The effects of propranolol on cognitive function and quality of life: a randomized trial among patients with diastolic hypertension

Effects of beta-blockers on quality of life and well-being in patients with myocardial infarction and preserved left ventricular function-a prespecified substudy from REDUCE-AMI

AIMS

In the Randomized Evaluation of Decreased Usage of Beta-Blockers after Acute Myocardial Infarction (REDUCE-AMI) study, long-term beta-blocker use in patients after acute myocardial infarction (AMI) with preserved left ventricular ejection fraction demonstrated no effect on death or cardiovascular outcomes. The aim of this prespecified substudy was to investigate effects of beta-blockers on self-reported quality of life and well-being.

METHODS AND RESULTS

From this parallel-group, open-label, registry-based randomized clinical trial, EQ-5D, and World Health Organization well-being index-5 (WHO-5) questionnaires were obtained at 6-10 weeks and 11-13 months after AMI in 4080 and 806 patients, respectively. We report results from intention-to-treat and on-treatment analyses for the overall population and relevant subgroups using Wilcoxon rank sum test and adjusted ordinal regression analyses. Of the 4080 individuals reporting EQ-5D (median age 64 years, 22% female), 2023 were randomized to beta-blockers. The main outcome, median EQ-5D index score, was 0.94 [interquartile range (IQR) 0.88, 0.97] in the beta-blocker group, and 0.94 (IQR 0.88, 0.97) in the no-beta-blocker group 6-10 weeks after AMI, OR 1.00 [95% CI 0.89-1.13; P > 0.9]. After 11-13 months, results remained unchanged. Findings were robust in on-treatment analyses and across relevant subgroups. Secondary outcomes, EQ-VAS and WHO-5 index score, confirmed these results.

CONCLUSION

Among patients after AMI with preserved left ventricular ejection fraction, self-reported quality of life and well-being was not significantly different in individuals randomized to routine long-term beta-blocker therapy as compared to individuals with no beta-blocker use. These results appear consistent regardless of adherence to randomized treatment and across subgroups which emphasizes the need for a careful individual risk-benefit evaluation prior to initiation of beta-blocker treatment.

Safety and tolerability of β-blockers: importance of cardioselectivity

Cardioselective β-blockade is generally well tolerated in practice and contraindications to this therapy are uncommon. β-blockers are a diverse therapeutic class, and their individual tolerability profiles are influenced strongly by their pharmacodynamic effects across different adrenergic receptors. Bisoprolol, probably the β-blocker with the highest selectivity for blockade of β1- vs. β2-adrenoceptors, does not block β2-adrenoceptors to an appreciable extent at doses in therapeutic use. Side-effects often attributed to β-blockers, such as erectile dysfunction and adverse metabolic effects are uncommon with bisoprolol and other β-blockers used at doses which only block β1-adrenoceptors. Cautious use of a cardioselective β-blocker is not contraindicated in people with chronic obstructive pulmonary disease or asthma and the outcomes benefits of β-blockers in patients with coronary heart disease or heart failure are also apparent in patients with concurrent COPD. Starting with a low dose and titrating upwards carefully is important for optimising the tolerability of a β-blocker. Most people with hypertension will receive combination antihypertensive therapy in practice, and the low-dose combination therapy approach provides a useful strategy for optimising the efficacy and tolerability of a regimen that includes a β-blocker, compared with up-titrating an existing monotherapy.

Associations between β-blockers and psychiatric and behavioural outcomes: A population-based cohort study of 1.4 million individuals in Sweden

BACKGROUND

β-blockers are widely used for treating cardiac conditions and are suggested for the treatment of anxiety and aggression, although research is conflicting and limited by methodological problems. In addition, β-blockers have been associated with precipitating other psychiatric disorders and suicidal behaviour, but findings are mixed. We aimed to examine associations between β-blockers and psychiatric and behavioural outcomes in a large population-based cohort in Sweden.

METHODS AND FINDINGS

We conducted a population-based longitudinal cohort study using Swedish nationwide high-quality healthcare, mortality, and crime registers. We included 1,400,766 individuals aged 15 years or older who had collected β-blocker prescriptions and followed them for 8 years between 2006 and 2013. We linked register data on dispensed β-blocker prescriptions with main outcomes, hospitalisations for psychiatric disorders (not including self-injurious behaviour or suicide attempts), suicidal behaviour (including deaths from suicide), and charges of violent crime. We applied within-individual Cox proportional hazards regression to compare periods on treatment with periods off treatment within each individual in order to reduce possible confounding by indication, as this model inherently adjusts for all stable confounders (e.g., genetics and health history). We also adjusted for age as a time-varying covariate. In further analyses, we adjusted by stated indications, prevalent users, cardiac severity, psychiatric and crime history, individual β-blockers, β-blocker selectivity and solubility, and use of other medications. In the cohort, 86.8% (n = 1,215,247) were 50 years and over, and 52.2% (n = 731,322) were women. During the study period, 6.9% (n = 96,801) of the β-blocker users were hospitalised for a psychiatric disorder, 0.7% (n = 9,960) presented with suicidal behaviour, and 0.7% (n = 9,405) were charged with a violent crime. There was heterogeneity in the direction of results; within-individual analyses showed that periods of β-blocker treatment were associated with reduced hazards of psychiatric hospitalisations (hazard ratio [HR]: 0.92, 95% confidence interval [CI]: 0.91 to 0.93, p < 0.001), charges of violent crime (HR: 0.87, 95% CI: 0.81 to 0.93, p < 0.001), and increased hazards of suicidal behaviour (HR: 1.08, 95% CI: 1.02 to 1.15, p = 0.012). After stratifying by diagnosis, reduced associations with psychiatric hospitalisations during β-blocker treatment were mainly driven by lower hospitalisation rates due to depressive (HR: 0.92, 95% CI: 0.89 to 0.96, p < 0.001) and psychotic disorders (HR: 0.89, 95% CI: 0.85 to 0.93, p < 0.001). Reduced associations with violent charges remained in most sensitivity analyses, while associations with psychiatric hospitalisations and suicidal behaviour were inconsistent. Limitations include that the within-individual model does not account for confounders that could change during treatment, unless measured and adjusted for in the model.

CONCLUSIONS

In this population-wide study, we found no consistent links between β-blockers and psychiatric outcomes. However, β-blockers were associated with reductions in violence, which remained in sensitivity analyses. The use of β-blockers to manage aggression and violence could be investigated further.

Prophylactic Efficacy of Riluzole against Anxiety- and Depressive-Like Behaviors in Two Rodent Stress Models

Introduction

Chronic stress-related illnesses such as major depressive disorder and post-traumatic stress disorder share symptomatology, including anxiety, anhedonia, and helplessness. Across disorders, neurotoxic dysregulated glutamate (Glu) signaling may underlie symptom emergence. Current first-line antidepressant drugs, which do not directly target Glu signaling, fail to provide adequate benefit for many patients and are associated with high relapse rates. Riluzole modulates glutamatergic neurotransmission by increasing metabolic cycling and modulating signal transduction. Clinical studies exploring riluzole's efficacy in stress-related disorders have provided varied results. However, the utility of riluzole for treating specific symptom dimensions or as a prophylactic treatment has not been comprehensively assessed.

Methods

We investigated whether chronic prophylactic riluzole (∼12-15 mg/kg/day p.o.) could prevent the emergence of behavioral deficits induced by unpredictable chronic mild stress (UCMS) in mice. We assessed (i) anxiety-like behavior using the elevated-plus maze, open-field test, and novelty-suppressed feeding, (ii) mixed anxiety/anhedonia-like behavior in the novelty-induced hypophagia test, and (iii) anhedonia-like behavior using the sucrose consumption test. Z-scoring summarized changes across tests measuring similar dimensions. In a separate learned helplessness (LH) cohort, we investigated whether chronic prophylactic riluzole treatment could block the development of helplessness-like behavior.

