Blood pressure variability and cognitive decline in older people: a 5-year longitudinal study

Association of longitudinal changes in 24-h blood pressure level and variability with cognitive decline

OBJECTIVE

A high office blood pressure (BP) is associated with cognitive decline. However, evidence of 24-h ambulatory BP monitoring is limited, and no studies have investigated whether longitudinal changes in 24-h BP are associated with cognitive decline. We aimed to test whether higher longitudinal changes in 24-h ambulatory BP measurements are associated with cognitive decline.

METHODS

We included 437 dementia-free participants from the Maracaibo Aging Study with prospective data on 24-h ambulatory BP monitoring and cognitive function, which was assessed using the selective reminding test (SRT) and the Mini-Mental State Examination (MMSE). Using multivariate linear mixed regression models, we analyzed the association between longitudinal changes in measures of 24-h ambulatory BP levels and variability with cognitive decline.

RESULTS

Over a median follow-up of 4 years (interquartile range, 2-5 years), longitudinal changes in 24-h BP level were not associated with cognitive function (P ≥ 0.09). Higher longitudinal changes in 24-h and daytime BP variability were related to a decline in SRT-delayed recall score; the adjusted scores lowered from -0.10 points [95% confidence interval (CI), -0.16 to -0.04) to -0.07 points (95% CI, -0.13 to -0.02). We observed that a higher nighttime BP variability during follow-up was associated with a decline in the MMSE score (adjusted score lowered from -0.08 to -0.06 points).

CONCLUSION

Higher 24-h BP variability, but not BP level, was associated with cognitive decline. Prior to or in the early stages of cognitive decline, 24-h ambulatory BP monitoring might guide strategies to reduce the risk of major dementia-related disorders including Alzheimer's disease.

Hypotension and cognitive impairment among the elderly: Evidence from the CLHLS

BACKGROUND

While high blood pressure has been linked to cognitive impairment, the relationship between low blood pressure, especially hypotension, and cognitive impairment has not been well studied. Therefore, this study aimed to assess the prevalence of hypotension and cognitive impairment in the seniors of China, and the association between hypotension and cognitive function impairment.

METHODS

The data was derived from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Systolic blood pressures (SBP) and diastolic blood pressures (DBP) were measured by objective examination. The Chinese version of the Mini-Mental State Examination (CMMSE) was used to evaluate the cognitive impairment of the elderly. Generalized linear models were conducted to evaluate the association of hypotension with cognitive impairment.

RESULTS

The prevalence of hypotension and cognitive impairment in the Chinese elderly were 0.76% and 22.06%, respectively. Participants with hypotension, lower SBP, and lower DBP, had odds ratios of 1.62, 1.38, and 1.48 for cognitive impairment, respectively. Besides, the CMMSE scores decreased by 2.08, 0.86, and 1.08 in the elderly with hypotension, lower SBP, and DBP, compared with those with non-hypotension, higher SBP, and DBP, respectively. Subgroup analyses showed that the association of cognitive impairment with hypotension was stronger in Chinese elderly who had decreased activity of daily living. Moreover, there was statistical evidence of a nonlinear dose-response relationship of SBP and DBP with cognitive impairment (Pnonlinear < 0.05).

CONCLUSION

Hypotension was a potential risk factor for cognitive impairment of the Chinese elderly, especially for those having decreased activity of daily living. Blood pressure management should be conducted to prevent them from cognitive impairment.

Cross-sectional associations between short and mid-term blood pressure variability, cognition, and vascular stiffness in older adults

Background

High blood pressure variability (BPV), particularly in older age, appears to be an independent risk factor for incident dementia. The current study aimed to investigate the association between different BPV measures (short- and mid-term BPV including circadian patterns) and cognitive functioning as well as vascular stiffness measures to better understand the role that BPV plays in cognitive impairment.

Methods

70 older adults (60-80-year-olds) without dementia completed a cognitive test battery and had their blood pressure (BP) assessed via a 24-hour ambulatory BP monitor (divided into sleep and wake for short-term BPV) and 4-day morning and evening home-based BP monitor (for day-to-day BPV). Arterial stiffness was evaluated via pulse wave analysis and pulse wave velocity (PWV) and cerebrovascular pulsatility was assessed via transcranial doppler sonography of the middle cerebral arteries.

