal awakenings in normal individuals as well as patients with diverse sleep pathologies. These findings have led to an increase in the number of individuals who ingest melatonin habitually to alleviate their sleep problem. Given the widespread use of melatonin, it is important to identify the factors capable of predicting physiological states while following a melatonin regimen. The result of this preliminary analysis showed that the number of hours spent outdoors is the best predictor of subjective sleepiness while under the influence of melatonin. Specifically, the more time individuals spend outdoors, the sleepier they are when administered melatonin.

Mood states and sleepiness in college students: influences of age, sex, habitual sleep, and substance use.

Survey and laboratory evidence suggests several factors affecting sleep-wake patterns of college students. These factors include social and academic demands, diminution of parental guidance, reduction of total sleep time, delayed bedtime, and increased nap episodes. In this study, we examined the problem of falling asleep in school as a correlate of negative moods in this population (N = 294). A multivariate analysis showed significant main effects of sleepiness on mood states based on the Profile of Mood States. Students who fell asleep in school reported higher negative mood states. Significant interactions were observed among sleepiness and age, sex, race, and duration of sleep. Specifically, younger men reported higher negative moods. No interactions were noted for alcohol and marijuana consumption; however, students who fell asleep in school consumed more alcoholic beverages and smoked more than those who did not. Perhaps falling asleep in school could be used as an index that characterizes students who manifest adaptive or psychological difficulty.

Effects of melatonin in two individuals with Alzheimer's disease.

Dementia has been associated with circadian rhythm disturbances expressed in several dimensions including body temperature, hormonal concentrations, sleep and wakefulness patterns, and rest-activity cycles. These disturbances may be the result of a dampening in the amplitude of the circadian rhythm. One of the symptoms associated with the aging process has been a decline in the amplitude of the melatonin rhythm. Here, the results of melatonin administration to two patients with Alzheimer's disease are presented. Melatonin administration enhanced and stabilized the circadian rest-activity rhythm in one of the patients along with some reduction of daytime sleepiness and an improvement in mood. The other patient, who was characterized by less cognitive impairment, showed no significant changes associated with melatonin ingestion. Interestingly, the acrophase of rest-activity was delayed for about one hour in both patients. These results suggest that melatonin may have beneficial effects in some patients with Alzheimer's disease.

Melatonin effects on sleep, mood, and cognition in elderly with mild cognitive impairment.

The effects of immediate-release melatonin on circadian rest-activity profiles, cognition, and mood were investigated in ten elderly individuals with self-reported sleep-wake disturbances. Melatonin (6 mg), administered 2 hr before habitual bedtime, enhanced the rest-activity rhythm and improved sleep quality as observed in a reduction in sleep onset latency and in the number of transitions from sleep to wakefulness. However, total sleep time was not significantly increased nor was wake within sleep significantly reduced. The ability to remember previously learned items improved along with a significant reduction in depressed moods. No side effects or contraindications were reported by any of our participants during the 10 day trials. These data suggest that melatonin can safely improve some aspects of sleep, memory, and mood in the elderly in short-term use.

The effects of photic driving on mood states.

The EEG photic driving response is a sensitive neurophysiological measure. It has been used to assess drug effects, forms of epilepsy, neurological status of Alzheimer's patients, and physiological arousal. Photic driving also impacts the psychological status of a person by producing increased visual imagery and decreased physiological and subjective arousal. In this study, ten volunteers underwent nocturnal polysomnography followed by six daytime testing sessions. The six sessions consisted of the alpha attenuation test, two visual analog scales for mood, the Stanford Sleepiness Scale, photic stimulation, and the multiple sleep latency test. These tests were administered 2 hours upon awakening and every 2 hours thereafter. The mean mood across the six daytime testing sessions was computed for all mood variables pre- and post-photic stimulation. Significant differences were found for the subjective moods "sleepy," "alert," and "effort." However, no significant differences were found for pre- and post-photic driving for "angry," "irritable," "hungry," "tense," "overall," "happy," "sexual," and "sad." Additionally, all participants reported increased visual imagery during photic driving, as measured by their responses to an imagery questionnaire.