The association of blood pressure with physical frailty and cognitive function in community-dwelling septuagenarians, octogenarians, and nonagenarians: the SONIC study

Genetically determined blood pressure, antihypertensive drug classes, and frailty: A Mendelian randomization study

Observational studies have suggested that the use of antihypertensive drugs was associated with the risk of frailty; however, these findings may be biased by confounding and reverse causality. This study aimed to explore the effect of genetically predicted lifelong lowering blood pressure (BP) through different antihypertensive medications on frailty. One-sample Mendelian randomization (MR) and summary data-based MR (SMR) were applied. We utilized two kinds of genetic instruments to proxy the antihypertensive medications, including genetic variants within or nearby drugs target genes associated with systolic/diastolic BP, and expression level of the corresponding gene. Among 298,618 UK Biobank participants, one-sample MR analysis observed that genetically proxied BB use (relative risk ratios, 0.76; 95% CI, 0.65-0.90; p = 0.001) and CCB use (0.83; 0.72-0.95; p = 0.007), equivalent to a 10-mm Hg reduction in systolic BP, was significantly associated with lower risk of pre-frailty. In addition, although not statistically significant, the effect directions of systolic BP through ACEi variants (0.72; 0.39-1.33; p = 0.296) or thiazides variants (0.74; 0.53-1.03; p = 0.072) on pre-frailty were also protective. Similar results were obtained in analyses for diastolic BP. SMR of expression in artery showed that decreased expression level of KCNH2, a target gene of BBs, was associated with lower frailty index (beta -0.02, p = 2.87 × 10-4). This MR analysis found evidence that the use of BBs and CCBs was potentially associated with reduced frailty risk in the general population, and identified KCNH2 as a promising target for further clinical trials to prevent manifestations of frailty.

Association between trajectories of systolic blood pressure and frailty outcome in middle-aged and older adults

OBJECTIVES

The association between blood pressure and frailty outcome in the middle-aged and older population remains controversial. This study aimed to examine the relationship between trajectories of systolic blood pressure (SBP) and new-onset frailty.

DESIGN

Cohort study with a 7-year follow-up.

SETTING AND PARTICIPANTS

Data were derived from 4 waves (2011, 2013, 2015 and 2018) of the China Health and Retirement Longitudinal Study and 6168 participants aged ≥45 years were included in the study.

METHODS

The frailty index (FI) was constructed based on 40 scored items, with FI ≥ 0.25 defined as frailty. We identified the 5-year trajectory of SBP by latent class trajectory modeling. The association between SBP trajectories and frailty was explored based on hazard ratios (HR) by four Cox proportional hazards models. Furthermore, we also investigated the relationship between mean SBP and systolic blood pressure variability (SBPV) and frailty.

RESULTS

6168 participants were included in this study with a mean age of 59 years. We identified five trajectories based on SBP, which are maintained low-stable SBP (T0), moderate-stable SBP (T1), remitting then increasing SBP (T2), increasing then remitting SBP (T3), and remaining stable at high SBP levels (T4). During the 7-year follow-up period, frailty outcome occurred in 1415 participants. After adjusting for other confounders, the two trajectories labeled "T2" and "T4" were associated with a higher risk of frailty compared with T0. In addition, elevated SBP and increased SBPV were associated with risk of frailty.

CONCLUSIONS

Higher risk of frailty occurred in two trajectories, remitting then increasing and remaining stable at high SBP levels, were associated with a relatively higher risk of frailty.

Hypertension facilitates age-related diseases. ~ Is hypertension associated with a wide variety of diseases?~

Hypertension, a disease whose prevalence increases with age, induces pathological conditions of ischemic vascular disorders such as cerebral infarction and myocardial infarction due to accelerated arteriosclerosis and circulatory insufficiency of small arteries and sometimes causes hemorrhagic conditions such as cerebral hemorrhage and ruptured aortic aneurysm. On the other hand, as it is said that aging starts with the blood vessels, impaired blood flow associated with vascular aging is the basis for the development of many pathological conditions, and ischemic changes in target organs associated with vascular disorders result in tissue dysfunction and degeneration, inducing organ hypofunction and dysfunction. Therefore, we hypothesized that hypertension is associated with all age-related vascular diseases, and attempted to review the relationship between hypertension and diseases for which a relationship has not been previously well reported. Following our review, we hope that a collaborative effort to unravel age-related diseases from the perspective of hypertension will be undertaken together with experts in various specialties regarding the relationship of hypertension to all pathological conditions.