Results

High systolic as well as diastolic short- and mid-term BPV were associated with poorer cognitive functioning, independent of the mean BP. Higher short-term BPV was associated with poorer attention and psychomotor speed, whilst day-to-day BPV was negatively linked with executive functioning. Circadian BP patterns (dipping and morning BP surge) showed no significant relationships with cognition after adjusting for covariates. Higher systolic short-term BPV was associated with higher arterial stiffness (PWV) and higher diastolic day-to-day BPV was linked with lower arterial stiffness. No significant associations between BPV measures and cerebrovascular pulsatility were present.

Conclusion

High BPV, independently of the mean BP, is associated with lower cognitive performance and increased arterial stiffness in older adults without clinically-relevant cognitive impairment. This highlights the role of systolic and diastolic BPV as a potential early clinical marker for cognitive impairment.

The impact of blood pressure variability on cognition: current limitations and new advances

Dementia is the most common neurodegenerative disease in the aging population. Emerging evidence indicates that blood pressure (BP) variability is correlated with cognitive impairment and dementia independent of mean BP levels. The state-of-the-art review summarizes the latest evidence regarding the impact of BP variability on cognition in cognitively intact populations, patients with mild cognitive impairment, and different dementia types, focusing on the important confounding factors and new advances. This review also summarizes the potential mechanisms underlying the relationship between BP variability and cognitive impairment, and dementia, briefly discussing sex differences in the relationship. At last, current limitations and future perspectives are discussed to optimize BP management in preventing cognitive impairment and dementia.

Do cardiovascular disease comorbidities affect the cognitive function of Multiple Sclerosis patients?

INTRODUCTION

Cognitive impairment is a core symptom of multiple sclerosis, leading to disability in 40-70% of patients. The most common cognitive domains affected by MS are information processing speed, complex attention, executive functions and less frequently, episodic declarative memory. Cardiovascular disease comorbidities have been shown to increase the decline rate in many neurological conditions. Our study aims to examine the possible impact of CVD risk factors in the cognitive decline rate of PwMS.

METHODS

Over the course of a year, 248 PwMS with and without Cardiovascular comorbidity were cognitively evaluated using the written version of SDMT and the MoCA.

RESULTS

Compared to control, MS patients with comorbid CVD had greater general cognitive decline and decreased processing speed. Patients with comorbid diabetes and dyslipidemia had the highest impairment, followed by those with hypertension, compared to the control group and those patients with a high BMI.

CONCLUSION

The presence of cardiovascular comorbidities and especially dyslipidemia increases the rate of cognitive decline in MS patients. In such cases, patients should be evaluated every 6 months instead of a year and the use of the SDMT is advised since it's time efficient,it requires minimal training and correlates with MRI findings.

Association between ambulatory blood pressure monitoring patterns with cognitive function and risk of dementia: a systematic review and meta-analysis

BACKGROUND

The objective of this systematic review and meta-analysis is to investigate whether nocturnal blood pressure fall, expressed by dipping patterns according to 24 h ambulatory blood pressure monitoring (ABPM), is associated with abnormal cognitive function (cognitive impairment or dementia).

METHODS

We systematically searched PubMed, Embase, and Cochrane databases to identify original articles through December 2022. We included any study with at least ten participants reporting on all-cause dementia or cognitive impairment incidence (primary outcome) or validated cognitive tests (secondary outcome) among ABPM patterns. We assessed risk of bias using Newcastle-Ottawa Quality Assessment Scale. We pooled odds ratios (OR) and standardized mean differences (SMD) using random-effect models for primary and secondary outcome, respectively.

RESULTS

In the qualitative synthesis, 28 studies examining 7595 patients were included. The pooled analysis of 18 studies showed that dippers had a 51% [OR 0.49(0.35-0.69)] lower risk of abnormal cognitive function and a 63% [OR 0.37(0.23-0.61)] lower risk of dementia alone, compared to non-dippers. Reverse dippers presented an up to sixfold higher risk [OR 6.06(3.15-11.64)] of abnormal cognitive function compared to dippers and an almost twofold higher risk [OR 1.81(1.26-2.6)] compared to non-dippers. Reverse dippers performed worse in global function neuropsychological tests compared with both dippers [SMD - 0.66(- 0.93 to - 0.39)] and non-dippers [SMD - 0.35(- 0.53 to - 0.16)].

