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a Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, CA
b School of Medicine, University of California at San Diego
c Department of Exercise Science, University of South Carolina, Columbia
d Division of Epidemiology, Department of Health Research & Policy, and the Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, CA
Correspondence: Audie A. Atienza, PhD, Stanford Center for Research in Disease Prevention, Stanford University, 730 Welch Road, Suite B, Palo Alto, CA 94304-1583. E-mail: audie.atienza{at}stanford.edu.
Decision Editor: Laurence G. Branch, PhD
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Abstract |
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.01). In contrast, no gender differences were found for ambulatory hemodynamic functioning when aggregated overall or when in the presence of the care recipient. Implications: Laboratory-based findings suggest that female caregivers experience greater blood pressure reactivity to caregiving-related stress than do male caregivers. However, these laboratory-based gender differences may not generalize to differences in hemodynamic functioning in caregivers' daily lives.
Key Words: Stress • Blood pressure • Heart rate
Cardiovascular reactivity (CVR; sympathetic nervous system activation) reverts to increases in blood pressure and/or heart rate levels in response to an acute stressor and has been implicated in the development of cardiovascular disease (
Gerin et al. 2000
;
Krantz and Manuck 1984;
Manuck 1994;
Matthews et al. 1986). Informal family caregivers of ill or disabled older adults represent a group who generally report high levels of stress and burden (
Schulz, Visintainer, and Williamson 1990;
Zarit 1989), the effects of which have been linked to higher ambulatory blood pressure levels (
King, Oka, and Young 1994) and greater mortality (
Schulz and Beach 1999) compared to noncaregivers. The caregiving literature further suggests that female caregivers report greater stress and burden than male caregivers (Dura, Haywood-Niler, & Keicolt-Glaser, 1990; Fitting, Rabins, Lucas, & Eastham, 1986; Lutzky & Knight, 1994; Miller & Cafasso, 1992;
National Alliance for Caregiving and The American Association of Retired Persons [AARP] 1997[Yee & Schulz, 2000), but only a few studies have examined gender differences in laboratory-based CVR to stress among caregivers. Results of these studies have been mixed. In one study that included caregivers, women displayed greater blood pressure reactivity to a laboratory-based emotional stress task compared with men (
Vitaliano, Russo, Bailey, Young, and McCann 1993). Vitaliano and colleagues suggested that the observed gender difference may be the result of the emotional stress task (i.e., discussing familial relationships) being more salient for women than men. Yet, other research on caregivers of persons with dementia has failed to detect gender differences in CVR in response to a laboratory-based emotional stress task in which caregiving problems were discussed (
Lutzky and Knight 1994).
In contrast to the caregiving literature, several studies have suggested that men experience greater blood pressure reactivity to laboratory-based stressors compared with women (
Allen, Stoney, Owens, and Matthews 1993;
Delahanty et al. 2000;
Matthews, Davis, Stoney, Owens, and Caggiula 1991;
Polefrone and Manuck 1987;
Stoney, Davis, and Matthews 1987). However, this prior research examining gender differences in CVR in the general population typically focused on young adults; it often did not indicate whether the individuals studied were, like caregivers, experiencing significant daily stressors that could exacerbate physiological responses to stress in the laboratory. The equivocal findings of prior caregiving studies on gender differences in CVR and the unique stress often experienced by older caregivers highlight the need for additional research examining gender differences in CVR among caregivers.
Central to the reactivity hypothesis is the assumption that cardiovascular responses detected in the laboratory generalize to cardiovascular functioning in the natural environment (
Manuck and Krantz 1986;
Pickering and Gerin 1990). According to the "prevailing state model," CVR states in the laboratory are posited to resemble typical cardiovascular functioning as experienced in everyday life (
Manuck and Krantz 1986). Based on this model, it would be predicted that if gender differences in laboratory-based CVR are present, then these gender differences should also be seen in the hemodynamic levels of caregivers in the natural setting. However, others have argued that laboratory-based CVR corresponds to the hemodynamic functioning in the natural environment only during times of stress (
Matthews, Owens, Allen, and Stoney 1992). According to this perspective, it would be predicted that if gender differences in CVR among caregivers are displayed in the laboratory, then gender differences in ambulatory hemodynamic functioning in caregivers should be seen during distressing time periods in the natural setting. In our review of the caregiving literature, we could find no studies assessing gender differences in ambulatory blood pressure and heart rate functioning among family caregivers as experienced in their natural environments. The present study, therefore, provides new information related to whether gender differences exist in ambulatory hemodynamic functioning in caregivers' natural environments.