Longitudinal association of hypertension and dyslipidemia with cognitive function in community-dwelling older adults: the SONIC study

The associations among cognitive function, hypertension, and dyslipidemia in older adults are controversial. Therefore, we investigated the associations among cognitive decline, hypertension, dyslipidemia, and their combination in community-dwelling older people in their 70s, 80s, and 90s in the long-term observational Septuagenarians, Octogenarians, Nonagenarians, Investigation with Centenarians (SONIC) study. We administered the Montreal Cognitive Assessment Japanese version (MoCA-J) by trained geriatricians and psychologists, and conducted blood testing and blood pressure (BP) measuring by medical staff involving 1186 participants. We performed multiple regression analysis to assess the relationships among hypertension, dyslipidemia, their combination, and lipid and BP levels with cognitive function at the 3-year follow-up after adjusting for covariate factors. At the baseline, the percentage of the combination of hypertension and dyslipidemia was 46.6% (n = 553), hypertension was 25.6% (n = 304), dyslipidemia was 15.0% (n = 178), and that without hypertension or dyslipidemia was 12.7% (n = 151). Conducting multiple regression analysis, no significant correlation was found between the combination of hypertension and dyslipidemia and MoCA-J score. In the group with the combination, high high-density lipoprotein cholesterol (HDL) levels resulted in higher MoCA-J scores at the follow-up (β = 0.06; P < 0.05) and high diastolic BP (DBP) also resulted in higher MoCA-J scores (β = 0.08; P < 0.05). The results suggest that high HDL and DBP levels of individuals with HT & DL and high SBP levels of individuals with HT were associated with cognitive function in community-dwelling older adults. In the SONIC study, which is an epidemiological study of Japanese older persons aged 70 years or older, a disease-specific examination suggested that high HDL and DBP levels of individuals with hypertension & dyslipidemia and high SBP levels of individuals with hypertension were associated with maintaining cognitive function in community-dwelling older adults.

Treatment of hypertension and obstructive sleep apnea counteracts cognitive decline in common neurocognitive disorders in diagnosis-related patterns

The aim of this study was to investigate the effect of arterial hypertension (AH) and of obstructive sleep apnea (OSA) on cognitive course in the neurocognitive disorder (NCD) cohort RIFADE which enrolled patients with NCD due to Alzheimer's disease (AD), vascular NCD (vNCD), and mixed NCD (AD + vNCD = mNCD). Multiple risk factors (RF), including AH and OSA, that contribute to the development of various kinds of dementia have been identified in previous studies. Studies that observed AH lacked investigation of long-term effects and did not isolate it from other RF. Studies involving OSA as a risk factor did not include participants with all stages of NCD. 126 subjects were screened for AH and OSA. Repeated cognitive measurements were performed with the DemTect as primary outcome and the clock drawing test as secondary outcome measure. 90 patients had AH (71.4%) and 40 patients had OSA (31.7%). RF-status had a significant effect on cognitive outcome in models with RF as single factors (AH p = 0.027, OSA p < 0.001), a 2-factor analysis with AH × OSA (AH as main factor p = 0.027) as well as a model including the 3 factors AH × OSA × diagnosis (p = 0.038). Similarly, a 3-factor model was significant for the clock-drawing test, whereas single factor-models remained insignificant. AH and OSA appear to be risk factors in common NCD and cognitive decline can be mitigated by treatment of these RF.

Factors associated with weight loss by age among community-dwelling older people

BACKGROUND

Factors associated with weight loss in community-dwelling older people have been reported in several studies, but few studies have examined factors associated with weight loss by age groups. The purpose of this study was to clarify factors associated with weight loss by age in community-dwelling older people through a longitudinal study.