CONCLUSION

Dysregulation of the normal circadian BP rhythm, specifically non-dipping and reverse dipping is associated with abnormal cognitive function. Further studies are required to determine potential underlying mechanisms and possible prognostic or therapeutic implications.

PROTOCOL REGISTRATION

PROSPERO database (ID: CRD42022310384).

Sex Differences in the Association Between Metabolic Dysregulation and Cognitive Aging: The Health and Retirement Study

BACKGROUND

Dysregulation of some metabolic factors increases the risk of dementia. It remains unclear if overall metabolic dysregulation, or only certain components, contribute to cognitive aging and if these associations are sex specific.

METHODS

Data from the 2006-2016 waves of the Health and Retirement Study (HRS) was used to analyze 7 103 participants aged 65 and older at baseline (58% women). We created a metabolic-dysregulation risk score (MDRS) composed of blood pressure/hypertension status, glycosylated hemoglobin (HbA1c)/diabetes status, total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and waist circumference, and assessed cognitive trajectories from repeated measures of the HRS-Telephone Interview for Cognitive Status (HRS-TICS) over 10 years of follow-up. Linear mixed-effects models estimated associations between MDRS or individual metabolic factors (biomarkers) with mean and change in HRS-TICS scores and assessed sex-modification of these associations.

RESULTS

Participants with higher MDRSs had lower mean HRS-TICS scores, but there were no statistically significant differences in rate of decline. Sex stratification showed this association was present for women only. MDRS biomarkers revealed heterogeneity in the strength and direction of associations with HRS-TICS. Lower HRS-TICS levels were associated with hypertension, higher HbA1c/diabetes, and lower HDL-C and TC, whereas faster rate of cognitive decline was associated with hypertension, higher HbA1c/diabetes, and higher TC. Participants with higher HbA1c/diabetes presented worse cognitive trajectories. Sex differences indicated that women with higher HbA1c/diabetes to have lower HRS-TICS levels, whereas hypertensive males presented better cognitive trajectory.

CONCLUSIONS

Our results demonstrate that metabolic dysregulation is more strongly associated with cognition in women compared with men, though sex differences vary by individual biomarker.

Association of cardiometabolic health factors with age-related executive function and episodic memory

Although decline of cognitive abilities in late life is regarded as a common facet of aging, there is inter-individual variability in this decline. Possible contributors are cardiometabolic risk factors associated with cerebrovascular dysfunction, but a dearth in unifying health-cognition models confound exactly how these risk factors mediate age-related changes in executive function (EF) and episodic memory. This study investigated the indirect effect of age on these cognitive abilities via cardiometabolic risk factors using a structural equation modeling approach. Participants included 738 adults (64% female) ranging from 21 to 85 years of age (M = 47.47, SD = 18.28). An exploratory factor analysis was applied to an EF battery yielding a two-factor solution, consisting of inhibition and cognitive flexibility, that showed acceptable fit (χ2(48) = 101.84, p < .001, CFI = .980, RMSEA = .039, SRMR = .035). The EF latent factors were then included in a confirmatory factor analysis exploring the indirect role of age on episodic memory and EF via blood pressure, cholesterol, triglycerides and body mass index. The theoretical model demonstrated acceptable fit, χ2(108) = 204.071, p < .001, CFI = .972, RMSEA = .035, SRMR = .035. Blood pressure was associated with lower cognitive flexibility (β = -.20, p < .001) and there was a significant indirect effect of age on episodic memory through cognitive flexibility (β = .07, p = .021). Results support the "Executive Decline Hypothesis" of age-related episodic memory decline and specifically implicate lower blood pressure control and cognitive flexibility in these changes.