The purpose of this study was twofold. Because of the relatively small number of caregiving studies previously conducted and equivocal findings, the first aim was to extend prior research by examining gender differences in cardiovascular responses to a laboratory-based emotional stressor among caregivers of persons with dementia, a group particularly vulnerable to the effects of stress and burden (
Pearlin, Mullan, Semple, and Skaff 1990;
Schulz and Williamson 1991). The second aim was to investigate gender differences in ambulatory hemodynamic (i.e., blood pressure and heart rate) functioning in the caregivers' natural environments. As research has found CVR to be relatively stable over time (
Kamarck 1992;
Veit, Brody, and Rau 1997), the present study conceptualized CVR as an individual difference variable.
It was first hypothesized that female caregivers would display greater CVR (i.e., systolic and diastolic blood pressure, heart rate) to a laboratory-based emotional stressor compared to male caregivers. This prediction was based on prior research indicating that women generally report greater stress as a result of caregiving than men. Based on the prevailing state model, it was further hypothesized that women would display greater overall ambulatory blood pressure (BP) and heart rate (HR) levels compared to men. We also tested the alternative hypothesis that gender differences in ambulatory BP and HR functioning would be present only during times of distress. Specifically, the present study examined ambulatory hemodynamic functioning among both male and female caregivers when they were in the presence of their care recipients, a time period previously associated with distress and increased BP among at least some groups of caregivers (
King et al. 1994).
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Methods |
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). Both male and female caregivers were recruited using a variety of strategies, including newspaper and radio advertisements, posters placed on public transportation, notices sent to Alzheimer's and other caregiver organizations, and newspaper articles describing the research project. Eligibility criteria were similar for both men and women, requiring participants to (a) provide care to a family member or friend diagnosed with some form of dementia (as documented by the care recipient's physician) in the caregiver's home; (b) be 50 years of age or older; (c) not participate in a regular program of physical activity (defined as 3 or more times per week of exercise lasting 20 minutes or more per session over the past 6 months); (d) be free of cardiovascular disease or physical limitations that would hinder participation in light to moderate intensity exercise; (e) be stable on all medications for at least 3 months prior to study entry; and (f) agree to visit the clinical outpatient clinic at Stanford University for a health assessment.
Eighty male caregivers were screened for eligibility, and 69% (n = 55) were found ineligible for participation or did not wish to participate. The primary reasons for ineligibility/nonparticipation among the male caregivers were: not interested (20%), not providing more than 10 hours of informal assistance (19%), being too active (17%), and not providing care to someone with dementia (15%). Similarly, the primary reasons for ineligibility/nonparticipation among the female caregivers were: not interested (25%), being too active (12%), not providing care to someone with dementia (18%), and not being in the target age range (5%). As some have argued that the effects of gender in caregiving studies may be confounded by the type of relationship to the care recipient (
Lutzky and Knight 1994), each of the eligible men (n = 25) was matched to a woman (n = 25) on type of relationship to the care recipient (e.g., spouse, adult child/parent). Other research has suggested that caregivers of Alzheimer's disease patients can experience greater caregiving stress and burden compared to caregivers of vascular dementia patients (
Vetter et al. 1999). Thus, male and female caregivers were also matched on whether they were caring for someone with Alzheimer's disease versus other types of dementia (e.g., vascular dementia). Finally, male and female caregivers were matched on age, based on research suggesting that age is linked to cardiovascular reactivity (
Uchino, Uno, Holt-Lunstad, and Flinders 1999). Thus, the present study compared 25 male caregivers with 25 female caregivers.
Procedure
Baseline study protocols for the male and female caregivers were identical, with the same research technicians performing the assessments for both. Participants were scheduled for morning clinic health assessments, which included measurement of height and weight, participation in a CVR task, a physical activity interview, and completion of questionnaires. After leaving the clinic (typically around 1:00 p.m.), participants wore the ambulatory BP/HR monitor throughout the day until they retired for the evening.