Results

UCMS induced an elevation in anhedonia-like behavior and overall behavioral emotionality that was blocked by prophylactic riluzole. In the LH cohort, prophylactic riluzole blocked the development of helplessness-like behavior.

Discussion/Conclusion

This study supports the utility of riluzole as a prophylactic medication for preventing anhedonia and helplessness symptoms associated with stress-related disorders.

Migraine Pharmacological Treatment and Cognitive Impairment: Risks and Benefits

Migraine is a common neurological disorder impairing the quality of life of patients. The condition requires, as an acute or prophylactic line of intervention, the frequent use of drugs acting on the central nervous system (CNS). The long-term impact of these medications on cognition and neurodegeneration has never been consistently assessed. The paper reviews pharmacological migraine treatments and discusses their biological and clinical effects on the CNS. The different anti-migraine drugs show distinct profiles concerning neurodegeneration and the risk of cognitive deficits. These features should be carefully evaluated when prescribing a pharmacological treatment as many migraineurs are of scholar or working age and their performances may be affected by drug misuse. Thus, a reconsideration of therapy guidelines is warranted. Furthermore, since conflicting results have emerged in the relationship between migraine and dementia, future studies must consider present and past pharmacological regimens as potential confounding factors.

Association between β-blocker dose and quality of life after myocardial infarction: a real-world Swedish register-linked study

BACKGROUND

β-blockers are routinely administered to patients following myocardial infarction (MI), yet their potential effect on health-related quality of life (HRQoL) is not entirely understood. We investigated the relationship between two different doses of β-blockers with HRQoL following MI.

METHODS AND RESULTS

This nationwide observational study used Swedish national registries to collate sociodemographic, clinical, medication, and HRQoL {the latter operationalized using EuroQol [European Quality of Life Five Dimensions Questionnaire (EQ-5D)]}. Estimates at 6-10 weeks and 12-14 months post-MI follow-up from pooled linear and logistic models were calculated after multiple imputation. We identified 35 612 patients with first-time MI, discharged with β-blockers, and enrolled in cardiac rehabilitation between 2006 and 2015. Upon discharge, patients were either dispensed <50% [24 082 (67.6%)] or ≥50% [11 530 (32.4%)] of the target dosage, as defined in previous trials. After adjusting for pre-defined covariates, neither the EQ-5D Index nor the Emotional Distress items were statistically different between groups. The EQ-VAS score was significantly lower in patients treated with ≥50% target β-blocker dose than those treated with <50% of the target dose [-0.87 [-1.23, -0.46], P < .001]. Results were similar at the 12-month follow-up and across sub-groups separated by sex and age.

CONCLUSION

No difference in HRQoL was found among patients taking <50% vs. ≥50% of the target β-blocker dose, except for the EQ-VAS in which higher scores were reported in those taking a lower dose. The clinical meaningfulness of this statistical significance is likely low.

Trials and Treatments for Vascular Brain Health: Risk Factor Modification and Cognitive Outcomes

There is robust evidence linking vascular health to brain health, cognition, and dementia. In this article, we present evidence from trials of vascular risk factor treatment on cognitive outcomes. We summarize findings from randomized controlled trials of antihypertensives, lipid-lowering medications, diabetes treatments (including antidiabetic drugs versus placebo, and intensive versus standard glycemic control), and multidomain interventions (that target several domains simultaneously such as control of vascular and metabolic factors, nutrition, physical activity, and cognitive stimulation etc). We report that evidence on the efficacy of vascular risk reduction interventions is promising, but not yet conclusive, and several methodological limitations hamper interpretation. Evidence mainly comes from high-income countries and, as cognition and dementia have not been the primary outcomes of many trials, evaluation of cognitive changes have often been limited. As the cognitive aging process occurs over decades, it is unclear whether treatment during the late-life window is optimal for dementia prevention, yet older individuals have been the target of most trials thus far. Further, many trials have not been powered to explore interactions with modifiers such as age, race, and apolipoprotein E, even though sub-analyses from some trials indicate that the success of interventions differs depending on patient characteristics. Due to the complex multifactorial etiology of dementia, and variations in risk factors between individuals, multidomain interventions targeting several risk factors and mechanisms are likely to be needed and the long-term sustainability of preventive interventions will require personalized approaches that could be facilitated by digital health tools. This is especially relevant during the coronavirus disease 2019 (COVID-19) pandemic, where intervention strategies will need to be adapted to the new normal, when face-to-face engagement with participants is limited and public health measures may create changes in lifestyle that affect individuals’ vascular risk profiles and subsequent risk of cognitive decline.

Association between common cardiovascular drugs and depression

Objective:

Cardiovascular diseases are associated with an increased risk of depression, but it remains unclear whether treatment with cardiovascular agents decreases or increases this risk. The effects of drugs on individual usage are also often unknown. This review aimed to examine the correlation between depression and common cardiovascular drugs, develop more potent interventions for depression in cardiovascular patients, and further research on the bio-behavioural mechanisms linking cardiovascular drugs to depression.

Data sources:

The data in this review were obtained from articles included in PubMed, EMBASE, and Web of Science.

Study selection:

Clinical trials, observational studies, review literature, and guidelines about depression and cardiovascular drugs were selected for the article.

Results:

We systematically investigated whether the seven most used cardiovascular drugs were associated with altered risk of incident depression in this literature review. Statins have been proven to have antidepressant effects. Some studies believe angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blocker (ARB) can exert an antidepressant influence by acting on the renin-angiotensin system, but further clinical trials are needed to confirm this. Beta-blockers have previously been associated with depression, but the current study found no significant association between beta blockers and the risk of depression. Aspirin may have antidepressant effects by suppressing the immune response, but its role as an antidepressant remains controversial. calcium channel blockers (CCBs) can regulate nerve signal transduction by adjusting calcium channels, but whether this effect is beneficial or harmful to depression remains unclear. Finally, some cases have reported that nitrates and diuretics are associated with depression, but the current clinical evidence is insufficient.

Conclusions:

Statins have been proven to have antidepressant effect, and the antidepressant effects of ACEIs/ARB and aspirin are still controversial. CCBs are associated with depression, but it is unclear whether it is beneficial or harmful. No association has been found with β-blockers, diuretics, and nitrates.

Pharmacological treatment of hypertension in people without prior cerebrovascular disease for the prevention of cognitive impairment and dementia

BACKGROUND

This is an update of a Cochrane Review first published in 2006 (McGuinness 2006), and previously updated in 2009 (McGuinness 2009). Hypertension is a risk factor for dementia. Observational studies suggest antihypertensive treatment is associated with lower incidences of cognitive impairment and dementia. There is already clear evidence to support the treatment of hypertension after stroke.

OBJECTIVES

To assess whether pharmacological treatment of hypertension can prevent cognitive impairment or dementia in people who have no history of cerebrovascular disease.