Association of blood pressure variability with short- and long-term cognitive outcomes in patients with critical illness

BACKGROUND

Blood pressure variability (BPV), a modifiable risk factor, can compromise cerebral perfusion in critically ill patients. We studied the association between BPV in the intensive care unit (ICU) and short- and long-term cognitive outcomes.

METHODS

All patients were ≥50 years old. The short-term cognitive end points were delirium and depressed alertness without delirium. The long-term outcome was change in the slope of longitudinal cognitive scores. Primary BPV measure was average real variability (ARV) of systolic blood pressure. Associations were assessed with multivariable multinominal logistic regression and linear mixed effects models.

RESULTS

Of 794 patients (1130 admissions) 185 developed delirium and 274 developed depressed alertness. There was a dose-response association of 24-h systolic ARV with delirium (adjusted OR, 95% CI 2.15 per 5 mm Hg increase, 1.31-3.06, P < 0.017) and with depressed alertness (OR 1.89, 95% CI 1.18-3.03, P < 0.008). For 371 patients with available longitudinal cognitive scores, the decline in cognitive trajectory was accelerated after discharge (annual change OR -0.097, 95% CI -0.122 to -0.073). This acceleration increased with delirium (additional decline -0.132 [-0.233 to 0.030], P = 0.011). We found no significant association between BPV and post-ICU cognitive trajectory.

CONCLUSIONS

BPV was associated with increased likelihood of delirium in the ICU. Delirium, but not BPV, was associated with long-term cognitive decline.

Blood Pressure Variability and Cognitive Function: a Scoping Review

PURPOSE OF REVIEW

To conduct a scoping review of articles which have evaluated BPV and cognitive function. Articles with keywords, titles or abstracts containing the terms 'cognitive' OR 'cognition' OR 'dementia' AND 'blood pressure variability' were identified from CINAHL, Medline, PMC and Web of Science.

RECENT FINDINGS

Methods of acquisition and analysis of BPV and cognitive measurements and their relationship were extracted from selected articles. Of 656 studies identified, 53 articles were selected. Twenty-five evaluated long-term (LTBPV), nine mid-term (MTBPV), 12 short-term (STBPV) and nine very short-term BPV (VSTBPV) with conflicting findings on the relationship between BPV and cognition. Variations existed in devices, period and procedure for acquisition. The studies also utilized a wide range of methods of BPV calculation. Thirteen cognitive assessment tools were used to measure global cognition or domain functions which were influenced by the population of interest. The interpretation of available studies was hence limited by heterogeneity. There is an urgent need for standardization of BPV assessments to streamline research on BPV and cognition. Future studies should also establish whether BPV could be a potential modifiable risk factor for cognitive decline, as well as a marker for treatment response.

Blood pressure variability and structural brain changes: a systematic review

BACKGROUND

Blood pressure variability (BPV) has been linked with cognitive impairment and dementia. However, the pathophysiological mechanisms by which BPV affects cognition are unclear. This systematic review aims to assess the links between different BPV measures and white and grey matter structures.

METHODS AND RESULTS

The following databases were searched from inception through to January 2021; EMBASE, MEDLINE, EMCARE and SCOPUS. Studies that reported on the relationship between within-individual BPV (short, medium or long-term variability) or a circadian blood pressure (BP) measurement and MRI assessed brain structures were included. Overall, 20 studies met the criteria and were included, of which 11 studies looked at short-term BPV, eight articles investigated visit-to-visit BPV and one study looked at a compositional BPV measurement. Due to heterogeneity in study samples, meta-analysis was not possible. Across the included studies, associations between MRI indices and BP dipping patterns were mixed; higher long-term BPV and higher sleep systolic BPV was found to be associated with lower whole brain volume and hippocampal volume.

CONCLUSION

Increased BPV, in particular systolic long-term and systolic night-time BPV, appears to be associated with lower brain volume and hippocampal volume. This highlights the adverse effect that increased BPV has upon the brain, potentially contributing to cognitive decline, including dementia, in late-life.