Measures
Demographics and Health
Participants completed a measure of demographic characteristics, including their age (in years), education (in years), annual household income, and ethnicity. They also completed a health history, including current medications.
Caregiving Characteristics
Participants completed a survey focused on various aspects of their caregiving experiences (
King and Brassington 1997). Items used in this investigation included their familial relationship to the care recipient, diagnosis of care recipient (confirmed by the care recipient's physician), age of care recipient, years or months spent caregiving, hours per week spent caregiving, and type of assistance provided to care recipient.
Psychological
Caregiver burden was measured with the 25-item Screen for Caregiver Burden (SCB;
Vitaliano, Russo, Young, Becker, and Maiuro 1991). It assesses the prevalence of experiences that are common among caregivers of persons with Alzheimer's disease and the distress associated with each of the experiences (on a scale ranging from 1 = "no distress" to 4 = "severe distress"), thus yielding an objective and subjective burden score. Possible scores on the subjective burden scale range from 25 to 100, with higher scores indicating greater distress related to the caregiving experiences. This measure has adequate internal consistency, reliability, and validity (
Vitaliano, Russo, Young, et al. 1991;
Vitaliano, Young, and Russo 1991). Depression was measured with the Beck Depression Inventory (BDI;
Beck, Ward, Mendelson, Mock, and Erbaugh 1961), a 21-item self-report questionnaire. For each item, participants choose one of four statements, graded in terms of severity, that describes their thoughts over the past week. The BDI has been used extensively in clinical as well as community samples and has adequate internal consistency, reliability, and validity (see review by
Beck, Steer, and Garbin 1988). Its psychometric properties are acceptable in noncognitively impaired older populations (
Scogin 1994).
CVR
CVR to a laboratory-based psychological stressor was measured using an interpersonal interview with a trained research technician, a strategy previously used by prior researchers examining CVR among older adult caregivers (
Lutzky and Knight 1994;
Vitaliano et al. 1993). During the CVR interview, BP (mm Hg) and HR (beats/minute) levels were assessed in 2-min intervals using a Colin ambulatory BP/HR monitor (Model ABPM-630; Colin Medical Instruments, Plainfield, NJ) attached to the nondominant arm. The Colin monitor records BP using both oscillometric and auscultatory (Korotkoff sound) methods (
White, Lund-Johansen, and McCabe 1989). As more complete data were obtained through the oscillometric method, and the two methods provided reasonably close reading in the study samples, only readings from the oscillometric method are reported (
King et al. 1994).
The CVR protocol proceeded as follows: First, participants were asked to sit alone quietly in a room and listen to relaxing music via headphones for a 10-minute rest period. Following the rest period, the research technician engaged the participant in conversation on a neutral topic for 2 minutes to obtain a recording while the caregiver was talking. Next, participants were asked to speak for about 6 minutes (i.e., task period) on the following topic: "Tell me what frustrates or disturbs you the most or what angers or upsets you about being a caregiver." The technician gave minimal verbal responses during the task period. An additional 10 minutes (i.e., recovery period) followed the speech task, in which the research technician left the room and the participants sat quietly. After the CVR protocol, participants were asked if they had additional comments or questions concerning the task. As prior research has suggested that aggregating multiple cardiovascular recordings within a particular time period increases measurement reliability (
Kamarck 1992), BP and HR recordings in the present study were averaged within each time portion of the emotional challenge (i.e., rest, task, recovery) to obtain mean systolic BP (SBP), diastolic BP (DBP), and HR levels.
Ambulatory BP and HR Monitoring
Details of procedures for collection of ambulatory monitoring data, described previously (
King et al. 1994), will be briefly described here. The ambulatory recording portion of the protocol began typically around 1:00 p.m., following the participants' study assessment visit. The ambulatory BP/HR monitor was programmed to automatically record at one-hour intervals up until the time that the participant retired for the night. The decision to use hourly rather than more frequent recordings was based on information obtained during a prior study with female caregivers (
King et al. 1994), in which caregivers indicated that more frequent recordings would create undue burden. To minimize movement artifact that could interfere with BP and HR recordings, participants were instructed to remain in the position (e.g., sitting, standing) they occupied during the initiation of the cuff inflation through end of the inflation, and to minimize movement of the cuffed arm (
White et al. 1989). The recorder was placed in a waist-worn belt, with leads to the cuff worn under clothing to minimize disruption or inconvenience.
