Ethnicity, Emotional Distress, Stress-Related Disruption, and Coping among HIV Seropositive Gay Males

Differences in psychosocial factors that impact immune function and which, therefore, are relevant to HIV infection have been reported between Hispanics and non-Hispanic whites in the cross-cultural literature. To determine whether there were differences between Hispanic and non-Hispanic white HIV-seropositive homosexual males on life stressors, coping style, social support, and emotional distress, a sample (Hispanics = 27, non-Hispanic whites = 49) of participants in a five-year longitudinal study of HIV disease progression was assessed on relevant measures. Hispanics in this sample were not found to evidence psychosocial deficits as compared to non-Hispanic whites. Although not more stressed overall, Hispanics reportedhigher severity of stress on daily interactions related to their homosexual lifestyle than did their non-Hispanic white counterparts. Level ofacculturation isproposedas apossible explanation forthe striking similarities along most other psychosocial parameters.

Impact of a secondary prevention intervention among HIV-positive older women

Despite the fact that older women represent a growing risk group for HIV, they have been rarely targeted by public health campaigns designed to prevent HIV/AIDS and are often excluded from many prevention studies. This unique cohort may be often overlooked due to beliefs that older women are not sexually active and do not engage in high risk sexual activity. Data suggest a need for increased attention to this unique cohort. Risk reduction interventions tailored to the special needs of people living with HIV/AIDS have begun to demonstrate promising results. In this manuscript, we report the 6 month outcomes for female participants in Project ROADMAP, a secondary prevention intervention designed to reduce high risk sexual behavior in older adults living with HIV/AIDS. Our results indicate that female participants in the intervention group were more likely to report a reduction in high risk sexual behavior than women in the control condition. Our findings also suggest that the intervention succeeded in increasing the HIV-related knowledge of the participants and decreasing their stigma vis-à-vis the HIV condition. The study findings suggest that Project ROADMAP is an effective secondary prevention intervention for sexually active older HIV positive women.

Project ROADMAP: Reeducating Older Adults in Maintaining AIDS Prevention: a secondary intervention for older HIV-positive adults

The number of older adults living with HIV/AIDS is larger than ever. Little is known about their sexual behaviors, although contrary to stereotypes, older adults desire and engage in sexual activity. Despite increased recognition of the need for prevention interventions targeting HIV-positive individuals, no secondary HIV prevention interventions have specifically targeted the older HIV-positive adult. Efforts to target high-risk sexual behaviors may be even more critical in the older population because of sociocultural, biological, and behavioral vulnerabilities. In response, Project ROADMAP (Reeducating Older Adult in Maintaining AIDS Prevention) intervention was developed to reduce high-risk sexual behaviors among older HIV-positive patients in primary care clinics. The purpose of this article is to report the 6-month outcomes of a behavioral intervention designed to reduce sexual risk behaviors in older HIV-positive adults.

Sexual risk behaviors in late middle age and older HIV seropositive adults

Little is known about the sexual behaviors of older adults, although the prevalence of HIV/AIDS is rapidly increasing in this population. As part of a larger multi-site study examining secondary HIV prevention, we recruited from an HIV primary care clinic 210 sexually active HIV positive individuals aged 45 and over (125 men, 85 women) who had engaged in vaginal or anal sex within the past six months. Twenty percent of the participants reported inconsistent use of condoms and 33% had multiple sexual partners during the previous six months. Negative mood and perceived HIV stigma were associated with inconsistent condom use. In addition, multiple sex partners and higher level of education were related to inconsistent condom use during sex with partners of negative or unknown serostatus. These findings indicate that contrary to current beliefs, sexually active older adults, similar to younger ones, may be engaging in high risk transmission behaviors.

Sexual risk behaviors in late middle age and older HIV seropositive adults

Little is known about the sexual behaviors of older adults, although the prevalence of HIV/AIDS is rapidly increasing in this population. As part of a larger multi-site study examining secondary HIV prevention, we recruited from an HIV primary care clinic 210 sexually active HIV positive individuals aged 45 and over (125 men, 85 women) who had engaged in vaginal or anal sex within the past six months. Twenty percent of the participants reported inconsistent use of condoms and 33% had multiple sexual partners during the previous six months. Negative mood and perceived HIV stigma were associated with inconsistent condom use. In addition, multiple sex partners and higher level of education were related to inconsistent condom use during sex with partners of negative or unknown serostatus. These findings indicate that contrary to current beliefs, sexually active older adults, similar to younger ones, may be engaging in high risk transmission behaviors.

Uncomplicated general anesthesia in the elderly results in cognitive decline: does cognitive decline predict morbidity and mortality?

Elderly surgical patients constitute a unique surgical group. They require special consideration in order to preempt the long term adverse effects of anesthesia. This paper examines the proposition that general anesthesia causes harm to elderly patients with its impact being felt long after the anesthetic agents are cleared from the body. One complication, Postoperative Cognitive Decline (POCD), is associated with the administration of anesthesia and deep sedation. Its' occurrence may herald an increase in morbidity and mortality. Based on both human and animal data, this paper outlines a unitary theoretical framework to explain these phenomena. If this hypothesis proves to be correct, anesthesiologist should consider regional rather than general anesthesia for equivalent surgical procedures to reduce POCD and consequently achieving superior patient outcome.