Annual Incidence of Dementia from 2003 to 2018 in Metropolitan Seoul, Korea: A Population-Based Study

National dementia plans were applied in dementia support centers established in Seoul, Korea between 2007 and 2009. However, the annual incidence rates of dementia in Seoul have not been reported. We investigated this annual incidence and the characteristics of incident cases from 2003 to 2018. The customized research database of the Korean National Health Insurance Services was used. The annual crude and age-standardized incidence of dementia patients and their characteristics were analyzed. This study analyzed 108,596 incident dementia cases aged ≥60 years. The incidence rate increased from 2003 to 2011, including a rapid increment from 2007 to 2011. From 2011 to 2018, the crude (age-standardized) incidence per 105 person-years decreased from 641.51 (577.12) to 448.26 (361.23). The proportion of incident dementia cases was highest in the highest income group every year. However, the proportion of incident dementia cases in the lowest income group increased from 10.4% in 2003 to 25.8% in 2011. The annual incidence rate of dementia showed a sharp increase immediately after 2007, the year dementia support centers began to be introduced, and then stabilized after 2011. The characteristics of incident dementia cases have changed, including the proportion in the low-income group.

High visit‐to‐visit blood pressure variability predicts global cognitive decline: The Multi‐Ethnic Study of Atherosclerosis

Background

Methods

Results

Conclusion

Adverse Childhood Experiences and Subjective Cognitive Decline in the US

OBJECTIVE

The aim of this study was to determine the association between adverse childhood experiences (ACEs) and subjective cognitive decline (SCD) among a representative sample of the adult US population.

METHODS

Data were obtained from the 2019 Behavioral Risk Factor Surveillance System (N = 82,688, ≥45 years). Adverse childhood experiences included sexual, physical/psychological and environmental ACEs, and a score. Multivariable logistic regression was used to determine the association between ACEs and SCD, and SCD-related outcomes.

RESULTS

Sexual (adjusted OR (aOR: 2.83; 95% CI: 2.42-3.31)), physical/psychological (aOR: 2.05; 95% CI: 1.83-2.29), and environmental (aOR: 1.94; 95% CI: 1.74-2.16) ACEs were associated with SCD in the past year. There was also a dose-response relationship between ACE score and SCD.

CONCLUSION

ACEs were associated with SCD. Interventions to maximize cognitive health in aging and prevent future cognitive impairment should consider the potential role of ACEs among affected populations.

Twenty-Four-Hour Blood Pressure Variability Is Associated With Lower Cognitive Performance in Young Women With a Recent History of Preeclampsia

BACKGROUND

Women with a history of preeclampsia (hxPE) exhibit sustained arterial stiffness and elevated blood pressure postpartum. Aortic stiffness and 24-hour blood pressure variability (BPV) are associated with age-related cognitive decline. Although hxPE is related to altered cognitive function, the association between aortic stiffness and BPV with cognitive performance in young women with hxPE has not been investigated. The objectives of this study were to (i) test whether cognitive performance is lower in young women with hxPE and (ii) determine whether aortic stiffness and BPV are associated with cognitive performance independent of 24-hour average blood pressure.

METHODS

Women with hxPE (N = 23) and healthy pregnancy controls (N = 38) were enrolled 1-3 years postpartum. Cognitive performance was assessed in domains of memory, processing speed, and executive function. Twenty-four-hour ambulatory blood pressure monitoring and carotid-femoral pulse wave velocity (cfPWV) were used to measure BPV and aortic stiffness, respectively.

RESULTS

Women with hxPE had slower processing speed (-0.56 ± 0.17 vs. 0.34 ± 0.11 Z-score, P < 0.001) and lower executive function (-0.43 ± 0.14 vs. 0.31 ± 0.10 Z-score, P = 0.004) compared with controls independent of education, whereas memory did not differ. BPV and cfPWV (adjusted for blood pressure) did not differ between women with hxPE and controls. Greater diastolic BPV was associated with lower executive function independent of 24-hour average blood pressure and education in women with hxPE (r = -0.48, P = 0.03) but not controls (r = 0.15, P = 0.38).

CONCLUSIONS

Select cognitive functions are reduced postpartum in young women with a recent hxPE and linked with elevated 24-hour diastolic BPV.

Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study

BACKGROUND

The evolution of cognitive impairment of vascular origin is increasingly becoming a prominent health threat particularly in this era where hypertension is the leading contributor of global disease burden and overall health loss. Hypertension is associated with the alteration of the cerebral microcirculation coupled by unfavorable vascular remodeling with consequential slowing of mental processing speed, reduced abstract reasoning, loss of linguistic abilities, and attention and memory deficits. Owing to the rapidly rising burden of hypertension in Tanzania, we sought to assess the prevalence and correlates of cognitive impairment among hypertensive patients attending a tertiary cardiovascular hospital in Tanzania.

METHODOLOGY

A hospital-based cross-sectional study was conducted at Jakaya Kikwete Cardiac Institute, a tertiary care public teaching hospital in Dar es Salaam, Tanzania between March 2020 and February 2021. A consecutive sampling method was utilized to recruit consented hypertensive outpatients during their scheduled clinic visit. General Practitioner Assessment of Cognition (GPCOG) Score was utilized in the assessment of cognitive functions. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with cognitive impairment. Odd ratios with 95% confidence intervals and p-values are reported. All tests were 2-sided and p < 0.05 was used to denote a statistical significance.

RESULTS

A total of 1201 hypertensive patients were enrolled in this study. The mean age was 58.1 years and females constituted nearly two-thirds of the study population. About three quarters had excess body weight, 16.6% had diabetes, 7.7% had history of stroke, 5.7% had heart failure, 16.7% had renal dysfunction, 53.7% had anemia, 27.7% had hypertriglyceridemia, 38.5% had elevated LDL, and 2.4% were HIV-infected. Nearly two-thirds of participants had uncontrolled blood pressure and 8.7% had orthostatic hypotension. Overall, 524 (43.6%) of participants had cognitive impairment. During bivariate analysis in a logistic regression model of 16 characteristics, 14 parameters showed association with cognitive functions. However, after controlling for confounders, multivariate analysis revealed ≤primary education (OR 3.5, 95%CI 2.4-5.2, p < 0.001), unemployed state (OR 1.7, 95%CI 1.2-2.6, p < 0.01), rural habitation (OR 1.8, 95%CI 1.1-2.9, p = 0.01) and renal dysfunction (OR 1.7, 95%CI 1.0-2.7, p = 0.04) to have independent association with cognitive impairment.

CONCLUSION

This present study underscore that cognitive decline is considerably prevalent among individuals with systemic hypertension. In view of this, it is pivotal to incorporate cognitive assessment in routine evaluation of hypertensive patients.

Association Between Blood Pressure Variability With Dementia and Cognitive Impairment: A Systematic Review and Meta-Analysis

[Figure: see text].

Long-Term Blood Pressure Variability Increases Risks of Dementia and Cognitive Decline: A Meta-Analysis of Longitudinal Studies

[Figure: see text].

Nocturnal blood pressure rise as a predictor of cognitive impairment among the elderly: a retrospective cohort study

Background

This study investigated the different blood pressure patterns that were evaluated by ambulatory blood pressure monitoring (ABPM) among elderly patients and explored the effect of pressure patterns on cognitive impairment and mortality.

Methods

A total of 305 elderly participants aged ≥65 years were divided into the cognitive impairment group (CI, n = 130) and the non-cognitive impairment group (NCI, n = 175) according to the MMSE score. All participants underwent ABPM to evaluate possible hypertensive disorder and cerebral MRI for the evaluation of cerebral small vessel disease. Follow-up was performed by telephone or medical records. The primary outcome was all-cause mortality. Secondary endpoints were major adverse cardiac and cerebrovascular events (MACCE).

Results

Among 305 participants, 130 (42.6%) were identified with cognitive impairment (CI), with average systolic blood pressure (BP) of 127 mmHg and diastolic BP of 66 mmHg. According to ABPM, only 13.1% had a dipper pattern, 45.6% had a nocturnal BP rise, while 41.3% had a non-dipper pattern. Compared with NCI patients, the CI group had significantly higher night-time systolic BP (130.0 ± 18.2 vs. 123.9 ± 15.1, p = 0.011), and more participants had nocturnal BP rise (52.3% vs. 40.6%, p = 0.042). Nocturnal BP rise was associated with greater white matter hyperintensities (WMH) (p = 0.013). After 2.03 years of follow-up, there were 35 all-cause deaths and 33 cases of major adverse cardiac and cerebrovascular events (MACCE). CI was independently associated with all-cause mortality during long-term observation (p < 0.01). Nocturnal BP rise had no significant predictive ability for all-cause mortality in elderly patients (p = 0.178).

