University of Nairobi Nonstroke Cardiovascular Disease Article Analysis HW This paper is already COMPLETE. Just need a quick addition of information. I hav

University of Nairobi Nonstroke Cardiovascular Disease Article Analysis HW This paper is already COMPLETE. Just need a quick addition of information. I have attached the seven sources and the completed paper. This is all I need changed.

Can you add the (method, sample, and purpose) used in each article and whether the article answer my research question or not. Thanks!

Original assignment for reference:

This is a research paper on behavioral genetics. The topic for this paper is the “genetical association” between (dementia or Alzheimer) and heart disease (cardiovascular disease). This is a literature review paper that I have sent and critically analyze and synthesize these papers. This will include

Literature review
Evaluation of articles, including critical analysis of any apparent contradictions or ambiguities in the field.
Synthesis of your own perspective on the state of the art in this area and suggest design of potential future experiments that would be important.

This paper should be 10 pages with APA style, using the 7 articles that I sent with this file. The paper should have the aim of: Reviewing the literature for evidence of association between the cardiovascular disease and dementia or Alzheimer. This paper should be critically analyzing the 7 articles and their results to write this paper! Don’t forget to cite these articles as APA style.

If you have further questions, please let me know as soon as possible! Health Psychology
2014, Vol. 33, No. 12, 1593–1601
© 2013 American Psychological Association
The Type A Behavior Pattern and Cardiovascular Disease as
Predictors of Dementia
Kathleen Bokenberger
Nancy L. Pedersen and Margaret Gatz
Karolinska Institutet
Karolinska Institutet and University of Southern California
Anna K. Dahl
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Karolinska Institutet and Jönköping University
Objective: Research has suggested that greater psychophysiological reactivity to stress increases risk of
dementia and that those with the Type A behavior pattern (TABP) are predisposed to elevated stress
reactivity and cardiovascular disease (CVD), but no study has evaluated the associations among TABP,
CVD, and dementia, prospectively. Hence, the present study aimed to investigate dementia risk in
relation to TABP and CVD. Methods: A population-based cohort of 1,069 persons with a baseline mean
age of 64.81 years from the Swedish Twin Registry was followed consecutively for up to 23 years. Based
on self-reported items, TABP was measured using 6 scales: Ambition, Stress, Hard-driving, Neuroticism,
Cynicism, and Paranoia. CVD was self-reported and dementia was diagnosed adhering to Diagnostic and
Statistical Manual of Mental Disorders, third edition, revised (DSM–III–R) or Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM–IV) criteria. Results: TABP was generally not
associated with dementia risk. However, significant interaction effects of stress, paranoia, and cynicism
with CVD on dementia risk were observed. That is, for those with CVD, high scores on stress, paranoia,
and cynicism were associated with increased risk of dementia (hazard ratio [HR] ⫽ 1.43, 95% confidence
interval [CI] ⫽ 0.95–2.15; HR ⫽ 1.39, 95% CI ⫽ 0.83–2.33; HR ⫽ 1.25, 95% CI ⫽ 0.76 –2.06,
respectively), whereas for those who did not have CVD, high scores on these measures appeared to be
protective (HR ⫽ 0.76, 95% CI ⫽ 0.50 –1.14; HR ⫽ 0.55, 95% CI ⫽ 0.34 – 0.89; HR ⫽ 0.50, 95% CI ⫽
0.29 – 0.84, respectively). Conclusion: Some features of TABP confer an increased risk for dementia in
those with CVD, whereas those without CVD are protected. When evaluating the risk of dementia, CVD
and personality traits should be taken into consideration.
Keywords: type A behavior pattern, cardiovascular disease, dementia, longitudinal studies, personality
type of dementia is Alzheimer’s disease (AD); the second most
common subtype is ischemic vascular disease (VaD), however
neuropathologic investigations suggest there are often multiple
forms of pathology in the same patient (Vinters et al., 2000). The
fact that some older adults develop dementia and some do not
indicates that dementia is not a normal process of aging (Whalley,
2002). Thus, there is a need to pinpoint risk factors associated with
dementia and to understand whether risk factors act in an additive
or interactive manner. Here, dementia risk is prospectively examined in relation to the Type A behavior pattern (TABP) and
cardiovascular disease (CVD).
It is generally agreed that TABP is a multidimensional personality construct belonging to individuals with poor behavioral coping mechanisms (Lichtenstein, Pedersen, Plomin, de Faire, &
McClearn, 1989). Although the classification of TABP varies
somewhat across studies, research has nevertheless characterized
TABP as comprising excessive drive, free-floating hostility, neuroticism, high ambition, and general impatience (Rosenman et al.,
1964; Smith, O’Keeffe, & Allred, 1989; Williams et al., 1980). It