METHODS

Participants in the SONIC study (Longitudinal Epidemiological Study of the Elderly) were community-dwelling people aged 70 or older. The participants were divided into two groups: 5% weight loss and maintenance groups, and compared. In addition, we examined factors affecting weight loss by age. The analysis method used was the χ² test, and the t-test was used for comparison of the two groups. Factors associated with 5% weight loss at 3 years were examined using logistic regression analysis with sex, age, married couple, cognitive function, grip strength, and the serum albumin level as explanatory variables.

RESULTS

Of the 1157 subjects, the proportions showing 5% weight loss after 3 years among all subjects, those aged 70 years, 80 years, and 90 years, were 20.5, 13.8, 26.8, and 30.5%, respectively. In logistic regression analysis, factors associated with 5% weight loss at 3 years by age were influenced by BMI of 25 or higher (OR = 1.90, 95%CI = 1.08-3.34, p = 0.026), a married couple (OR = 0.49, 95% = 0.28-0.86, p = 0.013), serum albumin level below 3.8 g/dL (OR = 10.75, 95% = 1.90-60.73, p = 0.007) at age 70, and the grip strength at age 90 (OR = 1.24, 95%CI = 1.02-1.51, p = 0.034), respectively.

CONCLUSIONS

The results suggest that factors associated with weight loss by age in community-dwelling older people through a longitudinal study differ by age. In the future, this study will be useful to propose effective interventions to prevent factors associated with weight loss by age in community-dwelling older people.

Current topics of frailty in association with hypertension and other medical conditions

Frailty is a state of increased vulnerability to stress resulting from physiological decline associated with aging. Topics of hypertension management and its association with frailty and cognitive function, recent studies of coronavirus disease 2019 infection (COVID-19) in elderly is discussed in this narrative review. While various guidelines for hypertension recommend that frailty is taken into account in treatment decisions, specific assessment tools and clinical decision criteria have not been explicitly established. Hypertension is prevalent in frail individuals, although a direct association has not been reported. Therefore, optimal blood pressure (BP) control is critical for managing cardiovascular risk reduction and preserving quality of life in frail hypertensive patients. BP typically decreases in later life or situations in which patients are dependent on nursing care. Mortality is reported to be high among frail patients with lower BP, raising questions about appropriate BP targets for frail patients. Cognitive decline is one of the domains of frailty, and is associated with a loss of autonomy, lack of self-management, and compromised quality of life. It remains to be clarified whether antihypertensive treatment is beneficial for cognitive function especially in older individuals. Increased severity and mortality of COVID-19 infection has been reported in older people. Clinical manifestations and biomarkers particular to older patients, and lifestyle changes including social isolation during the COVID-19 pandemic is reported. From the knowledge from recent literatures, future perspectives for holistic approach and management of frail older people is addressed.

Self-Monitoring Home Blood Pressure in Community-Dwelling Older People: Age Differences in White-Coat and Masked Phenomena and Related Factors—The SONIC Study

Some studies reported that home blood pressure (HBP) monitoring was conducted by community-dwelling older people themselves, but there have been few studies on HBP including very old populations aged over 90 years old. Thus, the aim of the present study was to clarify the current situation of white-coat and masked phenomena defined by on-site and home BP measurements in community-dwelling old and oldest-old populations. The study subjects were 380 participants from the SONIC study, a cohort study of a community-dwelling old population, who measured their HBP in a series of 3–5 days by themselves and brought their HBP records to the venue on the survey day. Study participants' characteristics were as follows: female, 185 (48.7%); male, 195 (51.3%); 70s, 95 (25.0%); 80s, 245 (64.5%); and 90s, 40 (10.5%). A total of 344 (90.5%) participants had hypertension. A total of 291 (76.6%) hypertensive participants taking antihypertensive medication were analyzed in the present study. Regarding the types of hypertension defined by home and on-site BP, they showed white-coat phenomenon, 183 (48.2%); masked phenomenon, 115 (30.3%); sustained hypertension, 130 (34.2%); and normotension, 82 (21.6%). On comparison of age groups, there was a tendency for the white-coat phenomenon to be common in young-old people in their 70s and the masked phenomenon to be common in very old people in their 90s. Therefore, since the detection of white-coat and masked phenomena is closely associated with appropriate BP management, it is very important for community-dwelling older populations to self-monitor HBP.