Conclusions

Nocturnal BP rise contributed to greater cognitive impairment in elderly patients. Not nocturnal BP rise, but CI could significantly increase all-cause mortality. Controlling BP based on ABPM is critical for preventing the progression of cognitive dysfunction.

Association between Blood Pressure, Blood Pressure Variability, and Post-Stroke Cognitive Impairment

After stroke, dynamic changes take place from necrotic-apoptotic continuum, inflammatory response to poststroke neurogenesis, and remodeling of the network. These changes and baseline brain pathology such as small vessel disease (SVD) and amyloid burden may be associated with the occurrence of early or late poststroke cognitive impairment (PSCI) or dementia (PSD), which affect not only stroke victims but also their families and even society. We reviewed the current concepts and understanding of the pathophysiology for PSCI/PSD and identified useful tools for the diagnosis and the prediction of PSCI in serological, CSF, and image characteristics. Then, we untangled their relationships with blood pressure (BP) and blood pressure variability (BPV), important but often overlooked risk factors for PSCI/PSD. Finally, we provided evidence for the modifying effects of BP and BPV on PSCI as well as pharmacological and non-pharmacological interventions and life style modification for PSCI/PSD prevention and treatment.

Metabolic Syndrome: Is It Time to Add the Central Nervous System?

Metabolic syndrome (MS) is a set of cardio-metabolic risk factors that includes central obesity, hyperglycemia, hypertension, and dyslipidemias. The syndrome affects 25% of adults worldwide. The definition of MS has evolved over the last 80 years, with various classification systems and criteria, whose limitations and benefits are currently the subject of some controversy. Likewise, hypotheses regarding the etiology of MS add more confusion from clinical and epidemiological points of view. The leading suggestion for the pathophysiology of MS is insulin resistance (IR). IR can affect multiple tissues and organs, from the classic “triumvirate” (myocyte, adipocyte, and hepatocyte) to possible effects on organs considered more recently, such as the central nervous system (CNS). Mild cognitive impairment (MCI) and Alzheimer’s disease (AD) may be clinical expressions of CNS involvement. However, the association between MCI and MS is not understood. The bidirectional relationship that seems to exist between these factors raises the questions of which phenomenon occurs first and whether MCI can be a precursor of MS. This review explores shared pathophysiological mechanisms between MCI and MS and establishes a hypothesis of a possible MCI role in the development of IR and the appearance of MS.

Blood pressure variability and cognitive dysfunction: A systematic review and meta-analysis of longitudinal cohort studies

The variability of blood pressure (BPV) has been suggested as a clinical indicator for cognitive dysfunction, yet the results from clinical studies are variable. This study investigated the relationship between BPV and the risk of cognitive decline or dementia. Bibliographic databases, including PubMed, Scopus, and Embase, were searched systematically for longitudinal cohort studies with BPV measurements and neuropsychological examinations or dementia diagnosis. A traditional meta‐analysis with subgroup analysis, and a further dose‐response meta‐analysis were conducted. Twenty cohort studies with 7 924 168 persons were included in this review. The results showed that a higher systolic BPV (SBPV), when measured with the coefficient of variation (SBP‐CV) or standard deviation (SBP‐SD), was associated with a higher risk of all‐cause dementia diagnosis but not incidence of cognitive decline on neuropsychological examinations. In subgroup analysis, the effect was more prominent when using BPV of shorter timeframes, during shorter follow‐ups, or among the elderly aged more than 65 years. No dose‐response relationship could be found. Our study suggested possible positive associations between SBPV and the risk of dementia. Further studies are required to validate these findings.