SEARCH METHODS

We searched the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, CENTRAL, MEDLINE, Embase, three other databases, as well as many trials registries and grey literature sources, most recently on 7 July 2020.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in which pharmacological interventions to treat hypertension were given for at least 12 months. We excluded trials of pharmacological interventions to lower blood pressure in non-hypertensive participants. We also excluded trials conducted solely in people with stroke.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected information regarding incidence of dementia, cognitive decline, change in blood pressure, adverse effects and quality of life. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 12 studies, totaling 30,412 participants, in this review. Eight studies compared active treatment with placebo. Of the four non-placebo-controlled studies, two compared intensive versus standard blood pressure reduction. The two final included studies compared different classes of antihypertensive drug. Study durations varied from one to five years. The combined result of four placebo-controlled trials that reported incident dementia indicated no evidence of a difference in the risk of dementia between the antihypertensive treatment group and the placebo group (236/7767 versus 259/7660, odds ratio (OR) 0.89, 95% confidence interval (CI) 0.72 to 1.09; very low certainty evidence, downgraded due to study limitations and indirectness). The combined results from five placebo-controlled trials that reported change in Mini-Mental State Examination (MMSE) may indicate a modest benefit from antihypertensive treatment (mean difference (MD) 0.20, 95% CI 0.10 to 0.29; very low certainty evidence, downgraded due to study limitations, indirectness and imprecision). The certainty of evidence for both cognitive outcomes was downgraded on the basis of study limitations and indirectness. Study durations were too short, overall, to expect a significant difference in dementia rates between groups. Dementia and cognitive decline were secondary outcomes for most studies. Additional sources of bias include: the use of antihypertensive medication by the placebo group in the placebo-controlled trials; failure to reach recruitment targets; and early termination of studies on safety grounds. Meta-analysis of the placebo-controlled trials reporting results found a mean change in systolic blood pressure of -9.25 mmHg (95% CI -9.73, -8.78) between treatment (n = 8973) and placebo (n = 8820) groups, and a mean change in diastolic blood pressure of -2.47 mmHg (95% CI -2.70, -2.24) between treatment (n = 7700) and placebo (n = 7509) groups (both low certainty evidence downgraded on the basis of study limitations and inconsistency). Three trials - SHEP 1991, LOMIR MCT IL 1996 and MRC 1996 - reported more withdrawals due to adverse events in active treatment groups than placebo groups. Participants on active treatment in Syst Eur 1998 were less likely to discontinue treatment due to side effects, and participants on active treatment in HYVET 2008 reported fewer 'serious adverse events' than in the placebo group. There was no evidence of a difference in withdrawals rates between groups in SCOPE 2003, and results were unclear for Perez Stable 2000 and Zhang 2018. Heterogeneity precluded meta-analysis. Five of the placebo-controlled trials provided quality of life (QOL) data. Heterogeneity again precluded meta-analysis. SHEP 1991, Syst Eur 1998 and HYVET 2008 reported no evidence of a difference in QOL measures between active treatment and placebo groups over time. The SCOPE 2003 sub-study (Degl'Innocenti 2004) showed a smaller drop in QOL measures in the active treatment compared to the placebo group. LOMIR MCT IL 1996 reported an improvement in a QOL measure at twelve months in one active treatment group and deterioration in another.

AUTHORS' CONCLUSIONS

High certainty randomised controlled trial evidence regarding the effect of hypertension treatment on dementia and cognitive decline does not yet exist. The studies included in this review provide low certainty evidence (downgraded primarily due to study limitations and indirectness) that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, leads to less cognitive decline compared to controls. This difference is below the level considered clinically significant. The studies included in this review also provide very low certainty evidence that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, prevents dementia.

Neuropsychiatric Consequences of Lipophilic Beta-Blockers

Beta-blockers are a class of drugs with important benefits in cardiovascular pathology. In this paper, we aim to highlight their adverse and therapeutic effects in the neuropsychiatric field. With respect to permeability, we would like to mention that most beta-blockers are lipophilic and can cross the blood–brain barrier. Observational studies show the presence of neuropsychiatric side effects when taking beta-blockers, and is the reason for which caution is recommended in their use in patients with depressive syndrome. From a therapeutic point of view, most current evidence is for the use of beta-blockers in migraine attacks, essential tremor, and akathisia. Beta-blockers appear to be effective in the treatment of aggressive behavior, beneficial in the prevention of posttraumatic stress syndrome and may play a role in the adjuvant treatment of obsessive–compulsive disorder, which is refractory to standard therapy. In conclusion, the relationship between beta-blockers and the central nervous system appears as a two-sided coin. Summarizing the neuropsychiatric side effects of beta-blockers, we suggest that clinicians pay special attention to the pharmacological properties of different beta-blockers.

Antihypertensive medications and sexual function in women: baseline data from the SBP intervention trial (SPRINT)

OBJECTIVES

Hypertension is a risk factor for the development of cardiovascular and kidney disease, but treatment can substantially reduce risks. Many patients avoid antihypertensive medications because of fear of side-effects. Although associations between antihypertensives and sexual dysfunction in men have been documented, it remains unclear whether antihypertensives are associated with sexual dysfunction in women. We conducted a cross-sectional analysis of baseline data from women in the Systolic Blood Pressure Intervention Trial (SPRINT) to evaluate the relations among class of antihypertensive medication and the outcomes: sexual activity and sexual function.

METHODS

SPRINT enrolled individuals 50 and older with hypertension at high risk for cardiovascular disease. A subset of participants completed questionnaires regarding quality of life, including sexual function. Antihypertensive class was determined by medications taken at baseline.

RESULTS

Of 690 women in the quality of life subset of SPRINT, 183 (26.5%) were sexually active. There were no significant differences in sexual activity among women taking one or more antihypertensives and women not taking any. Women taking an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker had higher odds of sexual activity [odds ratio 1.66 (1.12-4.27), P = 0.011]. Among sexually active women, the prevalence of sexual dysfunction was high (52.5%). No class of medication was associated with sexual dysfunction in the multivariable model.

CONCLUSION

Angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use was associated with higher odds of sexual activity. Although prevalence of sexual dysfunction was high, no single class of antihypertensive medication was associated with sexual dysfunction.

Drug-induced cognitive impairment: Effect of cardiovascular agents

INTRODUCTION

Cardiovascular agents can be associated with a negative effect on cognition, especially in older adults, critically ill people, and those with baseline cognitive impairment. Negative effect on cognition is commonly reported as uncomplicated acute confusion and delirium and, less commonly, chronic cognitive changes due to drug-induced depression and/or dementia.

METHODS

A literature review of case reports, case series, prospective cohort studies, clinical trials, and literature reviews were included in this study. Articles were located using online databases PubMed and Medline using the following keywords: antiarrhythmic agents, anticholinergic burden, antihypertensive agents, beta-blockers, cardiovascular agents, cognitive impairment, delirium, cognition, dementia, depression, digoxin, diuretics, and drug-induced cognitive impairment.

RESULTS

In general, use of all antihypertensives, especially in the case of polypharmacy or inappropriate dosing, can lead to hypotension and/or bradycardia, and thus lead to mental/cognitive status change due to decreased cerebral perfusion. Use of diuretics can be associated with fluid/electrolyte and/or acid-base imbalance, resulting in the onset of confusion and delirium. In addition, cardiovascular agents with central bioavailability, such digoxin and select antiarrhythmics, and antihypertensives may carry a risk for cognitive impairment due to various mechanisms proposed, such as antagonism of central muscarinic acetylcholine receptors, neurotransmission imbalance in the brain, and disruption of physiologic function of sodium/potassium ATPase in the neuronal cells.

DISCUSSION

When dealing with an individual who presents with acute, subacute, and chronic changes in cognitive function, one should perform a thorough medication history as the first step in order to aid in the identification of drug-induced cognitive impairment.