Association between control status of blood pressure and frailty among middle-aged and older adults with hypertension in China: a longitudinal study

OBJECTIVE

To assess the association between blood pressure (BP) control and frailty among middle-aged and older populations with hypertension in China from 2013 to 2018.

DESIGN

Prospective longitudinal study.

SETTING

This study analysed data from the China Health and Retirement Longitudinal Study, a nationally representative survey administered in 28 provinces of China.

PARTICIPANTS

A total of 3254 participants diagnosed with hypertension previous to 2013 were taken into analysis. 1932 participants who were not frail in 2013 were enrolled to calculate relative risk.

OUTCOME MEASURES

The frailty score was constructed following Rookwood's Cumulative deficit frailty index, with a score >0.25 defined as frailty (outcome variable). The self-reported status of BP control (exposure variable) represented the general status of the participant's BP level. A fixed-effects model was used to analyse the association between BP control and frailty. A Cox proportional hazard model was further used to further calculate the relative risk of frailty for different BP control levels.

RESULTS

The fixed-effects model showed that compared with well-controlled BP, poorly controlled BP exhibited a positive association with frailty score (β=0.015; 95% CI 0.011 to 0.019; p<0.001). The Cox proportional hazard model also revealed a higher risk of frailty in the poorly controlled group (HR=1.96; 95% CI 1.49 to 2.56; p<0.001). Based on subgroup analyses, poorly controlled BP was positively associated with frailty in respondents aged <60 years old (fix-effects model: β=0.015, p=0.021; Cox model: HR=2.25, p<0.001), but not significant among those aged ≥75 years old.

CONCLUSIONS

We provide new evidence of a negative association between BP control and frailty risk, but the findings differ among different age groups. Individualised strategies for BP management should be developed, especially for older hypertension patients.

Blood pressure, frailty status, and all-cause mortality in elderly hypertensives; The Nambu Cohort Study

Antihypertensive therapy is pivotal for reducing cardiovascular events. The 2019 Guidelines for the Management of Hypertension set a target blood pressure (BP) of <140/90 mmHg for persons older than 75 years of age. Optimal BP levels for older persons with frailty, however, are controversial because evidence for the relationship between BP level and prognosis by frailty status is limited. Here, we evaluated the relationship between systolic BP and frailty status with all-cause mortality in ambulatory older hypertensive patients using data from the Nambu Cohort study. A total of 535 patients (age 78 [70-84] years, 51% men, 37% with frailty) were prospectively followed for a mean duration of 41 (34-43) months. During the follow-up period, 49 patients died. Mortality rates stratified by systolic BP and frailty status were lowest in patients with systolic BP < 140 mmHg and non-frailty, followed by those with systolic BP ≥ 140 mmHg and non-frailty. Patients with frailty had the highest mortality regardless of the BP level. The adjusted hazard ratios (95% confidence intervals) of each category for all-cause mortality were as follows: ≥140 mmHg/Non-frailty 3.19 (1.12-11.40), <140 mmHg/Frailty 4.72 (1.67-16.90), and ≥140 mmHg/Frailty 3.56 (1.16-13.40) compared with <140 mmHg/Non-frailty as a reference. These results indicated that frail patients have a poor prognosis regardless of their BP levels. Non-frail patients, however, with systolic BP levels <140 mmHg had a better prognosis. Frailty may be a marker to differentiate patients who are likely to gain benefit from antihypertensive medication among older hypertensives.

[The usefulness of a questionnaire during medical examinations for older subjects in evaluating frailty: Utilization in clinical practice]

AIM

The late-stage medical care system for older people provides medical examinations, including questionnaires for frailty. We examined whether or not this approach is useful in clinical practice.

METHODS

We used this questionnaire for the screening of frailty as follows: according to the manual prepared by the Japan Geriatrics Society, each question was classified as concerning oral (Q4, 5), physical (Q6-9), cognitive (Q10, 11), or social (Q13-15) frailty. Each frailty was defined if there was at least one negative answer in each question. The grip power and skeletal muscle index (SMI) according to a bioelectrical impedance analysis were also evaluated. Subjects who showed a reduced grip strength and SMI were defined as having sarcopenia, and those who showed only a reduced grip strength were defined as having possible sarcopenia.

