1. Heart Disease, Hypertension, and Stroke

2. Psychological Issues in Advanced and Terminal Illness
Average life expectancy in North America is 76 years.
Leading causes of death in adults are chronic illness
What are the leading causes of death across the life span?

3. Mortality Rates Leading causes of death
< 1 year
congenital abnormalities;
sudden infant death syndrome (SIDS)
Children > 1 year old
Accidents (40% of all deaths)
Cancer (especially leukemia)
Adolescence
Unintentional injury
Homicide
AIDS
SIDS is higher in lower class urban environments, when mother smoked during pregnancy, and when baby is put to sleep lying on his/her stomach or side.
Accidents due to accidental poisoning, injuries, or falls. Later the main cause of death dues to accidents is automobile accidents.
Remember that leukemia strikes the bone marrow producing an excessive amount of white blood cells, resulting in severe anemia and other complications.

4. Mortality Rates Leading causes of death
Middle age
Sudden death due to heart attack or stroke
Cancer
Elderly
Heart disease
Stroke
When asked how they would like to die, most say sudden death. By the way, in women under the age of menopause, breast cancer remains the number one cause of premature deaths.

5. Why do women live longer than men?
More fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy.

6. Potential Reasons for Gender Differences in Mortality
Females are more hardy
Males engage in riskier behaviours (factor after birth and infancy)
Men engage in riskier sports
Males tend to hold high stress or higher risk jobs
Men tend to have poorer health habits (e.g., drink more alcohol)
Social support may be more protective in women
More fit – more males are conceived but more female fetuses are born. This trend persist in infancy so that more male babies are likely to die. Thus, females may be more hardy. Essentially, no one really knows why there is the female advantage.
Conflicting reports on social support since marriage appears to benefit men more than women.
All of these factors may operate to increase the mortality rates in men.

7. Risk Factors Family history
Marital status (adds 10 yrs in men; 4 yrs in women)
Economic status
Body weight
Exercise
Alcohol (add 2 years if drink 1-3 drinks/day)

8. Risk Factors - continued
Smoking
Disposition (add 2 yrs if reasoned, practical)
Education
Environment (add 4 yrs if rural)
Sleep (more than 9 hours subtract 5 years)
Temperature (add 2 yrs if thermostat is < 68)
Health care – regular check ups add 3 yrs

9. How do people adapt to chronic illness?

10. Adapting Under Good Circumstances
First concern upon hearing diagnosis is fears about mortality.
Optimistic but tentative about plans
May try to normalize activities
Risk is they may over-extend
May have feelings of helplessness
Risk is to become overly dependent

11. Three Themes of Adaptation
Find meaning: why illness happened or rethink priorities
Gain sense of control
control symptoms and treatment
Restore self-esteem
Often by comparison with worse off others

12. Adapting Under Bad Circumstances
Relapse seen as a bad sign with poor prognosis
Re-focuses one on the illness
Need to undergo the coping process again but likely less hopeful than before.
30%-40% of stroke victims have another stroke within five years.

13. Heart Disease Due to narrowing or blocking of the coronary arteries.
Angina pectoris
painful cramp in chest, arm, neck, or back due to brief blockage of oxygenated blood to the heart.
More often during exercise, stress, cold temperature, digesting large fat meal.
Little or no permanent damage

14. Heart Disease Myocardium Myocardium infarction (heart attack)
Muscle tissue around the heart
Myocardium infarction (heart attack)
Prolonged blockage of blood to an area of the heart resulting in muscle tissue damage.
Symptoms of a heart attack
Pressure in chest, fullness, squeezing pain.
Pain spreading to shoulders, neck, or arms
Lightheadedness, fainting, sweating, nausea

15. Who Is At Risk of Heart Disease?
Prevalence increases with age, particularly after 45 years of age
Prior to 50s, 60s, men at greater risk than women but increases in women after menopause.
More women than men are likely to die from a heart attack
Blacks at higher risk, Asians at lower risk

16. Heart Disease Risk Factors
High blood pressure
Family history
Cigarette smoking
High LDL and total cholesterol levels
Physical inactivity
Diabetes
Obesity
Stress

17. Why high blood pressure a risk factor?
Heart has to work harder.
Since heart muscle is working harder, it can become enlarged.
Wear and tear on the arterial wall can increase the likelihood of lipid and calcium deposits adhering to the arterial wall. This leads to hardening of the arteries.

18. Type A Behaviours Hostile, cynical Judgmental (opinionated)
Competitive
Time urgent
Uses gestures while talking
Nodding of head while others are talking
Intense

19. Physiological Reactivity
Physiological and cardiovascular reactivity to acute stress (“hot reactors”).
Exaggerated increases in blood pressure, heart rate, catecholamines, corticosteroids
High levels of these hormones can damage heart and blood vessels
Presence of epinephrine (a catecholamine) increases the formation of clots.