A review of the positive and negative effects of cardiovascular drugs on sexual function: a proposed table for use in clinical practice

Several antihypertensive drugs, such as diuretics and β-blockers, can negatively affect sexual function, leading to diminished quality of life and often to noncompliance with the therapy. Other drug classes, however, such as angiotensin II receptor blockers (ARBs) are able to improve patients' sexual function. Sufficient knowledge about the effects of these widely used antihypertensive drugs will make it possible for cardiologists and general practitioners to spare and even improve patients' sexual health by switching to different classes of cardiac medication. Nevertheless, previous data (part I) indicate that most cardiologists lack knowledge about the effects cardiovascular agents can have on sexual function and will thus not be able to provide the necessary holistic patient care with regard to prescribing these drugs. To be able to improve healthcare on this point, we aimed to provide a practical overview, for use by cardiologists as well as other healthcare professionals, dealing with sexual dysfunction in their clinical practices. Therefore, a systematic review of the literature was performed. The eight most widely used classes of antihypertensive drugs have been categorised in a clear table, marking whether they have a positive, negative or no effect on sexual function.

Hypertension and vascular dementia in the elderly: the potential role of anti-hypertensive agents

BACKGROUND

Vascular dementia (VaD) - a severe form of vascular cognitive impairment - and cognitive decline are associated with hypertension and therefore it seems logical to consider that reducing BP with anti-hypertensive therapy may protect against the development/onset of cognitive function impairment or dementia.

SCOPE

This narrative, non-systematic review discusses the available evidence on the potential correlation between the use of anti-hypertensive agents and the risk of VaD and cognitive decline.

METHODS

MEDLINE was searched for inclusion of relevant studies. No limitations in time were considered.

RESULTS

A consensus on the potential effects of anti-hypertensive treatment in the reduction of VaD and associated cognitive decline has not been reached. A protective effect of anti-hypertensive agents has been observed in a number of studies although it is still unclear whether different classes of anti-hypertensive agents have a different effect on the development of VaD.

CONCLUSIONS

The protective effect of anti-hypertensive agents appears to depend on the specific drug used - positive effects have been observed with calcium channel blockers (CCBs), such as lercanidipine and nitrendipine, the combination perindopril-indapamide and telmisartan.

[Anxiogenic and depressogenic side-effects of non-psychiatric drugs]

Although medications such as anticancer, antimicrobial, immunomodulatory, neurological or hormonal therapies may have a negative impact on mood, adequate attention was not paid until the withdrawal of rimonabant in 2008. In the present study the authors review full spectrum of currently available medications discussing anxiety and depression as possible adverse effects of treatment. A relatively high risk of depression should always be considered when pharmacotherapy applied, especially if current depressive episodes, positive family history, or neurotic personality traits increasing susceptibility to depressogenic effects. Prior to start of medical treatment, the potential effectiveness of the given drug should be precisely evaluated, and alternative medical and non-medical treatment options should also be carefully considered. In addition, monitoring patients during treatment for signs of depressive or anxious symptoms is necessary.

The use of propranolol for complicated infantile hemangiomas

OBJECTIVE

To assess propranolol efficacy and safety in complicated infantile hemangiomas in two different age groups.

PATIENTS AND METHODS

We report on 68 infants with infantile hemangiomas treated with oral propranolol at the lowest effective dose at different ages for a period of six months. Inclusion criteria were life-threatening hemangiomas, function-threatening hemangiomas, facial hemangiomas with risk for disfigurement, and extensive and ulcerated hemangiomas. A previously designed safety protocol was applied to all patients. The evolution of all hemangiomas since baseline (pre-therapy) until the end of follow-up was assessed on the basis of clinical features (color, palpable softening, size, and volume) and taken at follow-up visits.

RESULTS

Our results showed that propranolol was effective in arresting the proliferative phase and in accelerating the involution of infantile hemangiomas in 92.6% of cases. Propranolol efficacy was clear even when it was started after 12 months of life at low dose; after discontinuation of therapy there was a moderate-to-severe regrowth in 9.3% of cases and a mild regrowth in 22.5%. No adverse events were observed.

CONCLUSIONS

Propranolol should be used as first-line medical treatment in all cases of complicated infantile hemangiomas.

Psychiatric side effects of medications prescribed in internal medicine

Several pharmacological treatments used in internal medicine can induce psychiatric side effects (PSEs) that mimic diagnoses seen in psychiatry. PSEs may occur upon withdrawal or intoxication, and also at usual therapeutic doses. Drugs that may lead to depressive, anxious, or psychotic syndromes include corticosteroids, isotretinoin, levo-dopar mefloquine, interferon-a, and anabolic steroids, as well as some over-the-counter medications. PSEs are often difficult to diagnose and can be very harmful to patients. PSEs are discussed in this review, as well as diagnostic clues to facilitate their identification.

Therapeutic approaches to age-associated neurocognitive disorders

The United Nations projects that the number of individuals with dementia in developed countries alone will be approximately 36,7 million by the year 2050. International recognition of the significant emotional and economic burden of Alzheimer's disease has been matched by a dramatic increase in the development of pharmacological and nonpharmacological approaches to this illness in the past decade. Changing demographics have underscored the necessity to develop similar approaches for the remediation of the cognitive impairment associated with more benign syndromes, such as mild cognitive impairment (MCI) and age-associated cognitive decline (AACD). The present article aims to provide an overview of the most current therapeutic approaches to age-associated neurocognitive disorders. Additionally, it discusses the conceptual and methodological issues that surround the design, implementation, and interpretation of such approaches.

[Use of beta blockers in various clinical states]

INTRODUCTION

According to the convincing evidence, a decline in mortality rate has been achieved with beta-blockers in patients with an acute myocardial infarction and in post-infarction follow-up. In fact, there has been a clear reduction of sudden coronary death. The necessary condition for the efficiency of beta-blockers is an early use. They are also a medication of choice for angina after an infarction. The objective of this work was to evaluate the use of beta-blockers after a myocardial infarction in various clinical states and to eliminate doubts concerning their prescription.

BETA BLOCKERS

Even in conditions considered contraindications for administration of beta blockers such as old age, diabetes, non-Q-wave myocardial infarction, peripheral vascular disease, arterial disease, heart insufficiency; ventricular arrhythmias, renal disease, chronic obstructive pulmonary disease, asthma and depression, patients benefit from beta blockers when they are given along with a right choice of the medication and a regular followup of the patient. Preference is given to cardioselective beta blockers in patients with diabetes or lung disease. Beta-blockers do not cause long-term lipid alterations. Therefore, the matter of clinically significant alterations of lipids or blood glucose levels should not need further consideration as a problem of the treatment of diabetics.

DISCUSSION AND CONCLUSION

Investigations have proved that the use of beta-blockers reduces the development of cerebrovascular accidents, heart insufficiency and hypertension. Despite strong arguments and numerous recommendations, beta-blockers have not been accepted to a sufficient extent as an integral part of treatment of acute coronary syndrome and related diseases, to the detriment of many lost lives and in spite of favourable pharmaco-economic aspect.

Depressogenic effects of medications: a review

The literature is filled with reports that link medications with the onset or progression of depression. Because depression is so common in patients with medical illness, assessing whether a medication has in fact caused depression, or whether the relationship is coincidental, can be challenging. In this article, we review the literature on the association between medications and depression. For most agents, there are case reports or small studies linking the medication with the onset of depression, but more rigorous prospective studies are either lacking or found no association between the agent and depression. However, several medications, (eg, barbiturates, vigabatrin, topiramate, flunarizine, corticosteroids, mefloquine, efavirenz, and interferon-α) do appear to cause depression in some patients and should be used with caution in patients at risk for depression.

A review on the putative association between beta-blockers and depression

Several kinds of systematic studies have been conducted verifying the putative association between β-blockers and depressive symptoms. However, many of these studies had important limitations in their design. In most of the studies, no effect of β-blockers on depressive symptoms was seen. Because individual susceptibility cannot be ruled out, clinicians must stay vigilant, especially with patients who have a positive personal or family history and who have been prescribed lipophilic β-blockers. However, fear for depression should not be the reason for reluctance in prescribing β-blockers to cardiovascular patients.