The role of family functioning in the stress process of dementia caregivers: a structural family framework

PURPOSE

The purpose of the study was to evaluate the role of family functioning in the stress process in a sample of caregivers of dementia patients by using a structural family framework. The stress-process model of caregiver distress included family functioning as an intervening variable in the relationship between objective burden and distress. We theorized family functioning to partially mediate the relationship between objective burden and distress and to significantly account for the prediction of distress beyond well-recognized predictors.

DESIGN AND METHODS

One hundred eighty-one family caregivers from the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health project participated in this study. We assessed sociodemographics, burden, depression, anxiety, and perceived health for each caregiver. We measured family functioning by using a multidimensional and observational instrument. We used structural equation modeling to assess the fit of the model for the overall sample and for different caregiver subgroups and to examine whether demographic variables affected the relationships in the model.

RESULTS

The results of the study indicated that family functioning significantly contributed to distress in the overall sample and partially mediated the relationship between objective burden and distress. We also found that the stress-process model was adequately fit by the hypothesized relationships between objective burden, family functioning, and distress for the overall sample and all of the subsamples, except for wives.

IMPLICATIONS

This study provides support for the structural family approach as an explanatory model for the influence of family functioning on dementia caregivers. Family structural functioning is one contributor to the caregiver stress process. This suggests that interventions targeting structural family problems may reduce caregiver distress.

The value of telephone support groups among ethnically diverse caregivers of persons with dementia

PURPOSE

Dementia caregiving is a rapidly growing public health problem. Logistical problems prevent many caregivers from utilizing available interventions. This article provides a demonstration of the usefulness of technology for conducting telephone-based support groups in ethnically diverse dementia caregivers.

DESIGN AND METHODS

Participants were 41 White American and Cuban American dementia caregivers participating at the Miami site of the Resources for Enhancing Alzheimer's Caregiver Health (known as REACH) program. Support groups were conducted over the telephone in English and Spanish as appropriate.

RESULTS

Eighty-one percent of the participants found the group "valuable," largely because of the social and emotional support and useful information obtained from other group members. The majority of caregivers also reported that their participation had increased their knowledge and skills as caregivers.

IMPLICATIONS

The findings demonstrate that telecommunications technology can overcome the often formidable logistical problems faced by both English- and Spanish-speaking caregivers, and it can provide benefits similar to those obtained in face-to-face support groups.

Split treatment: a measurement of coordination between psychiatrists

The objective of this study was to examine the adherence rates of psychiatrists with APA standards for coordination of care in split treatment. Coordination of care in split treatment is monitored from claims paid data in an academic MBHO as an ongoing quality improvement activity. For an 18-month period, 93 psychiatrists were identified with 559 patients in split treatment and were mailed a survey. Surveys were controlled for change of providers. Self-report survey results were obtained from 69 psychiatrists for 295 patients in split treatment. The average rate of coordination was 66 percent; however, the distribution was bimodal with 36 percent of psychiatrists always coordinating and 26 percent never coordinating. Not obtaining a release accounted for 87 percent of non-coordination. In conclusion, while coordination of care in split treatment is an APA standard of practice, only 36 percent of psychiatrists fully complied. That one third of patients in split treatment did not receive coordinated care suggests a need for improvement to meet the APA standards of practice and avoid legal exposure.

HIV-1 infection and its impact on the HPA axis, cytokines, and cognition

Immediately after infection, Human immunodeficiency virus, type 1 (HIV-1) enters the central nervous system (CNS) and is localized in highest concentration in the hippocampus and basal ganglia. Since these areas are associated with HPA axis and autonomic activities as well as cognition, it has been hypothesized that these functions will be impacted adversely in HIV-1 infection. In the treatment of HIV infection, although the highly potent antiretroviral (HAART) drugs have been effective in reducing peripheral viral load and prolonging life expectancy, these drugs do not cross the blood-brain barrier in therapeutic concentrations. Therefore, it has been proposed that the beneficial effects of HAART on the CNS will be limited. Our investigations on seropositive individuals, showing hypo-reactivity of the autonomic system and HPA axis activity suggest that HIV-1 infection is a model of chronic stress. Furthermore, an elevated baseline TNF-alpha level as well as its increased reactivity to an alpha-adrenergic challenge among HIV-1+ individuals, may lead to additional neurodegeneration. It is proposed that the effects of HIV-1 infection on the brain will have implications for neurocognitive and mental health functioning in seropositive individuals even in patients undergoing HAART therapy. These outcomes may result in the need to develop facilities for long term "care-giving".

The effect of a family therapy and technology-based intervention on caregiver depression

PURPOSE

The majority of persons with Alzheimer's disease (AD) are cared for at home by a family member such as a spouse or daughter. Caregiving places enormous demands on these caregivers, and the negative consequences associated with caregiving are well documented. This paper reports results from the Miami site of the REACH (Resources for Enhancing Alzheimer's Caregiver Health) program that examined the efficacy of a family therapy and technology-based intervention in reducing depressive symptoms (according to the Center for Epidemiological Studies Depression scale) among family caregivers of AD patients at 6 months and 18 months follow-up.