has been remarked that individuals who carry a combination of the
above mentioned traits differ from non–Type A persons not only in
personality and self-evaluative processes, but also in their physiological reaction to perceived stressful situations (Dembroski,
MacDougall, Shields, Petitto, & Lushene, 1978; Rosenman et al.,
Although public health efforts have helped increase longevity
over the last century, the incidence and prevalence of dementia
have consequently increased as old age is the strongest known risk
factor for dementia (Fratiglioni, De Ronchi, & Aguero-Torres,
1999). Dementia, a chronic and debilitating disorder in which
cognitive processes such as memory, cognition, language, judgment, and behavior are affected to the extent that normal daily
functioning is disrupted, imposes significant economic and emotional burdens on society (Knopman, 2011). The most common
This article was published Online First December 23, 2013.
Kathleen Bokenberger, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden; Nancy L. Pedersen
and Margaret Gatz, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden, and Department of Psychology, University of Southern California, Los Angeles; Anna K. Dahl,
Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, and School of Health Sciences, Jönköping University,
Jönköping, Sweden.
Correspondence concerning this article should be addressed to Kathleen
Bokenberger, Department of Medical Epidemiology and Biostatistics,
Karolinska Institutet, Stockholm, Sweden. E-mail: Kathleen.Bokenberger@
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
1964). A major focus has been on Type A personality in relation
to CVD, a group of disorders of the heart and blood vessels
including events such as heart attack and stroke. Despite the
controversy surrounding TABP as a predictor of CVD, considerable research supports an association between the two (Lichtenstein et al., 1989; Miller, Turner, Tindale, Posavac, & Dugoni,
1991; Smith & MacKenzie, 2006; Williams et al., 1980), particularly when individual facets of TABP are assessed (Smith, Glazer,
Ruiz, & Gallo, 2004). The mechanism for this relationship is often
suggested to be hyper cardiovascular reactivity to stress via neuroendocrine pathways. The behavioral responses in TABP could be
activating the hypothalamic-pituitary-adrenal (HPA) axis, the primary system activated during a stress response (Rosmond &
Bjorntorp, 2000). Prolonged activation of the HPA axis could, in
turn, produce an above average amount of glucocorticoid hormones such as cortisol, which could then lead to cardiovascular
problems or exacerbate cardiovascular conditions in patients with
coronary heart disease (Steptoe & Kivimaki, 2012).
Increasing evidence supports that CVD is associated with an
elevated risk of dementia, including VaD as well as AD (Eriksson,
Bennet, Gatz, Dickman, & Pedersen, 2010; Qiu et al., 2006;
Rosano & Newman, 2006). Moreover, risk factors for vascular
disease appear to be linked to both VaD and AD, and having
cerebrovascular disease in the presence of AD likely results in an
additive effect with respect to impairment (Breteler, 2000).
Whereas an extensive amount of research has assessed the relationship between Type A personality traits and CVD, and more
recently CVD and dementia, few studies have examined the link
between TABP and dementia risk, and to an even lesser extent, the
associations among TABP, CVD, and dementia in one model.
Assuming there is an association between TABP and dementia,
one might imagine such an association as being either mediated or
moderated by CVD.
In initial tests of the hypothesis that Type A behavior influences
risk of dementia, two case– control studies that investigated premorbid behavior characteristics among persons with dementia did
not report an association (Amaducci et al., 1986; Motomura et al.,
1998). Another case– control study observed that individuals with
mild cognitive impairment, a state often thought to be a precursor
to dementia, were characteristically more hostile than healthy
matched controls (Clément, Belleville, Belanger, & Chasse, 2009).
Two population-based longitudinal studies have explored the relationship between midlife stress and dementia 30 to 35 years later.
Crowe et al. concluded that self-reported reactivity to stress was a
predictor of elevated dementia risk (Crowe, Andel, Pedersen, &
Gatz, 2007), whereas the other study found a relationship between
self-reported frequent psychological stress and subsequent dementia risk (Johansson et al., 2010). Studies on proneness to psychological distress, measured as high neuroticism, have found an
association with AD (Wilson et al., 2003) and cognitive decline
(Crowe, Andel, Pedersen, Fratiglioni, & Gatz, 2006). Similarly,
higher neuroticism evaluated before dementia onset has been reported to be associated with AD neuropathology (Duberstein et al.,
2011; Terracciano et al., 2013). Conversely, one prospective study
with a 6-year follow-up did not observe neuroticism alone to be
associated with higher dementia risk, but among people with an
inactive or socially isolated lifestyle, low neuroticism was shown