Hypertension, dementia, and antihypertensive treatment: implications for the very elderly

A wealth of longitudinal epidemiologic evidence links high blood pressure or hypertension to cognitive decline and incident dementia. Some (but not all) studies have suggested that antihypertensive treatment is beneficial, reducing risk of decline and dementia. There are plausible mechanisms to support the possibility that hypertension may increase the risk of dementia. There is also evidence suggesting that the two dementia types thought to be most common, Alzheimer's disease and vascular dementia, have overlapping risk factors. Seven placebo-controlled trials of antihypertensive treatment have assessed cognitive function, incident dementia, or both, with mixed outcomes. The Hypertension in the Very Elderly Trial (HYVET), despite showing reductions in mortality and stroke with active treatment, found no significant reduction of incident dementia, although the trial was stopped early. Meta-analyses used to explore this area further are inconclusive, and comparative trials are now required.

The relationship between depression, anxiety, and cardiovascular outcomes in patients with acute coronary syndromes

Depression and anxiety occur at high rates among patients suffering an acute coronary syndrome (ACS). Both depressive symptoms and anxiety appear to adversely affect in-hospital and long term cardiac outcomes of post-ACS patients, independent of traditional risk factors. Despite their high prevalence and serious impact, mood and anxiety symptoms go unrecognized and untreated in most ACS patients and such symptoms (rather than being transient reactions to ACS) persist for months and beyond. The mechanisms by which depression and anxiety are linked to these negative medical outcomes are likely a combination of the effects of these conditions on inflammation, catecholamines, heart rate variability, and endothelial function, along with effects on health-promoting behavior. Fortunately, standard treatments for these disorders appear to be safe, well-tolerated and efficacious in this population; indeed, selective serotonin reuptake inhibitors may actually improve cardiac outcomes. Future research goals include gaining a better understanding of the combined effects of depression and anxiety, as well as definitive prospective studies of the impact of treatment on cardiac outcomes. Clinically, protocols that allow for efficient and systematic screening, evaluation, and treatment for depression and anxiety in cardiac patients are critical to help patients avoid the devastating effects of these illnesses on quality of life and cardiac health.

Cardiovascular and biochemical risk factors for incident dementia in the Hypertension in the Very Elderly Trial

OBJECTIVES

Several cardiovascular and biochemical factors including hypertension have been associated with cognitive decline and dementia, although both epidemiological and intervention evidence is mixed with the majority of studies examining those in midlife or younger elderly and the recent Hypertension in the Very Elderly Trial showing no significant association between blood pressure lowering and incident dementia. It has also been suggested that risk factors may differ in the very elderly. The aim of these analyses was to examine the impact of baseline cardiovascular and biochemical factors upon incident dementia and cognitive decline in a very elderly hypertensive group.

METHODS

Participants of the Hypertension in the Very Elderly Trial were aged at least 80 years and hypertensive. Cognitive function was assessed at baseline and annually with diagnostic information collected for dementia and relationships between baseline total and high-density lipoprotein cholesterol, creatinine, glucose, haemoglobin, heart failure, atrial fibrillation, diabetes, previous stroke and later dementia/cognitive decline were examined.

RESULTS

There were 3336 participants with longitudinal cognitive function data. In multivariate analyses higher creatinine was associated with a lower risk of incident dementia and cognitive decline. Higher total and lower high-density lipoprotein cholesterol were associated with lower risk of cognitive decline. Other variables were not significant.

CONCLUSIONS

In very elderly hypertensive patients heart failure, diabetes, atrial fibrillation, prior stroke, glucose and haemoglobin levels did not demonstrate a relationship with cognitive decline or dementia. Higher creatinine (excluding moderate renal impairment) was associated with a lower risk of dementia and cognitive decline. The findings for total and high-density lipoprotein cholesterol add to the varied literature in this area and together these findings may add weight to the suggestion that risk factor profiles differ in the very elderly.

Blood pressure and dementia - a comprehensive review

Alzheimer's disease (AD) and vascular dementia (VaD) are important causes of cognitive decline in the elderly. As a result of an ageing population worldwide, the incidence of dementia is expected to rise exponentially over the coming decades. Vascular risk factors are implicated in the pathogenesis of both AD and VaD. Hypertension in midlife is particularly associated with an increased risk of developing dementia. One might hope the treatment of high blood pressure in midlife would reduce the risk of developing dementia, as it does the risk of stroke. Divergent results have been reported in studies examining this effect, with the evidence suggesting that certain antihypertensives confer benefits beyond others. This implies that certain drugs may have neuroprotective properties separate to their blood pressure lowering capabilities. Recent trials have added to our understanding of these relationships.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Blood pressure and cognition in the Aberdeen 1936 birth cohort

BACKGROUND

The relationship between blood pressure and cognition in old age remains unclear. Some data indicate that elevated blood pressure causes cognitive deficits whilst others show that lower early life mental ability predicts high blood pressure in adulthood. Longitudinal studies in which mental ability earlier in life is known are needed to clarify the relationship.

OBJECTIVE

To measure the effect of blood pressure on cognition in late adulthood after adjusting for early life mental ability.

METHODS

The sample comprised survivors of the 1947 Scottish Mental Survey who had validated IQ scores at age 11. Six cognitive tests - Mini-Mental State Examination, Raven's Progressive Matrices, Rey Auditory Verbal Learning Test, Uses of Common Objects Test, Digit Symbol Test and Block Design - were administered at ages 64, 66 and 68 years. Sitting and standing blood pressure was also measured at each wave of follow-up. Mixed general linear models were constructed with each cognitive test treated as a repeated measure of an underlying cognitive trait and with wave of testing also set as a repeated measure. Mental ability at age 11 was entered as a covariate.

RESULTS

504 participants were tested at wave 1 with 368 returning at wave 2 and 300 at wave 3. Age 11 mental ability did not predict any of the blood pressure measures. There were several significant associations between blood pressure variables and cognitive test scores in univariate models. After adjusting for significant effects of wave of testing, type of cognitive test, the interaction between these, age 11 mental ability, age, gender and occupation in a multivariate model, the main effect of BP trait was no longer significant (p = 0.44) nor its effect over time (p = 0.26), though there was a significant interaction between blood pressure trait (BP) and test type with a distinctly negative effect of BP on Auditory Verbal Learning Test (p = 0.007, -0.13 points per mm Hg higher, 95% CI -0.22 to -0.033).

CONCLUSION

The effects of blood pressure on cognition in old age are finely nuanced. Multivariate repeated measures models reveal a differential effect of blood pressure on verbal recall.