DESIGN AND METHODS

There were 225 White American and Cuban American caregivers that were randomized into a structural ecosystems therapy, structural ecosystems therapy + computer-telephone integrated system, or minimal support control condition.

RESULTS

Caregivers in the combined family therapy and technology intervention experienced a significant reduction in depressive symptoms at 6 months. The 18-month follow-up data indicated that the intervention was particularly beneficial for Cuban American husband and daughter caregivers.

IMPLICATIONS

The results indicate that information technology has a promising role in alleviating distress and depression among groups of AD caregivers. The data also demonstrate that interventions have differential impacts according to ethnic group and the caregiver-patient relationship.

"Putting a face" on HIV infection/AIDS in older adults: a psychosocial context

Older HIV-1-seropositive individuals largely have not been investigated with respect to their psychosocial characteristics. In this article, the authors review research reported to date regarding the psychosocial context of this growing subgroup of HIV-1-infected individuals. Specifically, the authors consider the characteristics of mood state, life stressor burden, social support network, and coping strategies that individuals older than 50 years are more likely to adopt in adjusting to HIV-1 infection. The authors also separately consider issues of caregiving burden. Data supporting a theoretically based stressor-support-coping model are presented and related to targeting psychotherapeutic interventions for this age group.

Cognitive functioning in younger and older HIV-1-infected adults

In young adults, a major neurologic complication of HIV-1 infection is cognitive motor impairment. Epidemiologic findings suggest that increasing age is a significant risk factor for HIV-1-associated dementia as the AIDS-defining illness. Findings from the few studies that have directly measured cognition in younger and older HIV-1-infected adults, however, have been mixed, in part, because of small sample sizes and other methodologic differences between studies. The authors present preliminary findings on cognitive functioning in symptomatic HIV-1-infected younger (aged 20-39 years) and older (aged 50 years or older) adults. Independent of age, HIV-1 infection was accompanied by learning and memory retrieval deficits, which were significantly associated with high plasma viral loads in the young adults. Relative to the younger and older HIV-1-negative (HIV-1-) groups, only the younger HIV-1-positive (HIV-1+) group had significantly longer reaction times (RTs). Within the older HIV-1+ group, however, longer simple and choice RTs were significantly correlated with higher viral loads and lower CD4 cell counts. Although HIV-1 infection affects cognition independent of age, longitudinal studies involving large numbers of older individuals are needed to determine whether there are age differences in the prevalence, nature, and severity of HIV-1-associated cognitive dysfunction.

The role of macrophage/microglia and astrocytes in the pathogenesis of three neurologic disorders: HIV-associated dementia, Alzheimer disease, and multiple sclerosis

Macrophage/microglia (M phi) are the principal immune cells in the central nervous system (CNS) concomitant with inflammatory brain disease and play a significant role in the host defense against invading microorganisms. Astrocytes, as a significant component of the blood-brain barrier, behave as one of the immune effector cells in the CNS as well. However, both cell types may play a dual role, amplifying the effects of inflammation and mediating cellular damage as well as protecting the CNS. Interactions of the immune system, M phi, and astrocytes result in altered production of neurotoxins and neurotrophins by these cells. These effects alter the neuronal structure and function during pathogenesis of HIV-1-associated dementia (HAD), Alzheimer disease (AD), and multiple sclerosis (MS). HAD primarily involves subcortical gray matter, and both HAD and MS affect sub-cortical white matter. AD is a cortical disease. The process of M phi and astrocytes activation leading to neurotoxicity share similarities among the three diseases. Human Immunodeficiency Virus (HIV)-1-infected M phi are involved in the pathogenesis of HAD and produce toxic molecules including cytokines, chemokines, and nitric oxide (NO). In AD, M phis produce these molecules and are activated by beta-amyloid proteins and related oligopeptides. Demyelination in MS involves M phi that become lipid laden, spurred by several possible antigens. In these three diseases, cytokine/chemokine communications between M phi and astrocytes occur and are involved in the balance of protective and destructive actions by these cells. This review describes the role of M phi and astrocytes in the pathogenesis of these three progressive neurological diseases, examining both beneficent and deleterious effects in each disease.

The HPA axis in HIV-1 infection

Several lines of evidence suggest that neuroendocrine abnormalities in general and HPA axis activity in particular occur in both HIV-1 infection and individuals engaging in chronic drug use. For instance, our studies showing attenuated norepinephrine as well as ACTH and cortisol responses to a cold pressor challenge in asymptomatic HIV-1 persons support such a concept. Furthermore, our data on investigations on mirror-star tracing and speech challenges also support the finding that neuroendocrine responses are compromised in HIV-1 infection. Although the mechanisms leading to adverse effects on HPA axis activity in HIV infection are not fully understood, several lines of evidence suggest that a number of mechanisms may be involved, including homologies in molecular structures of various mediators of neuroendocrine activity and HIV-related structures, HIV as a chronic stress model, and virus-induced toxic factors. This article reviews our recent findings in this area and also presents research hypotheses needed for testing and understanding the mechanisms involved in the development of neuroendocrine abnormalities in HIV-1-infected injection drug users.