Participants concurrently recorded psychosocial and health-related information on an hourly basis using a lightweight (440g) pocket computer diary (Casio PB-1000, Casio Corporation, Tokyo, Japan) until they retired for the night (detailed description of the Casio PB-1000 provided by
King et al. 1994). The pocket computer was programmed to automatically inform the participant each hour, via a series of auditory beeps, that it was time to complete the diary. At each hour, participants answered a series of questions by touching the computer screen at designated times; the diary took approximately 3 minutes to complete. Information gathered via the computer included who was present (e.g., care recipient, other family members, coworker), position during each BP/HR recording (e.g., sitting, standing), current mood (anger, upset, tension/anxiety, and sadness; 1 = "none" to 10 = "extreme"), level of control over the situation (1 = "low" to 10 = "high"), level of demand of the situation (1 = "low" to 10 = "high"), and physical activity level. The PB-1000 has been found to be an accurate and reliable method of obtaining momentary health-related information in the natural environment in both caregiving (
King et al. 1994) and noncaregiving (
Taylor, Fried, and Kenardy 1990) samples.
Analysis Plan
CVR in Laboratory
Descriptive analyses were first conducted to examine male and female caregivers on a number of demographic and caregiving-related variables. To test the first hypothesis (laboratory-based CVR gender differences), the female caregivers' SBP, DBP, and HR scores were subtracted from the respective SBP, DBP, and HR scores of the matched male caregivers, thus removing any influence of the matching factors. All participants had BP and HR scores for each time period (i.e., rest, task, and recovery). A multivariate analysis of variance (MANOVA) was first conducted for the three outcome measures to test the overall main effect of Gender x Time. Given that individuals can demonstrate different levels of response across different hemodynamic variables (
Matthews et al. 1986), the MANOVA test for overall Gender x Time effect was expected to be significant. Two-way ANOVA procedures (Pair x Time) were then conducted for each outcome (i.e., SBP, DBP, & HR). In each analysis, the main effect of Gender (i.e., grand mean) and Gender x Time were tested. When there was a significant Gender x Time effect, contrast analyses were conducted comparing (a) rest versus task scores to further examine gender difference in reactivity, and (b) task versus recovery scores to examine gender differences in recovery following the task. As some have suggested that the use of antihypertensive (including beta blockers and calcium channel blockers) and anxiolytic medication may confound the relationship between gender and CVR (
Vitaliano et al. 1993), we also conducted multivariate analyses controlling for the use of these medications. None of the caregivers reported using anxiolytic medication in the absence of antihypertensive medication (one woman caregiver reported using both anxiolytic and antihypertensive medication), and the proportions of men and women using antihypertensive medication were equivalent (see Table 1 ). As the findings from multivariate analyses (not shown) controlling for these medications were identical to the original analyses (not controlling for medication), only the original analyses are displayed.
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For the second set of analyses, ambulatory SBP, DBP, and HR scores were each averaged only if the caregiver indicated (using the pocket computer) that the care recipient was present during the time the blood pressure was being measured. For each outcome (SBP, DBP, and HR in the presence of the care recipient), a t-test analysis compared male caregivers with their matched female caregivers. Two men and five women had missing pocket computer and/or hemodynamic functioning data, and their respective matched pairs were subsequently deleted from analyses. Thus, the sample sizes for the second set of analyses examining ambulatory functioning were 19 male caregivers and 19 female caregivers.
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), and level of depression (BDI;
Beck et al. 1961). The ages of the care recipients and the types of caregiving tasks performed were also comparable. Despite matching on type of relationship with the care recipient, type of dementia, and age, women spent somewhat more hours providing care per week than men (89.5 vs 61.5 h/week, respectively; p .05). However, correlational analyses (not shown) indicated that gender differences in hours per week providing care were unrelated to the outcome measures (SBP, DBP, and HR reactivity; p values > .05). Among the female caregivers, descriptive analyses showed that those who were included were similar to those who were excluded in years of education (p = .88), years of providing care (p = .60), type of dementia (e.g., Alzheimer's disease, p = .33), level of caregiving burden (subjective: p = .25; objective: p = .37), level of depression (p = .16), level of SBP reactivity (task—rest; p = .47), DBP reactivity (task—rest; p = .33), and HR reactivity (task—rest; p = .08). Women included in the present study were more likely to be spouses of dementia patients (p < .001) and were older (p < .001) compared with women not included.