Pre- and postsynaptic beta-adrenergic activation enhances excitatory synaptic transmission in layer V/VI pyramidal neurons of the medial prefrontal cortex of rats

Norepinephrine exerts an important influence on prefrontal cortical functions. The physiological effects of beta-adrenoceptors (beta-ARs) have been examined in other brain regions. However, little is known about beta-AR regulation of synaptic transmission in the prefrontal cortex (PFC). The present study investigated beta-AR modulation of glutamate synaptic transmission in layer V/VI pyramidal cells of the medial PFC (mPFC) of rats. Our results show that 1) isoproterenol (ISO), a selective beta-AR agonist, increased the frequency of spontaneous and miniature excitatory postsynaptic currents (EPSC's); 2) ISO enhancement of miniature EPSC's (mEPSC's) frequency no longer appeared in the presence of the voltage-gated Ca(2+) channel blocker cadmium; 3) ISO enhanced the evoked excitatory postsynaptic currents (eEPSC's) mediated by non-N-methyl-D-aspartic acid receptors (non-NMDA-Rs) and NMDA-Rs. The ISO facilitation of non-NMDA-R eEPSC was blocked by the membrane-permeable cyclic adenosine monophosphate (cAMP) inhibitor Rp-adenosine 3',5'-cyclic monophosphorothioate triethylammonium salt (Rp-cAMPS); 4) ISO enhanced NMDA-induced current, with no effect on glutamate-induced non-NMDA-R current; 5) ISO enhancement of NMDA-R eEPSC and NMDA-induced current was blocked by intracellular application of Rp-cAMPS or the cAMP-dependent protein kinase (PKA) inhibitor PKI(5-24); and 6) ISO suppressed the paired-pulse facilitation of non-NMDA-R and NMDA-R eEPSC's. Taken together, these results provide the first electrophysiological demonstration that beta-AR activation facilitates excitatory synaptic transmission in mPFC pyramidal cells through pre- and postsynaptic mechanisms, probably via cAMP or cAMP/PKA signaling.

Neuropsychiatric consequences of cardiovascular medications

The use of cardiovascular medications can have a variety of neuropsychiatric consequences. Many cardiovascular agents cause higher rates of fatigue and sedation than placebo, and case reports of medication-induced mood syndromes, psychosis, and cognitive disturbances exist for many cardiovascular drugs. Depression has been associated with β-blockers, methyldopa, and reserpine, but more recent syntheses of the data have suggested that these associations are much weaker than originally believed. Though low cholesterol levels have been associated with depression and suicide, lipid-lowering agents have not been associated with these adverse effects. Finally, cardiovascular medications may have beneficial neuropsychiatric consequences; for example, the use of clonidine in patients with attention deficit-hyperactivity disorder, the use of prazosin for patients with post-traumatic stress disorder, and the use of propranolol for performance anxiety and akathisia.

The influence of beta-blockers on delayed memory function in people with cognitive impairment

Adrenergic signaling is important for the retrieval of intermediate-term contextual and spatial memories. The role of norepinephrine in retrieval requires signaling through beta1-adrenergic receptors in the hippocampus. Environmental cues activate the locus ceruleus, the main adrenergic nucleus of the brain, when an environmental stimulus is memorable. This leads to norepinephrine activation in the hippocampus, which is important for retrieving memories. Although beta-blockers do not impair cognition in normal subjects, this article explores the possibility that central nervous system (CNS)-active beta-blockers could affect delayed memory in patients with cognitive impairment. The authors investigated the influence of beta-blockers on delayed memory function in cognitively impaired patients. There was a trend for worse delayed memory retrieval in patients who were on CNS-active beta-blockers. These data support the notion that common medications used in cognitively impaired elderly patients can worsen cognition and that careful selection of medications may help to maximize retrieval of newly formed memories.

The Influence of prolonged β-blockers treatment on male rabbit's sexual behavior and penile microcirculation

The aim of the study was to assess the effect of the prolonged intake of three beta-blocking drugs (propranolol, metoprolol and nebivolol) on the sexual behavior and penile microcirculation of rabbits. Drugs were administered p.o. for 9 weeks and every three weeks in each group (n=13) one subgroup (n=7) performed behavioral tests, whereas in the second subgroup (n=6) penile microcirculation was measured with a laser Doppler flowmeter. The copulation studies revealed significant impairment of sexual function only in the propranolol treated group. The measured behavioral parameters suggest that at a given dose propranolol affects more performance rather than arousal aspects of rabbits' sexual behavior. In the course of the whole study no significant difference was observed among groups in penile blood flow. The data indicate that among the beta-blockers given only propranolol interferes with sexual behavior, and that beta-blockers do not appear to have a negative effect on penile microcirculation.

Do Randomized Controlled Trials Always Trump Case Reports? A Second Look at Propranolol and Depression

STUDY OBJECTIVE

To explore reasons for discrepancies between findings from case reports and those from a meta-analysis of randomized controlled trials regarding the association between beta-adrenergic blockers and depression.

DESIGN

Systematic review.

DATA SOURCE

PubMed/MEDLINE database.

MEASUREMENTS AND MAIN RESULTS

We reviewed 24 published case reports showing an association between beta-blockers and depression and eight randomized controlled trials included in a meta-analysis of the adverse effects of these drugs. We abstracted the beta-blocker taken, patients' age and sex, diagnoses, history of depression, type of depressive symptoms reported, and method and timing of the assessment of depression. Naranjo criteria were used to evaluate the strength of evidence from each case report for a possible association between beta-blockers and depression. Twelve case reports had a Naranjo score of 5 or more (suggesting a likely causal relationship), nine of which involved propranolol. In all nine, depression began soon after treatment, and in four, the patient had a history of depression. Three randomized controlled trials assessed propranolol. Depression rates in the control groups of these studies differed substantially from each other (0-40%, p<0.0001). In only one randomized controlled trial did investigators assess depression systematically; they evaluated depression after 1 year of treatment and eliminated patients who had previously been prescribed an antidepressant.

CONCLUSION

A criterion standard to assess the true relationship between beta-blockers and depression is lacking. Factors such as the lack of systematic assessment of depression, the timing of assessments, and the selection of patients may have reduced the ability of researchers in the randomized controlled trials to detect depression as an adverse effect. Evidence from case reports should be carefully considered when relevant randomized controlled trials have not been adequately designed to detect adverse effects.

Evaluation of erectile dysfunction therapy in patients previously nonadherent to long-term medications: a retrospective analysis of prescription claims

Erectile dysfunction (ED) can lead to treatment noncompliance in patients taking medications for chronic health conditions. Using the Intelligent Health Repository, NDCHealth's longitudinal, United States health care claims database, we examined the impact of treating ED on adherence to long-term therapies in previously nonadherent patients. Male patients >or=18 years of age were identified who received antidepressant (AD), antihypertensive (AH), oral hypoglycemic (OHG), or lipid-lowering (LL) agents and initiated therapy with sildenafil citrate (Viagra) between January and June 2003. Treatment adherence was determined using medication possession ratios (MPRs) for the 12 months before and after the first prescription of sildenafil. Prior to initiation of therapy for ED with sildenafil, 64% of patients with comorbid medications were not adherent (MPR <0.8). Among these patients, 728 (27%) received AD, 2112 (78%) received AH, 984 (18%) received OHG, and 1078 (40%) received LL agents, with 66% of patients receiving multiple therapeutic classes. During the 12-month period after the first sildenafil prescription, patients had a significant increase in medication adherence compared with the 12 months before the first prescription of sildenafil (P < 0.0001). The percentage of patients who became adherent (MPR >or=0.8) with medications after sildenafil treatment was from 22% to 36%. With the exception of the LL group, there was a significant relationship between >or=3 sildenafil prescriptions and change in MPR (P < 0.05). Patients aged >or=65 years had similar improvement in MPR as patients <or=65 years. Treatment of ED with sildenafil improved adherence in patients taking common long-term medications who were previously nonadherent.

An analysis of administrative data found that proximate clinical event ratios provided a systematic approach to identifying possible iatrogenic risk factors or complications

OBJECTIVE

A method to generate hypotheses about iatrogenic risk factors and complications from administrative data was developed and tested using hospitalization of the elderly for depression as a model.

STUDY DESIGN AND SETTING

Hospital claims were selected for 30,998 elderly inpatients admitted for the first time for depression. Common principal diagnoses and procedures in hospitalizations within 90 days of the index depression admission were tallied. For each of these proximate clinical events, the ratio of how many happened before the index admission to how many occurred afterward was calculated. Ratios diverging markedly from unity were identified to generate hypotheses about possible risk factors associated with depression and complications associated with its management.