Aging and neuro-AIDS conditions and the changing spectrum of HIV-1-associated morbidity and mortality

Older individuals (>50 years of age) now comprise over 11% of patients with AIDS in the United States. This percentage is expected to continue to grow, due both to the improved longevity of patients prescribed highly active antiretroviral therapy (HAART) and to new infections among older individuals. This review focuses on the neuropsychiatric and neurological conditions that are most likely to be affected by advancing age-HIV-1-associated cognitive-motor disorder, peripheral neuropathy, progressive multifocal leukoencephalopathy, primary CNS lymphoma, and risk for cerebrovascular accident. Age associations with incidence of these disorders and with treatment foci are specified. Implications for future changes in management are discussed.

Caregivers' judgments of the functional abilities of the Alzheimer's disease patient: impact of caregivers' depression and perceived burden

Research has demonstrated that caregivers of cognitively impaired patients may misjudge aspects of the patient's functional capacities. The nature and directions of these relationships are not well understood, however. Further, the effects that depression and perceived caregiver burden have on the caregivers' ability to render accurate judgments of patient's functional abilities have not been addressed. In this study, the primary caregivers of 128 patients with Alzheimer's disease (AD) were administered a questionnaire regarding the patients' functional capacities. These judgments were subsequently compared to actual functional performance of AD patients on an extended version of the Direct Assessment of Functional Status scale administered in the patients' home environment. A significant proportion of caregivers overestimated AD patients' functional performance in telling time, counting currency, making change for a purchase, brushing teeth, and using eating utensils. Further analyses revealed that self-reported depression, but not perceived burden, was related to the type of caregiver bias errors observed.

Cerebrospinal fluid 5-hydroxytryptamine and 5-hydroxyindoleacetic acid in HIV-1 infection

Reduced level of serotonin (5-hydroxytryptamine, 5-HT) in humans has been associated with a number of mental health and behavioral problems including depression, aggression, violence, sexual dysfunctions, sleep and eating disorders. Even though among HIV-1-infected individuals, prevalence of mental health and behavioral problems are common, their relationship with central nervous system serotonin functions is not clearly understood. This investigation was carried out to study the status of CSF 5-HT in HIV-1+ subjects (n = 21), in the early stage of infection, and HIV-1- control subjects (n = 24). Samples of CSF were obtained by lumbar puncture and were analyzed for 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA), using high-performance liquid chromatography equipped with electrochemical detector. Levels of CSF 5-HT were significantly lower in the HIV-1+ group compared to the HIV-1- group. There was no significant difference in the CSF 5-HIAA levels between the two groups. In both groups, however, there was a significant correlation between CSF 5-HT and 5-HIAA. In the HIV-1 + group, although CSF 5-HT level was significantly negatively correlated with serostatus, there was no correlation between either CSF 5-HT or 5-HIAA levels and CD4 cell number or any behavioral measures evaluated in this study, including Beck's Depression Inventory and state/trait anxiety scores. These data suggest that HIV-1 infection affects the CNS 5-HT status with no significant association with measures of depression and anxiety, at least in the early stage of infection.

A comparison of antecedents of homicide-suicide and suicide in older married men

The authors compared characteristics of 27 older men who perpetrated a spousal homicide-suicide and 36 age-matched married men who committed suicide in west central Florida between 1988 and 1994. Data were collected as part of an ongoing retrospective study of homicide and suicide among older adults in Florida. Men who committed suicide had significantly more disease conditions than homicide-suicide perpetrators (P<0.0001). Half of the latter were in caregiving roles, vs. 17% of the suicides (chi(2)=5.40; P=0.027). Depression was a prominent premorbid feature of both groups, but none of the perpetrators tested positive for antidepressants postmortem.

Caregivers' judgments of the functional abilities of the Alzheimer's disease patient: a comparison of proxy reports and objective measures

The assessment of functional capacity is essential for the diagnosis of dementia by DSM-IV criteria and has important implications for patient intervention and management. Although ratings of functional disability by family or other proxy informants are widely used by clinicians, there have been concerns and empirical evidence that potential reporter biases may result in either overestimation or underestimation of specific functional deficits. In this study, we compared family members' judgments of the functional abilities of seventy-two patients diagnosed with Alzheimer's disease (AD). These judgments were compared to actual objective functional performance on an array of real-world tasks using the Direct Assessment of Functional Status (DAFS) scale. The results indicate that caregivers were extremely accurate in predicting the functional performance of AD patients who were not impaired during objective evaluation. In contrast, caregivers significantly overestimated the ability of impaired AD patients to tell time, to identify currency, to make change for a purchase, and to utilize eating utensils. Higher patient MMSE scores were associated with caregivers' overestimation of functional capacity, while the degree of caregivers' depressive symptoms, as measured by the CES-D depression scale, was not related to either overestimation or underestimation of patients' functional performance.