Cardiovascular Reactivity in Laboratory
Results of the MANOVA revealed a significant main effect of Gender x Time, Pillai's Trace, F(6,94) = 2.26, p .05. Results of two-way ANOVA procedures testing the first hypothesis for each outcome measure (SBP, DBP, and HR) are presented in Table 2 .
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.01); recovery period SBP levels for both men and women were comparable to SBP levels during the rest period.
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.01); recovery period DBP levels were comparable to DBP levels during the rest period.
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Fig. 4 illustrate average daily (i.e., overall) ambulatory hemodynamic functioning in male and female caregivers (group means, representing the day, were obtained for each participant and then scores were averaged for each gender). In t-test analyses, no significant gender differences were detected for overall ambulatory SBP, t(1,23) = 0.46, p = .65; DBP, t(1,23) = 1.31, p = .20; or HR, t(1,23) = –0.42, p = .68. Taken together, findings indicated that overall ambulatory SBP, DBP and HR functioning were similar for male and female caregivers.
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.05), upset (p .05), and tension/anxiety (p .05) when their care recipient was present compared with when their care recipient was absent. In addition, caregivers reported lower levels of control over the current situation (p .001) and higher levels of demand (p .05) when their care recipient was present compared with when the care recipient was absent. Taken together, these findings suggest that caregivers experienced greater distress and burden during the time period when the care recipient was present versus absent. Given this, it is possible that comparing male and female caregivers on hemodynamic functioning in the absence versus presence of the care recipient may represent a better reflection of caregivers' CVR in their natural environments than overall ambulatory levels. However, 7 male and 9 female caregivers in the present sample were either always with the care recipient during the monitoring period (n = 10) or did not have pocket computer data indicating whether or not they were with the care recipient (n = 6). Elimination of the matched pairs that corresponded to these 16 caregivers resulted in a significant reduction sample size (by nearly two thirds) and, thus, precluded our ability to assess gender differences in hemodynamic functioning in the absence versus presence of the care recipient. |
Discussion |
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). Caregivers of persons with dementia are particularly vulnerable to the experience of stress and burden (
Pearlin et al. 1990;
Schulz and Williamson 1991). Furthermore, some research has suggested that female caregivers experience greater stress and burden than male caregivers (
Dura et al. 1990;
Fitting et al. 1986;
Lutzky and Knight 1994;
Miller and Cafasso 1992; National Alliance for Caregiving & AARP, 1997;
Yee and Schulz 2000). An issue not as well researched concerns gender differences in physiological responses (i.e., CVR) to caregiving stress.
Laboratory results from the present investigation indicated that female caregivers experienced greater BP reactivity in response to a stressor compared with male caregivers. Gender differences were found even after controlling for (i.e., matching on) type of relationship to the care recipient, type of dementia, and age. Although the BP levels of male caregivers increased when discussing caregiving difficulties in the laboratory, female caregivers' BP reactivity responses were stronger and more pronounced. Insofar as CVR has been implicated in the development of cardiovascular disease (CVD;
Gerin et al. 2000;
Krantz and Manuck 1984;
Manuck 1994;
Matthews et al. 1986), the present laboratory findings suggest that female caregivers of dementia patients may be at increased risk of CVD by virtue of their elevated CVR levels.