RESULTS

Hospitalization for degenerative joint disease or back problems; abdominal pain or gastritis and duodenitis; coronary artery disease; or cerebrovascular disease was more common before an index depression admission than after it, as were coronary artery surgery, total knee replacement, and cholecystectomy. Admissions for fracture of the femoral neck--an established iatrogenic complication--were disproportionately likely after the index admission. So were admissions for aspiration pneumonia or acute respiratory failure.

CONCLUSION

Proximate clinical event ratios provide a systematic approach to screening administrative data to identify candidates for further evaluation as possible iatrogenic risk factors or complications.

Differential cognitive outcomes in the Hypertensive Old People in Edinburgh study

Hypertension is associated with cognitive impairment in older adults. The Hypertensive Old People in Edinburgh (HOPE) study reported improved scores in two psychometric tests in those subjects with the greatest fall in diastolic blood pressure during a 24-week randomised, double-blind trial of captopril versus bendrofluazide in 81 elderly hypertensive people with mild cognitive impairment. Three hundred and eighty-seven of the original sample of 603 older people with and without hypertension and/or cognitive impairment from which the trial subsample was drawn were available for adequate psychometric testing 4 years later. Blood pressure was related prospectively to Raven's Progressive Matrices (RPM), a measure of fluid intelligence, but not memory differences. RPM scores were obtained at baseline, 6 weeks, 12 weeks and at the end of the randomised controlled trial. For subjects on captopril mean scores at each time point adjusted for blood pressure change were 27.6 (95% CI 25.5-29.6), 27.2 (95% CI 25.1-29.2), 28.4 (95% CI 26.6-30.3) and 28.9 (95% CI 26.9-30.9), and for bendrofluazide 27.1 (95% CI 25.1-29.0), 28.9 (95% CI 26.9-30.9), 28.9 (95% CI 27.2-30.7) and 28.7 (95% CI 26.8-30.6). There was a significant improvement in scores for those on bendrofluazide compared with captopril at week 6 (F=8.10, p=0.006, partial eta2=0.11). There were no significant effects for either drug or blood pressure at any time point for tests of memory. Future trials of the effects of antihypertensive therapy on cognition should focus more on outcomes other than memory. Early differential effects of therapeutic agents may not be maintained.

Influence of losartan and atenolol on memory function in very elderly hypertensive patients

The aim of this study was to compare the effect of the beta-adrenergic blocker atenolol and the Angiotensin II type 1 (AT1) receptor antagonist losartan on cognitive function in very elderly hypertensive patients. A total of 120 mild to moderate essential hypertensive (DBP >90 and <105 mmHg) patients, aged 75-89 years, were studied. After a 4-week wash-out period on placebo, they were randomized to receive atenolol 50 mg or losartan 50 mg for 24 weeks according to a parallel arm design. At the end of the placebo period and of each active treatment period, BP was measured (by mercury sphygmomanometer, Korotkoff I and V) and cognitive function was evaluated through three different tests (word list memory, word list recall and word list fluency). Both atenolol and losartan were equally effective in reducing SBP (-22.1 and -23.1 mmHg, respectively, P< 0.01 vs baseline) and DBP (-10.3 and -11.2 mmHg, respectively, P< 0.01 vs baseline). Atenolol treatment did not induce significant changes in any test score, whereas losartan significantly increased the score of both the word list memory (+2.2, P<0.05 vs baseline) and the word list recall test (+2.1, P<0.05 vs baseline). The comparison between losartan and atenolol was significant (P<0.05) for both memory tests. These data suggest that in very elderly hypertensive patients, chronic AT1 receptor blockade by losartan could improve cognitive function, in particular immediate and delayed memory.

Effect of Antihypertensive Agents on Quality of Life in the Elderly

Management of hypertension in the elderly should take into account, in particular, the possible negative impact of antihypertensive drugs on the patient's quality of life, the deterioration of which may result in a loss of independence and reduced treatment compliance. Quality of life is recognised as a multifactorial variable and can be subdivided into different domains (symptomatic well-being, emotional, physical, work-social, cognitive and life satisfaction), which are generally explored by means of specific questionnaires or scales. When evaluating elderly patients with hypertension, it is necessary to pay particular attention to specific domains such as symptomatic well-being, cognitive function, activity and sexual function, which have already been diminished by the age itself and the disease. The results of some large trials that specifically evaluated the quality of life effects of long-term therapy of hypertension in older people (Medical Research Council's [MRC] Trial of Hypertension in Older Adults, Systolic Hypertension in the Elderly Program [SHEP], Systolic Hypertension in Europe [Syst-Eur], Study on COgnition and Prognosis in the Elderly [SCOPE]) have shown that antihypertensive treatment as a whole either had no negative impact on quality of life, or even produced some improvement. The question whether some classes of antihypertensive agents are more beneficial or harmful than others in terms of quality-of-life effects remains largely unanswered. Results from long-term trials suggest that treatment with diuretics is not associated with adverse effects on quality of life. Nevertheless, chlortalidone and other diuretics have been more often associated with sexual dysfunction in men, including decreased libido, erectile dysfunction and difficult ejaculation, than other drug classes. Nonselective lipophilic beta-adrenoceptor antagonists, such as propranolol, have been reported to exert some negative effect on quality of life and have been associated with depression, impairment of memory function and adverse effects such as erectile problems. A less unfavourable impact has been described with beta(1)-adrenoceptor antagonists and those with vasodilating properties. Calcium channel antagonists have generally been associated with a positive effect on quality of life, although some trials have shown high rates of adverse effects and withdrawals, particularly with first-generation dihydropyridines. Concern has also been raised about the potential for adverse cognitive effects associated with the use of calcium channel antagonists, but studies on this topic are not univocal. ACE inhibitors have usually been reported to exert favourable effects on quality of life. These drugs seem to be effective in maintaining, or even improving, cognitive function through mechanisms other than blood pressure control. In addition, a number of studies reported favourable impact of ACE inhibitors on sexual function. Angiotensin II receptor antagonists have been associated with good tolerability and low withdrawal rate. They have been demonstrated not to interfere with or even improve cognitive function as well as sexual performance. Although no class of antihypertensive agents presents a clearly superior effect over the others in terms of quality of life, the current impression is that ACE inhibitors and angiotensin II receptor antagonists may offer some advantage, at least in regard to effects on cognitive function and sexual activity.

Drug Therapy in Transplant Recipients

Elderly patients with end-stage organ failure are now more frequently undergoing transplantation. Medication management in this population is challenging because of the combination of multiple comorbidities, polypharmacy, and immunological, pharmacokinetic and pharmacodynamic changes attributable to the aging process. Immunosuppressive medications can exacerbate pre-existing medical conditions and promote the development of disease processes. Cardiovascular disorders, such as hypertension, coronary artery disease, congestive heart failure and arrhythmias are common in elderly transplant recipients, and account for most of the deaths in this population. Blood pressure, blood glucose and cholesterol control is of particular concern because elderly transplant recipients frequently have or develop these complications. Elderly transplant recipients are commonly receiving anticoagulation therapy with warfarin and are at a higher risk of bleeding, especially if they have renal dysfunction. Infectious complications occur frequently in the transplanted population, with pneumonia being the most common infection seen in hospitalised patients. Attention to vaccination for the prevention of influenza and pneumococcal infections is important because of the increased risk of these diseases in this population. Depression itself has been associated with decreased survival in older individuals, and depression in elderly transplant recipients may be reversible with the administration of pharmacological agents. Effective long-term care of transplant recipients demands an understanding of how particular medications affect clinical evaluation and treatment. This article addresses some of the practical issues surrounding medication management and prevention of these particular problems in elderly transplant recipients.