RESULTS

One hundred and seventy-one subjects aged 81.0±4.2 years old (63.1% female) were enrolled. A total of 12.3% of subjects showed sarcopenia, and 17.5% showed possible sarcopenia. The prevalence of physical, cognitive, and social frailties was associated with sarcopenia. Oral frailty, defined as having decreased swallowing and mastication functions (Q4 and 5), was significantly related to sarcopenia. Physical frailty was associated with age. In patients with hypertension, a low incidence of cognitive frailty was found. Social frailty was related to a decreased body weight.

CONCLUSIONS

A questionnaire during medical examinations for older subjects may be useful for screening various frailties and may lead to promotion of the preventive care activities in the community. Further studies are needed to elucidate the relationship between each type of frailty and background characteristics.

[Seasonal changes in blood pressure and related factors among older patients receiving home medical care]

AIM

We investigated seasonal variations in blood pressure (BP) and factors related to these variations among older patients receiving home medical care.

METHOD

A total 57 patients ≥ 65 years old receiving home medical care who participated in the Osaka Home Care REgistry study (OHCARE), a prospective cohort study, were included. We investigated the seasonal patient characteristics and variations in the BP. In addition, to determine the influence of seasonal variations in the systolic blood pressure (SBP) on the occurrence of clinical events (hospitalization, falls and death), we classified patients into larger- and smaller- change groups based on the median seasonal variations in SBP.

RESULT

About 60% of subjects were very frail or bedridden. The mean BP was higher in winter than in summer (124.7±11/69.5±7 vs.120.5±12/66.9±8 mmHg) (P< 0.01). On comparing the characteristics of the two groups with larger and smaller changes in the SBP, the group with large BP changes had a significantly lower BP in summer than the group with small BP changes. In addition, the incidence of "hospitalization" was significantly higher in the group with large BP changes than in the group with small BP changes (P = 0.03).

CONCLUSION

The present study revealed that there were seasonal changes in the BP in older patients receiving home medical care. It was also suggested that seasonal changes in the BP might be associated with the risk of hospitalization events. Given these BP variations, doctors and visiting nurses should be alert for systemic abnormalities, especially in frail patients receinving home medical care.

Blood pressure, frailty and dementia

High blood pressure (BP) affects 75% of people aged over 70. Ageing alters BP homeostasis, resulting in postural hypotension and increased BP variability. Co-morbidity and frailty add complexity to understanding BP changes in later life. Longitudinal BP declines are likely driven by accumulating co-morbidity and are accelerated in both frailty and dementia. This narrative review summarises what is known about the association between BP and frailty, the clinical management of BP in frailty and the association between BP, cognitive decline and dementia.

The relationship between blood pressure and cognitive function

Background

Although an elevated systolic blood pressure (SBP) is associated with cognitive dysfunction, BP may decrease with advanced cognitive dysfunction; therefore, we attempted to identify the turning point in the relationship between cognitive function and SBP in elderly subjects.

Methods

In pooled datasets of general populations and outpatient clinics (age>65 years), in which the risk of frailty or cognitive dysfunction was assessed (N = 4076), the relationship between SBP and the Mini Mental State Examination (MMSE) score was examined.

Results

Mean age was 72.5 ± 6.2 years (male 45.1%), and SBP was 133.0 ± 19.5 mmHg. In an analysis of locally weighted scatter plot smoothing, the relationship between SBP and MMSE scores changed at an MMSE score of 24 points. In subjects with preserved cognitive function (MMSE ≥24 points), MMSE scores decreased with increases in SBP (B = −0.047 per 10 mmHg increase, P = 0.002) after adjustments for age, sex, body mass index, alcohol habit, smoking status, diabetes, a history of stroke, and the geriatric nutritional index; however, in subjects with reduced cognitive function (MMSE<24 points), decreases in the MMSE score were associated with reductions in SBP (B = 1.178 per 1 point decrease in the MMSE score, P = 0.002).

Conclusion

The relationship between SBP and cognitive function changed at a MMSE score of approximately 24 points (mild to moderate cognitive dysfunction). In patients with preserved MMSE, higher BP values were associated with a reduction of cognitive function, but this was not a case for those with impaired MMSE.