Peripheral serotonin levels in women: role of aging and ethnicity

Serotonin has been implicated to play an important role in regulating emotions and behavior, and it is well accepted that the platelet serotonergic system mirrors the presynaptic central serotonergic system. Since prevalence of psychiatric problems increases with age and women are known to be more vulnerable than men, the present investigation was carried out to study the relationship between serotonin activity and age in women. Levels of serotonin (5-hydroxytryptamine, 5-HT) and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) were measured in platelets and plasma in women (n = 49) aged 40-84 years (30 women aged 40-60 years and 19 women aged 61-84 years). There was a significant age difference between the two groups (mean: 47.6 +/- 5.91 years in the younger and 73.0 +/- 6.83 years in the older women, respectively, p < 0.00001). Platelet 5-HT as well as 5-HIAA levels were significantly higher in older women as compared to those in the younger women (89.41 +/- 21.95 ng/10(8) platelets in younger vs. 112.9 +/- 36.07 in older women, p < 0.02, and 1.20 +/- 1.10 in younger vs. 2.19 +/- 1.88 ng/10(8) platelets in older women, p < 0.05, respectively). Pearson correlation coefficients determined in the combined group (n = 49) showed a significant positive correlation between platelet 5-HT and age (r = 0.31, p < 0.03). Plasma 5-HT levels on the other hand were lower in older women compared to those in the younger women (4.50 +/- 3.20 in younger vs. 1.04 +/- 1.28 ng/ml plasma in older women, p < 0.0001) and a significant negative correlation was observed between plasma 5-HT and age (r = -0.44, p < 0.002). Plasma 5-HIAA concentration did not differ between the two groups. Platelet 5-HT levels in the younger group were independent of ethnicity. Since high serotonin activity has also been associated with psychiatric problems, our results of increased concentration of platelet 5-HT as well as 5-HIAA with age may have implications in predisposing aging women to behavioral/psychiatric problems.

Cobalamin level is related to self-reported and clinically rated mood and to syndromal depression in bereaved HIV-1(+) and HIV-1(-) homosexual men

OBJECTIVE

An examination of the relationship of plasma cobalamin (vitamin B(12)) level to overall psychological distress, specific mood states, and major depressive disorder was conducted in 159 bereaved men (90 HIV-1(+) and 69 HIV-1(-)).

METHODS

The relationship of a continuous measure of cobalamin level to psychological distress was examined, while controlling for HIV-1 serostatus, life stressors, social support, and coping styles.

RESULTS

Of this sample, 23.9% were either overtly or marginally cobalamin deficient; however, the deficiency rate was not significantly different by HIV-1 serostatus. Cobalamin level was inversely related to self-reported overall distress level and specifically to depression, anxiety, and confusion subscale scores, as well as to clinically rated depressed and anxious mood. Lower plasma cobalamin levels also were associated with the presence of symptoms consistent with major depressive disorder.

CONCLUSION

These findings suggest that cobalamin level may be physiologically related to depressed and anxious mood level, as well as to syndromal depression.

Music therapy increases serum melatonin levels in patients with Alzheimer's disease

CONTEXT

Music therapy is known to have healing and relaxing effects. Although these effects appear to be mediated by release of neurotransmitters and neurohormones, the specific neurohormonal systems involved have not been fully investigated.

OBJECTIVE

To assess the effects of a music therapy intervention on concentrations of melatonin, norepinephrine, epinephrine, serotonin, and prolactin in the blood of a group of patients with Alzheimer's disease.

DESIGN

Blood samples were obtained before initiating the therapy, immediately at the end of 4 weeks of music therapy sessions, and at 6 weeks follow-up after cessation of the sessions.

SETTING

Miami Veterans Administration Medical Center, Miami, Fla.

PATIENTS

20 male inpatients with Alzheimer's disease.

INTERVENTION

30- to 40-minute morning sessions of music therapy 5 times per week for 4 weeks.

MAIN OUTCOME MEASURES

Changes in melatonin, norepinephrine, epinephrine, serotonin, and prolactin following music therapy.

RESULTS

Melatonin concentration in serum increased significantly after music therapy and was found to increase further at 6 weeks follow-up. A significant increase was found between baseline values and data recorded after the music therapy sessions as well as at 6 weeks follow-up. Norepinephrine and epinephrine levels increased significantly after 4 weeks of music therapy, but returned to pretherapy levels at 6 weeks follow-up. Serum concentration of prolactin and platelet serotonin levels remained unchanged after 4 weeks of music therapy and at 6 weeks follow-up.

CONCLUSION

Increased levels of melatonin following music therapy may have contributed to patients' relaxed and calm mood.

Independent evolution of HIV type 1 in different brain regions

HIV-1-associated brain pathology exhibits regional variability and we therefore studied the genetic differences in the V1-V5 domains of the HIV env gene in up to four regions of brain (frontal lobe, basal ganglia, medial temporal lobe, and nonmedial temporal lobe) from three patients. We found that in each separate brain region HIV-1 forms different quasispecies and that there is little gene flow among these regions. In further support of brain region-specific evolution of HIV-1, we analyzed amino acid signatures in these clones. In addition to known amino acid signatures associated with macrophage tropism and the lack of syncytium formation, we found 15 majority amino acid signature patterns from the V1-V5 env sequences associated with the neuroanatomical regions analyzed from the three individuals. Furthermore, on average, intrabrain genetic distances for the HIV-1 env were estimated to be much smaller than genetic distances between brain regions. Specific strains of HIV-1 may be neurotropic or neuroinvasive (replication preference in brain tissue) and may contribute to pathology, cognitive loss, and neuropsychiatric disease.