to be protective (Wang et al., 2009). In sum, the literature concerning the relationship between Type A–related traits and demen-
tia is suggestive, but scarce and sometimes contradictory. Further,
many previous studies have adopted case– control designs or had
relatively short follow-up periods, thus limiting the ability to
differentiate baseline personality from dementia-affected personality.
Taken together, dementia has been studied in relation to CVD
and to aspects of TABP, but there remains a gap in the literature
concerning the associations among TABP, CVD, and dementia.
Hence, this study aims to explore whether TABP is a risk factor for
dementia, and to examine whether CVD mediates or moderates
such a relationship using baseline Type A personality measures
and dementia diagnoses obtained up to 23 years later in a
population-based sample.
The participants of the longitudinal Swedish Adoption/Twin
Study of Aging (SATSA) were drawn from the population-based
Swedish Twin Registry (STR). The sampling procedures and selection criteria for participants have been described in detail previously (Finkel & Pedersen, 2004; Pedersen et al., 1991). In short,
SATSA consists of two longitudinal components: a questionnaire
assessment and an in-person-testing (IPT) phase. In 1984, the first
wave of questionnaires (Q1) that consisted of two parts was mailed
out to all participants that were alive from the baseline sample. The
second part (Q1 Blue) was mailed out only to those responding to
the first part (Q1 Red). Subsequent questionnaires were sent out in
3-year intervals. Questionnaire items from both parts of Q1 that
were of relevance to the present study included questions about
personality and health. Starting in 1986, a subsample of SATSA
twins (n ⫽ 645) aged 50 and above participated in the first IPT
assessment. All previous IPT participants as well as twins who had
participated in Q1 and had turned 50 years of age since the last IPT
were invited to subsequent IPTs at rolling 3-year intervals between
1986 and 2007. The IPT sessions comprised an interview, cognitive testing, and a health examination performed by registered
nurses in a health care setting or in the participant’s own home.
The present study used data from the first questionnaire and
dementia diagnoses from IPT1 through IPT7 as well as from two
Swedish population health registers that will be described in
greater detail below.
Of the 2,018 participants who responded to Q1 Red (71%
response rate), 1,736 participants responded to Q1 Blue (86%
response rate). Those who were aged 50 years and above (n ⫽
1,509) were selected for the current analyses so that the sample
was representative of the population at risk for dementia. As
dementia is slowly progressive, those who developed the condition
within 5 years after baseline (n ⫽ 63) were excluded to reduce the
risk of including persons with dementia-related personality
changes. Participants were also excluded if they were diagnosed
with dementia prior to or at baseline Q1 (n ⫽ 24), if they died
within 5 years after baseline (n ⫽ 177), or if they had missing
information (n ⫽ 176). The exclusion of those who died shortly
after baseline was to avoid including persons experiencing changes
in personality that are associated with terminal decline. Thus, a
total of 1,069 persons (M ⫽ 64.81 years, SD ⫽ 8.25) at baseline
were followed up until diagnosis of dementia, death, or the end of
the study period.
SATSA has been approved by the Ethics Committee at Karolinska Institutet. All participants received a letter that described the
purpose, content, and duration of the SATSA study and were
assured confidentiality and anonymity as part of the informed
consent process. Participants were informed that their involvement
in the study was voluntary and that they were free to withdraw
from the study at any point in time.
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Measurement of the Type a Behavior Pattern
TABP was assessed with six scales: Ambition, Stress, Harddriving, Neuroticism, Cynicism, and Paranoia. The ambition,
stress, and hard-driving scales used items derived from the Framingham Type A scale (Haynes, Feineib, Levine, Scotch, &
Kannel, 1978) and the Bortner scale (Bortner, 1969), both of which
have been widely used as measures of TABP and tested in relation
to coronary heart disease (Smith et al., 1989). Originally a total of
16 items were used; however, five of these items were not used to
measure Type A in this study because the work-related elements of
these items would have only allowed them to be applicable to
those who were working at the time the questionnaire was distributed. Therefore, the scales were based on 11 items; five from the
Framingham scale and six based on the Bortner scale. The neuroticism scale was from a short version of the Eysenck Personality
Inventory (Floderus, 1974). The paranoid and cynicism scales
consisted of a total of 19 items from the Cook and Medley
Hostility scale (Costa, Zonderman, McCrae, & Williams, 1986),
which have been validated and found to be correlated with measures of hostility and agreeableness from the NEO personality