Hypertension and the brain: vulnerability of the prefrontal regions and executive functions

Untreated hypertension negatively affects brain anatomy and cognitive functions, but the effects of medically treated hypertension are unclear. The authors compared 40 middle-age and older adults diagnosed with essential hypertension to demographically matched normotensive peers. Volumes of 7 brain regions and deep and periventricular white-matter hyperintensities (WMH) were measured on magnetic resonance imaging scans. Performance in 4 cognitive domains (perseveration, working memory, fluid reasoning, and vocabulary knowledge) was evaluated. Persons with hypertension had smaller prefrontal cortex and underlying white matter volumes and increased frontal WMH. No group differences were found in other examined brain regions. Among examined cognitive variables, hypertensive patients committed significantly more perseverative errors. Thus, even controlled hypertension may be associated with deficits in brain structure and cognition, warranting further study.

Beta-blockers after acute myocardial infarction in elderly patients with diabetes mellitus: time to reassess

Beta-blockers effectively reduce mortality and recurrent cardiovascular events in patients surviving myocardial infarction. However, these agents are underused in clinical practice, especially in older patients with diabetes mellitus. The current literature shows that beta-blockers are at least as effective in older diabetic patients as in other patients, without major safety concerns for their possible adverse effects. The use of these agents in clinical practice should therefore be encouraged, in order to reduce the burden of cardiovascular mortality and morbidity in older diabetic patients post-infarction.

Prevalence of depression in hospitalized patients with congestive heart failure

OBJECTIVE

Prevalence estimates of depression in hospitalized patients with congestive heart failure (CHF) differ considerably across studies. This article reports the prevalence of depression in a larger sample of hospitalized patients with CHF and identifies demographic, medical, psychosocial, and methodological factors that may affect prevalence estimates.

METHODS

A modified version of the Diagnostic Interview Schedule was administered to a series of 682 hospitalized patients with CHF to determine the prevalence of DSM-IV major and minor depression; 613 patients also completed the Beck Depression Inventory. Medical, demographic, and social data were obtained from hospital chart review, echocardiography, and patient interview.

RESULTS

In the sample as a whole, 20% of the patients met the DSM-IV criteria for a current major depressive episode, 16% for a minor depressive episode, and 51% scored above the cutoff for depression on the Beck Depression Inventory (>or=10). However, the prevalence of major depression differed significantly between strata defined by the functional severity of heart failure, age, gender, employment status, dependence in activities of daily living, and past history of major depression. For example, the prevalence ranged from as low as 8% among patients in New York Heart Association class I failure to as high as 40% among patients in class IV.

CONCLUSIONS

The prevalence of depression in hospitalized patients with CHF is similar to rates found in post-myocardial infarction patients. However, it is considerably higher in certain subgroups, such as patients with class III or IV heart failure. Further research is needed on the prognostic importance and treatment of comorbid depression in CHF.

Protective effect of anti-hypertensive treatment on cognitive function in essential hypertension: analysis of published clinical data

Hypertension is a risk factor for stroke and may also contribute to the development of vascular cognitive impairment (VCI) and vascular dementia (VaD). Cognitive complications of hypertension and the influence of anti-hypertensive treatment were underestimated until recently. In this paper, trials investigating the effect of anti-hypertensive treatment on cognitive function were evaluated. Analysis of these studies revealed that until approximately 1990-1995 investigations have assessed primarily if anti-hypertensive treatment impaired cognitive function. Only more recent studies have investigated positive effects on cognition of anti-hypertensive medication. Drugs more extensively evaluated were diuretics, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, sartanes and Ca(2+) channel blockers. Available studies have confirmed that elevated diastolic blood pressure or pulse pressure and isolated systolic hypertension play an important role in the development of cognitive impairment. Randomized placebo-controlled trials have provided evidence that reduction of hypertension safely and effectively decreases morbidity and mortality rates and cognitive complications of hypertension. Ca(2+) channel blockers and ACE inhibitors have been shown to be effective and probably better than diuretics and beta-blockers on cognitive domains of hypertension. More extensive investigations could contribute to establishing optimal choice and drug dosage for the treatment of cognitive complications of hypertension.

Systemic adverse effects of beta-adrenergic blockers: an evidence-based assessment

PURPOSE

To present an evidence-based review of the systemic adverse effects of beta-adrenergic blockers and recommend safety guidelines for use of ophthalmic beta-adrenergic blockers.

DESIGN

Literature review of published articles in peer-reviewed journals and medical texts.

METHODS

Pre-MEDLINE and MEDLINE search of relevant English language articles from 1966 to the present. Cardiovascular, pulmonary, endocrine/metabolic, central nervous system, sexual, exercise, and neuromuscular effects of systemic or ophthalmic beta-adrenergic blockers were reviewed.

RESULTS

Systemic beta-adrenergic antagonists unequivocally reduce mortality in patients with mild, moderate, and even severe congestive heart failure. Development of symptomatic bradycardia on systemic or ophthalmic beta-adrenergic blockers alone likely indicates underlying cardiac conduction disturbances. Beta 2-adrenergic blockade, regardless of route of administration, may exacerbate or trigger bronchospasm in patients with asthma or pulmonary disease associated with hyper-reactive airways. This review identifies no scientific studies supporting the development of worsening claudication, depression, hypoglycemic unawareness, or prolonged hypoglycemia in non-insulin-dependent diabetes, sexual dysfunction, or impaired neuromuscular transmission with systemic or ophthalmic beta-adrenergic blockers.

CONCLUSIONS

Many commonly presumed adverse beta-adrenergic blocker effects observed via systemic or ocular administration are not supported by published randomized clinical trials. Wide acceptance of such traditionally purported side effects has been largely due to propagation of isolated case reports and short series as well as personal communication felt to reflect expert opinion. Many more patients may be eligible to use these drugs. Obtaining a careful medical history and checking pulse rate and rhythm in the office should identify the vast majority of patients with potential cardiopulmonary contraindications.

The relationship between temporal changes in blood pressure and changes in cognitive function: atherosclerosis risk in communities (ARIC) study

BACKGROUND

Although previous epidemiological studies have reported that hypertension is a major risk factor for decline in brain perfusion and atrophy, which are known to be related to cognitive decline, the impact of temporal changes in blood pressure on age-related cognitive declines has not been assessed.

METHODS

The present study evaluates changes in blood pressure and cognitive decline over a 6-year period in the Atherosclerosis Risk in Communities (ARIC) Study. This report is based on 8,058 men and women aged 48-67 years examined in the second (1990-92), and fourth (1996-98) ARIC cohort visits. Changes between these visits were measured in hypertension status and three cognitive function tests: Delayed Word Recall (DWR), the Digit Symbol Subtest of the Wechsler Adult Intelligence Scale-Revised (DSS/WAIS-R), and the Word Fluency (WF). Adjusted mean differences in cognitive function were compared among five categories of hypertension status by using linear regression modeling.

RESULTS

In the present study, older subjects with uncontrolled hypertension had a significantly larger mean DSS/WAIS-R score decline than normotensive subjects. Although other cognitive declines did not achieve statistical significance, both cross-sectional and change analysis suggested that partially controlled or uncontrolled hypertension is associated with a less favorable cognitive profile, particularly when considering results of the DSS and the WF tests.

CONCLUSIONS

The present study results provide some support to the hypothesis that hypertension status changes over 6 years in individuals initially aged 48-67 years are related to cognitive changes.