20. Effects of Stress On Cardiac Risk

21. Psychosocial Predictors of Sudden Cardiac Death (BDI>10)
1.00
0.95
0.90
0.85
Proportion
Surviving
High scores on the Beck Depression Inventory in the placebo group was associated with a 2-times greater risk of mortality over 2 –years follow-up.
Irvine J, Basinski A, Baker B, Jandciu S, Paquette M, Cairns J, Connolly S, Gent M, Roberts R, Dorian P. Depression and risk of sudden cardiac death after acute myocardial infarction: Testing for the confounding effects of fatigue. Psychosomatic Medicine, 1999; 61:
Placebo, BDI <10
Placebo, BDI >10
AMIO, BDI <10
AMIO, BDI >10
Survival in days

22. When do heart attacks occur?
Less likely during sleep.
Among the employed, more often on a Monday between 6 and 11 am.
In part due to waking and becoming active shortly after dreaming which increases BP.
In part because of circadian rhythm effects, increases in arousal hormones and blood pressure.

23. Medical Treatment
Initial treatment may involve clot-dissolving medication and close monitoring
Balloon angioplasty
Tiny balloon is inserted into blocked vessel and inflated to open blood vessel
Bypass surgery
Use grafted vessel (e.g., piece from leg) to bypass blockage in artery to the heart

24. Medical Treatment
Medications (e.g., beta blockers, calcium channel blockers) to protect heart and improve function.
Risk management
Control of high blood pressure
Control of lipid abnormalities

25. Rehabilitation Promote recovery and reduce risk of another attack
Heart disease is chronic condition requiring ongoing management.

26. Rehabilitation Includes:
Exercise
Physiological and psychological benefits
Weight management
Smoking cessation
Lipid and BP management include dietary changes to control lipids
Reduce excessive alcohol intake
Stress management

27. Rehabilitation Exercise is the key component but:
50% drop-out rate within first 6 months
For those who continue benefits include:
Improved self concept, perceived health, sexual activity, involvement in social activities.
Those who stop are more likely to:
Smoke, have poorer cardiac function, have higher body weight, be more sedentary, experience greater anxiety and depression.

28. Symptoms of a Stroke Sudden
weakness or numbness of the face, arm, or leg (usually on one side of the body)
dimness or loss of vision (usually one eye)
Loss of speech or trouble talking or understanding speech
Unexplained, severe headache
Dizziness, unsteadiness, or sudden fall

29. What is a stroke?
Tissue damage to area of the brain due to disruption in blood supply, depriving that area of the brain of oxygen.

30. Causes of Strokes
Infarction – blockage in cerebral artery that cuts off or reduces blood supply
Thrombosis – blood clot
Embolus – piece of plaque becomes lodged in the artery.
Hemorrhage – happens suddenly. Less frequent than infarction but more damaging and more likely to cause death.

31. Stroke Risk Factors
Rare up to age 55, than risk increases sharply with age (doubling with each decade).
More common in men but women more likely to die from them.
Rates highest among blacks and lowest among Asians.
Family history

32. Stroke Risk Factors High blood pressure Cigarette smoking
Heart disease, diabetes, and their risk factors such as obesity and physical inactivity.
High red blood cell count (making the blood thicker and likelier to clot).
Mini-strokes – transient ischemic attacks (TIA)
TIAs may occur one or more times before a stroke.

33. Effects of a Stroke
Some motor, sensory, cognitive, or speech impairment usually occurs
Limitations may be permanent but lessen in severity over time.
Younger patients recover better
Impairments caused by hemorrhages more easily overcome than those caused by infarctions.

34. Effects of Stroke
Motor impairments often due to paralysis on one side of the body (side opposite to brain damage).
After about 6 weeks of rehab about 50% of patients can perform independently (many with cane or walker).
Language, learning, memory, and perception problems depend on location of the injury.

35. Effects of Stroke
Left-hemisphere damage more commonly associated with language problems called aphasia.
Receptive aphasia – difficulty understanding verbal information.
Expressive aphasia – difficulty producing and using language.
Damage to right side of brain often associated with difficulties in visual processing and emotions.
The difficulty with emotions can be either managing their own emotions or understanding those of others.

36. Psychosocial Aspects of Stroke
Denial is common
Unclear whether psychological or physiological basis.
This ambiguity also applies to depression when it occurs after a stroke.
Less than ½ of the patients return to work following a stroke.