inventory (Barefoot, Dodge, Peterson, Dahlstrom, & Williams,
1989). Paranoia and cynicism items were included in Q1 Blue
while all other items were included in Q1 Red.
All Type A measures mentioned above were derived by summing the scores for items that corresponded with the particular
Type A trait. A high score signified a high degree of the Type A
trait, whereas a low score signified the opposite. All items except
for neuroticism items used a 5-point Likert scale response format
(1 ⫽ strongly agree, 2 ⫽ agree, 3 ⫽ neither agree nor disagree,
4 ⫽ disagree, 5 ⫽ strongly disagree). Neuroticism was based on
the sum of 9 yes–no items, in which 0 represented low neuroticism
and 9 represented high neuroticism. Cronbach’s alphas for the
scales (with the exception of the single item stress scale) were as
follows: ambition (4 items; .56), hard-driving (5 items; .54), neuroticism (9 items; .74), paranoia (10 items; .69), and cynicism (9
items; .74). Details concerning the items of each scale can be
found in the Appendix.
Dementia Diagnoses
Participants were continuously screened for dementia throughout the study. To be considered as a suspected case, at least one of
the following criteria had to be met: a score lower than 24 on the
Mini-Mental State Examination (MMSE), a decline of 3 points or
more on the MMSE since the participant’s last visit, low scores on
the cognitive tests, a history of dementia documented in their
medical records, being suspected of having dementia by the research nurses, and/or being reported of having cognitive problems
by a proxy (Gatz et al., 1997). Further, those who were nonresponders at any point were contacted and asked to respond to a
telephone-screening interview that incorporated a 10-item Mental
Status Questionnaire, other brief cognitive measures, and questions concerning health and daily functioning (Gatz, Reynolds,
Finkel, Pedersen, & Walters, 2010).
Suspected cases were diagnosed during a consensus conference
based on all available information from the IPT visit, which
included cognitive testing and nurses’ impressions, as well as
proxy interviews, and reviews of medical records. Through IPT 4,
participants suspected of cognitive impairment were invited for a
complete clinical work-up that included a full somatic and neurological evaluation, as well as a neuropsychological examination by
a physician. This information was also considered during the
consensus conference (Gatz et al., 1997). From IPT 5 and onward,
the dementia diagnoses were based upon information derived from
the aforementioned IPT visits and from information gathered from the
longitudinal follow-up of various aspects, particularly cognitive
data (Dahl et al., 2010; Gatz et al., 2010). All participants were
diagnosed according to the edition of the Diagnostic and Statistical Manual of Mental Disorders current at that time (either DSM–
III–R or DSM–IV; American Psychiatric Association, 1987, 1994).
A complete differential diagnosis of dementia was assigned based
on standard criteria for each disease entity. Participants diagnosed
with dementia were given a differential diagnosis of AD, VaD,
mixed dementia, other specific dementias such as Parkinson’s
disease dementia, dementia secondary to other conditions, or dementia not otherwise specified.
For those who were lost to IPT follow-up or for those who had
been screened but not diagnosed with dementia at least one year
before the register’s date of diagnosis, dementia status and age of
dementia ascertainment were pulled from the Cause of Death
Register (CDR) and the inpatient and outpatient records of the
National Patient Register (NPR) to classify dementia status.1 If
there was discordance between the sources, the consensus diagnoses were considered the gold standard.
CVD Measures
CVD was self-reported in the baseline questionnaire. One was
classified as having CVD if any of the following cardiovascular
conditions were present: hypertension without use of antihypertensive medication, angina pectoris, myocardial infarction, phlebitis, circulation problems in the limbs, claudication, thrombosis,
stroke, tachycardia, having a heart valve problem, and having a
heart operation. Persons with hypertension taking antihypertensive
medication were not considered as having CVD. Based upon
literature suggesting self-reported stroke as being underreported
(Englert et al., 2010), national health register diagnoses of hemorrhagic stroke and ischemic stroke that occurred before baseline
were extracted from the National Patient Register and the Cause of
The following ICD codes were used to identify dementia diagnoses:
290.0, 290.1, 290.4, 290.8, 290.9, 294.1, 331.0, 331.1, 331.2, 331.9 (ICD9); F00, F01, F02, F03, F05.1, G30, G31.1, G31.8A (ICD-10).
Death Register as a supplement to the self-reported data on CVD.2
An additional CVD variable categorized into three groups in terms
of the life threatening severity of the cardiovascular conditions as
rated previously by a five-member panel of physicians was created
(Gold, Malmberg, McClearn, Pedersen, & Berg, 2002).
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