Mild cognitive impairment and risk of mortality in HIV-1 infection

HIV-1-associated cognitive impairment has only been preliminarily investigated for associations with mortality. The authors examined 119 HIV-1-positive homosexual men (asymptomatic: n = 96; early symptomatic: n = 23). At follow-up (to 3.5 years), there were 105 survivors and 14 nonsurvivors. Those at the 25th percentile in response speeds and in long-term memory retrieval accuracy were at 6.4 (P < 0.02) and 3.5 (P < 0.05) times increased mortality risk, respectively, of those at the 75th percentile--independent of baseline CDC clinical stage, CD4 cell count, hemoglobin level, antiretroviral and prophylactic medication use, and sociodemographics. Cognitive impairment should be identified early--for maximization of both functional status and survival time.

Psychological distress in HIV-1 disease in relationship to hypocholesterolemia

OBJECTIVE

Altered levels of serum cholesterol, which are prevalent in early HIV-1 infection, have been associated with disturbances in mood state and behavior. The objective of this study was to evaluate the relationship of serum cholesterol status and psychological distress in HIV-1 seropositive and seronegative men.

METHOD

The association between serum cholesterol level and psychological distress, measured with the Profile of Mood States (POMS), was examined in 169 individuals (117 HIV-1 seropositive and 52 seronegative homosexual men), controlling for negative life events, social support, coping style, and HIV-1 serostatus.

RESULTS

Individuals with hypocholesterolemia (serum cholesterol levels < 150 mg/dL), exhibited significantly higher levels of distress, relative to individuals with values of cholesterol > 150 mg/dL (p = 0.01). HIV-1 seropositive men had significantly lower cholesterol levels (p = 0.0001) and higher levels of distress than the seronegative men (p = 0.03). A significant interaction between negative life events and cholesterol status was demonstrated as well (p = 0.04).

CONCLUSIONS

Hypocholesterolemia appears to be associated with increased psychological distress. Whereas the causal direction of the cholesterol-distress association cannot be specified, our results suggest that HIV-1 infected men with low cholesterol levels may benefit from being monitored for changes in distress level, so that appropriate psychosocial intervention can be instituted, as necessary.

Homicide-suicide in older persons

OBJECTIVE

The objective of this study was to determine the annual incidence of homicide-suicide and to compare patterns and antecedents in old and young spousal/consortial cases.

METHODS

Homicide-suicide cases were ascertained in four medical examiner districts covering seven entire Florida counties from 1988 to 1994. The districts were chosen to determine rates in two regions of Florida, comparable in size of the total population and proportion of older persons. Annual homicide-suicide incidence rates per 100,000 population and homicide-suicides as a percentage of total homicides and total suicides separately were calculated by age group and Florida region. Complete medical examiner files were obtained, and 160 variables were coded from medical examiner reports to compare features and clinical characteristics by age and region.

RESULTS

Annual incidence rates ranged from 0.3 to 0.7 per 100,000 for persons under age 55 and from 0.4 to 0.9 per 100,000 for persons age 55 and older, with higher rates in the older group every year but two. Cases of spousal/consortial homicide-suicide were the most common in both age groups. The younger couples in both regions were comparable, except for racial composition, but the older couples differed. West central Florida couples were in their seventies, Caucasian, usually married, and both in poor health; and there were indications of depression or alcohol abuse in half the perpetrators. Two-thirds of the southeastern Florida couples were Hispanic; there was a mean age difference of 18 years between perpetrators and victims; and verbal discord, physical violence, and separation were prominent antecedents.

CONCLUSIONS

The base rate for homicide-suicide in both age groups was higher than that reported in previous studies. Spousal/consortial homicide-suicides were the dominant form, and although psychopathology was strongly implicated, homicide-suicides are violent lethal acts resulting from additive or multiplicative effects of diathesis, including culture, and stressful experiences.

Serotonin uptake and its kinetics in platelets of women with Alzheimer's disease

The uptake of serotonin (14C-5-hydroxytryptamine, 5HT) in platelets and its kinetic characteristics were investigated in a group of women (n = 20) with probable Alzheimer's Disease (mean age = 76.0, years, SD = 8.27, range = 63-88) and in healthy normal women (n = 18, mean age = 72.6 years, SD = 7.24, range = 61-84). Both the apparent affinity of binding of 5HT to the platelet membrane (Km) and the maximum velocity (Vmax) of the rate of transport of 14C-5HT into platelets were significantly higher in the Alzheimer's Disease group than in the normal comparison group. Initial velocity of 14C-5HT uptake not passive diffusion (nonspecific uptake of 14C-5HT at 4 degrees C) differed significantly in the two groups. Our findings suggest abnormalities in the kinetic mechanisms involved in the uptake of 14C-5HT by platelets in women with Alzheimer's Disease.

Micronutrients and HIV-1 disease progression

OBJECTIVE

To determine whether nutritional status affects immunological markers of HIV-1 disease progression.

DESIGN

A longitudinal study, to evaluate the relationship between plasma levels of nutrients and CD4 cell counts, along and in combination with beta 2-microglobulin (beta 2M; AIDS index) over an 18-month follow-up.

METHODS

Biochemical measurements of nutritional status including plasma proteins, zinc, iron and vitamins B1, B2, B6, B12 (cobalamin), A, E, C and folate and immunological markers [lymphocyte subpopulations (CD4) and beta 2M] were obtained in 108 HIV-1-seropositive homosexual men at baseline and over three 6-month time periods. Changes in nutrient status (e.g., normal to deficient, deficient to normal), were compared with immunological parameters in the same time periods using an autoregressive model.