The laboratory-based CVR protocol (i.e., interpersonal interview) in the present study was analogous to strategies used to detect reactivity in prior caregiving research (
Lutzky and Knight 1994;
Vitaliano et al. 1993). The present laboratory findings converge with prior caregiving research indicating that women display greater blood pressure reactivity than men (
Vitaliano et al. 1993), and contrast with other studies that have failed to detect gender differences in CVR among caregivers (
Lutzky and Knight 1994). Although caregivers in the present study were similar to the 94 caregivers studied by
Lutzky and Knight 1994 in age, ethnicity, type of caregiver (i.e., dementia caregiver), and years providing care, the caregivers in the present study had higher income and education levels. Yet, it remains unclear whether these socioeconomic differences in caregiver samples can explain the differential findings. The present results replicate results obtained by
Vitaliano and colleagues 1993, who suggested that salience of the emotional task may explain gender differences in CVR to laboratory-based stress. However, support for this explanation in studies on the general population has been equivocal. Some studies have indicated that gender-relevant stress tasks influence gender differences in CVR (
Lash, Eisler, and Southard 1995;
Lash, Gillespie, Eisler, and Southard 1991), whereas others failed to find a relationship between gender relevance and cardiovascular responses to laboratory-based stress (
Matthews et al. 1991). Other possible explanations for gender differences in CVR among caregivers that future investigations could explore include gender differences in psychological (e.g., dispositional factors), physiological (e.g., circulating catecholamines), social (e.g., social support), and caregiving-specific (e.g., frequency of caregiving stressors experienced) characteristics.
The present study also sought to examine whether laboratory-based gender differences in CVR generalized to hemodynamic functioning in the caregivers' daily lives. Findings from the present study were not consistent with the pattern of results as would have been predicted by the prevailing state model, which posits that CVR states in the laboratory should be similar to conditions typically experienced in everyday life. Overall ambulatory BP and HR levels were not significantly different for male and female caregivers as measured in their natural environments. We also failed to detect gender differences in ambulatory hemodynamic functioning among caregivers when they were in the presence of their care recipients. Thus, the difference between men and women in acute physiological stress reactions displayed in the laboratory was not found to generalize to the daily BP and HR levels of caregivers. Further research is needed to examine if gender differences in laboratory-based CVR generalize to specific situations (i.e., acute daily stressors), rather than more general conditions experienced in caregivers' everyday lives. Because of the undue burden of more frequent monitoring (
King et al. 1994), the present study assessed ambulatory hemodynamic functioning on an hourly basis. Increased frequency of monitoring would, however, enhance power to detect group differences. Future research could also assess gender differences in hemodynamic functioning when the care recipient was absent versus present to better determine if such conditions are more sensitive in evaluating whether laboratory-based CVR findings generalize to the natural environment in this population. A challenge for this assessment strategy is monitoring hemodynamic functioning more frequently and over longer periods of time (i.e., more than one day) to more thoroughly capture hemodynamic functioning in different situations, while also avoiding undue burden.
Some limitations of the present investigation must be acknowledged. First, all participants in the present study were caregivers of dementia patients. It is unclear whether the results would generalize to those providing care to older adults with other types of illnesses or disabilities. As most of the caregivers in the present study were spouses, the extent to which gender differences in CVR found in the present study would generalize to nonspousal (e.g., adult children) caregivers remains unclear. The limited number of male nonspousal caregivers in the study precluded an exploration of this issue. In addition, caregivers were primarily White, well educated, and of middle to high socioeconomic backgrounds. It is possible that male and female caregivers who differ from individuals assessed in our sample may show dissimilar patterns of physiological responses to stress as a result of different cultural and/or life experiences. Secondly, because a cross-sectional design was utilized, we can not ascertain whether gender differences in CVR emerged following the stress of caregiving or were present prior to the beginning of caregiving. Longitudinal and prospective caregiving research would help to shed light on when gender differences in CVR emerge or become pronounced during the course of caregiving.
The exploration of gender differences in psychophysiological responses to stress among caregivers warrants further investigation, particularly given the high level of stress often reported by caregivers (
Zarit 1989) and the detrimental health consequences linked to caregiving stress (
King et al. 1994;
Schulz and Beach 1999;
Schulz et al. 1990). This study contributes to the caregiving literature by providing further evidence that female caregivers experience greater cardiovascular reactivity to a caregiving-specific stressor compared to male caregivers. Additional research is required to clarify and refine when laboratory-based gender differences in CVR among caregivers may generalize to hemodynamic functioning in real life.
Practice Concepts
The Forum
Book Reviews
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Acknowledgments |
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Received for publication October 11, 2000. Accepted for publication March 19, 2001.
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