RESULTS

Development of deficiency of vitamin A or vitamin B12 was associated with a decline in CD4 cell count (P = 0.0255 and 0.0377, respectively), while normalization of vitamin A, vitamin B12 and zinc was associated with higher CD4 cell counts (P = 0.0492, 0.0061 and 0.0112, respectively). These findings were largely unaffected by zidovudine use. For vitamin B12, low baseline status significantly predicted accelerated HIV-1 disease progression determined by CD4 cell count (P = 0.041) and the AIDS index (P = 0.005).

CONCLUSIONS

These data suggest that micronutrient deficiencies are associated with HIV-1 disease progression and raise the possibility that normalization might increase symptom-free survival.

Psychotropic drug use in relation to psychiatric symptoms in community-living persons with Alzheimer's disease

We attempted to determine the relationship between psychiatric symptoms and psychotropic drug use in persons with Alzheimer's disease based on a multicenter patient registry of 671 community-living persons diagnosed with the disease by published criteria. Logistic regression was performed to determine which symptoms were associated psychotropic use after controlling for age, sex, and Mini-Mental Status Examination (MMSE) score. At least one psychotropic drug was reported by 31% of patients, and 66% had at least one psychiatric symptom. Antipsychotics were associated with a lower MMSE score (odds ratio = 0.92, 95% confidence interval 0.88-0.97), emotional lability (OR = 4.52, 95% CI 1.69-11.94), and hallucinations (OR = 6.54, 95% CI 2.99-14.26). Antidepressants were associated with depressive symptoms (OR = 5.8, 95% CI 2.61-13.46), and benzodiazepines with a lower MMSE score (OR = 0.93, 95% CI 0.90-0.97). Community-living persons with Alzheimer's disease are frequently prescribed psychotropic drugs; however, more than 50% of patients with a psychiatric symptom did not report taking one of these agents. This suggests that alternative therapies and no treatment are also prevalent.

Plasma cobalamin levels affect information processing speed in a longitudinal study of HIV-1 disease

OBJECTIVE

To determine whether information processing speed is influenced by change in plasma cobalamin status in human immunodeficiency virus type 1 disease.

DESIGN

A longitudinal study, using autoregression, to evaluate the relationship between plasma cobalamin status and change in information processing speed assessed by Posner Letter Matching, Sternberg Short-Term Memory Search, Figure Visual Scanning and Discrimination of Pictures, and continuous paired associates learning tasks.

SETTING

University of Miami (Fla) School of Medicine from fall 1987 through summer 1991.

PARTICIPANTS

Eighty-four human immunodeficiency virus type 1-infected homosexual men aged 20 to 55 years. None of the subjects displayed acquired immunodeficiency syndrome-defining symptoms at baseline; over the course of the study, 9.5% progressed to acquired immunodeficiency syndrome.

MAIN OUTCOME MEASURES

Biochemical measurement of plasma cobalamin; performance on information processing speed tasks.

RESULTS

Significant improvement in the Posner Letter Matching NI-PI (Name Identity minus Physical Identity) differential was associated with becoming cobalamin adequate or remaining adequate. Becoming cobalamin deficient, in contrast, was associated with a significant decline in the speed of accessing overlearned name codes.

CONCLUSION

Normalization of plasma cobalamin inadequacy in human immunodeficiency virus type 1 disease may provide significant improvement in the speed of retrieving overlearned information from long-term memory.

Peripheral serotonin in Alzheimer's disease

The platelet has been suggested to be a peripheral model of the central serotonergic neuron. This investigation was carried out in order to test the hypothesis that levels of serotonin (5-HT) in the platelet will be decreased in Alzheimer's disease (AD) since neurochemical studies suggest that levels of 5-HT are decreased in the brain of AD patients. We investigated platelet and plasma 5-HT in a group of AD patients (n = 22) as well as in age-matched normal control subjects (n = 20). The results show that the platelet level of 5-HT was significantly reduced in AD (65.7 +/- 28.41 ng/10(8) platelets in AD vs. 112.9 +/- 35.11 ng/10(8) platelets in controls; p = 0.0001). There was no effect on the levels of its metabolite 5-hydroxyindoleacetic acid. These findings suggest that the peripheral serotonergic system in AD is adversely affected.

Deterioration of functional capacities in Alzheimer's disease after a 1-year period

There is a paucity of data regarding Alzheimer's disease (AD) patients' longitudinal deterioration in the ability to conduct numerous activities required for daily living. In this study, 52 patients with AD were assessed at baseline and at a 1-year follow-up using the Direct Assessment of Functional Status (DAFS) scale, an objective, well-validated measure of a broad spectrum of functional capacities that is administered within the clinical setting. An important finding was that the level of initial performance on each of the 11 functional tasks measured did not relate to the degree of functional decline in that particular area. Communication skills, such as using the telephone (deterioration among 35.4% of the patients) and preparing a letter for mailing (deterioration among 32.7%), showed the most frequent deterioration among patients upon follow-up. More than half of the AD patients studied demonstrated impairment on one or both of these measures. The pattern of findings indicates that many subtests of the DAFS were sensitive to functional decline after a 1-year period and that the scale has utility in objectively establishing longitudinal patterns of deterioration.

Community resources and the management of dementia patients

Clinical management of the Alzheimer's disease patient in his or her home requires an array of services. Such services are often available from voluntary organizations, religious groups, for profit, not-for-profit, or governmental agencies. This article reviews the structure and range of those services that contribute much help to maintain the patient outside of the institution.

Evaluation of the demented patient

Approaching the patient with Alzheimer's disease often requires the participation of a team of collaborating physicians and psychologists as well as others both for diagnosis and for management. This article describes the approach to the disease by a neurologist, geriatrician, psychiatrist, and psychologist. Each describes a specific diagnostic approach, and the reader can appreciate the incremental value to assessment and care that emerges from the aggregate.

Impact of vitamin B6 status on psychological distress in a longitudinal study of HIV-1 infection

OBJECTIVE

Inadequate vitamin B6 status has been associated with altered neuropsychiatric function, possibly through its effect on the metabolism of neurotransmitters, including serotonin (5-HT). The present eighteen month longitudinal study evaluated the relationship between vitamin B6 status and psychological distress in HIV-1 infected individuals, controlling for the influence of negative life events, social support and coping style.

METHOD

Biochemical measurements of nutritional status, and dietary intake evaluations were obtained in HIV-1 seropositive homosexual men, (at baseline: CDC Stages II and III, n = 70; Stage IVA, IVC2 n = 18) at six month intervals. Alterations in nutrient status (e.g., vitamin B6 adequate to inadequate; inadequate to adequate), were compared with changes in psychological distress, measured by the Profile of Mood States, using a multiple regression analysis.

RESULTS

A significant decline in psychological distress was demonstrated with normalization of vitamin B6 status from inadequate to adequate status (p < 0.02). A decrease in psychological distress was also observed with increased tryptophan intake in subjects who were vitamin B6 adequate (p < 0.02).

CONCLUSIONS

Significant effects for the nutritional variables remained even when negative life event stressors, social support, and coping style were controlled, suggesting that vitamin B6 status may be an important co-factor in determining level of psychological distress over time in HIV-1 infected individuals.

Psychopathology associated with Alzheimer's disease and related disorders

BACKGROUND

This study compared the occurrence of psychiatric symptoms in a large group of community-residing participants enrolled in an Alzheimer's disease patient registry who met clinical diagnostic criteria for Alzheimer's disease or multi-infarct dementia, as well as mixed Alzheimer's disease and multi-infarct dementia.

METHODS

Psychiatric morbidity observed from a psychiatric examination of 514 patients with Alzheimer's disease, 135 patients with multi-infarct dementia, and 86 cases with mixed dementia was analyzed using analysis of variance comparing symptoms across groups and chi-square test for differences in frequency of occurrence. Associations between pairs of symptoms were also reported.

RESULTS

The frequency of occurrence and patterns of psychiatric problems were similar in patients with Alzheimer's disease and multi-infarct dementia. Agitation was the most frequent symptom, followed by depression, apathy, and behavioral disorders. Patients with mixed dementia had significantly more psychopathology.

CONCLUSION

This study demonstrated that significant psychopathology occurs in individuals with Alzheimer's disease or multi-infarct dementia. The high levels of symptoms in mixed dementia suggest that the two conditions have a synergistic effect on behavioral problems. The prevalence of multiple symptoms is higher than previously reported.

Drug use patterns of persons with Alzheimer's disease and related disorders living in the community

OBJECTIVE

To describe drug use patterns by persons with Alzheimer's disease, multi-infarct dementia, and mixed Alzheimer's disease and multi-infarct dementia.

DESIGN

Multicenter, patient registry.

SETTING

Community-living persons evaluated in primary care, geriatric, and Alzheimer ambulatory settings.

PARTICIPANTS

Of the 930 persons in three diagnostic categories, there were 671 with probable or possible Alzheimer's disease by NINCDS/ADRDA criteria or Alzheimer's disease by DSM-III-R criteria, 162 multi-infarct cases by DSM-III-R criteria, and 97 mixed cases by DSM-III-R criteria. In each diagnostic category, 65% were women, and the majority were 70 years or older.

MEASUREMENTS

The average number of all prescription and non-prescription drugs and selected therapeutic categories by age, sex, diagnosis, and mini-mental status score at the time of diagnosis or evaluation.

RESULTS

Alzheimer patients average 2.3 drugs compared with multi-infarct (4.3; P < 0.0001) and mixed (3.7; P = 0.002) patients, and their pattern of drug use was different when stratified by therapeutic categories and drug classes. Drug use increased with age, and women used significantly more drugs than men in all three diagnostic categories. Women with Alzheimer's disease used significantly more cardiovascular drugs than men with Alzheimer's disease (P < 0.05). The lower the mini-mental status score in patients with any dementia, the greater the mean number of central nervous system agents used. The higher the mini-mental status score in a patient with multi-infarct or mixed dementia, the greater the use of cardiovascular drugs.

CONCLUSION

Drug use by Alzheimer patients was lower than in multi-infarct and mixed patients, primarily due to a lower prevalence of cardiovascular drugs.