Vascular mild cognitive impairment and its relationship to hemoglobin A1c levels and apolipoprotein E genotypes in the Dominican Republic

Dementia and vascular mild cognitive impairment (VaMCI) currently impose a tremendous human and economic burden on patients from aging populations and their families worldwide. Understanding the interplay of cardiometabolic risk factors and apolipoprotein E (APOE) may direct us to a more personalized medicine and preventative care in MCI and dementia.

Blood Pressure Variability and Dementia: A State-of-the-Art Review

Accumulating evidence demonstrates that blood pressure variability (BPV) may contribute to target organ damage, causing coronary heart disease, stroke, and renal disease independent of the level of blood pressure (BP). Several lines of evidence have also linked increased BPV to a higher risk of cognitive decline and incident dementia. The estimated number of dementia cases worldwide is nearly 50 million, and this number continues to grow with increasing life expectancy. Because there is no effective treatment to modify the course of dementia, targeting modifiable vascular factors continues as a top priority for dementia prevention. A clear understanding of the role of BPV in dementia may shed light on the etiology, early prevention, and novel therapeutic targets of dementia, and has therefore gained substantial attention from researchers and clinicians. This review summarizes state-of-art evidence on the relationship between BPV and dementia, with a specific focus on the epidemiological evidence, the underlying mechanisms, and potential intervention strategies. We also discuss challenges and opportunities for future research to facilitate optimal BP management and the clinical translation of BPV for the risk assessment and prevention of dementia.

Screening for cognitive impairment among the elderly attending the noncommunicable diseases clinics in a rural area of Punjab, North India

BACKGROUND

Amongst all the ailments among the elderly persons, cognitive impairment has significant impact on the quality of life. Non-communicable diseases (NCDs) like diabetes and hypertension increase the risk of cognitive impairment and dementia. Little is known about the prevalence and correlates of cognitive impairment in elderly with NCDs.

AIM

The present study aimed to evaluate the prevalence and correlates of cognitive impairment among elderly patients living with NCDs.

METHODOLOGY

297 patients attending the chronic disease clinic of two Community Health Centres were evaluated using Hindi mini-mental scale (HMSE), University of California Los Angeles Loneliness Scale (UCLA LS), Geriatric Depression Scale, Generalized Anxiety Disorder (GAD-7 scale) and Vulnerability to Abuse Screening Scale.

RESULTS

More than one-fourth (27.3 %) of participants had cognitive impairment as per the HMSE scores. The mean HMSE score was lowest (23.90+6.61) among patients with hypertension followed by patients with diabetes alone (26.90+4.46). People with hypertension had lower mean scores on all the domains of HMSE. Multivariable binary logistic regression depicted younger age, high education status, per capita income, long duration of diseases, loneliness, and hypertension emerged as the significant risk factors associated with cognitive impairment.

CONCLUSION

Older adults with non-communicable diseases have high prevalence of cognitive impairment. Physicians should make the patients and their family members aware about the association of non-communicable diseases with cognitive impairments and should encourage these persons to use remedial measures to reduce the risk of future development of dementia.

Greater Blood Pressure Variability Is Associated With Lower Cognitive Performance

An increasing number of individuals will face age-related cognitive difficulties because life expectancy has increased. It is, therefore, important to identify modifiable risk factors for cognitive impairment. Very short-term to mid-term blood pressure variability (BPV) may be such a factor because it may cause cerebral ischemia. To this end, we investigated whether greater systolic and diastolic BPV are cross-sectionally associated with memory function (n=1804), information processing speed (n=1793), and executive function (n=1780) in 40- to 75-year-old individuals from The Maastricht Study. A composite BPV-index was derived by standardizing within-visit, 24-hour, and 7-day BPV. We performed linear regression with adjustments for age, sex, educational level, 24-hour systolic or diastolic pressure, and cardiovascular risk factors. We found that a 1-SD greater systolic BPV was not associated with information processing speed (β [SD difference], -0.10; 95% CI, -0.14 to 0.06), or executive function (-0.09; 95% CI, -0.20 to 0.02) but was marginally associated with lower memory function (-0.11; 95% CI, -0.21 to 0.00). A 1-SD greater diastolic BPV was associated with lower information processing speed (-0.10; 95% CI, -0.20 to -0.00) and executive function (-0.12; 95% CI, -0.22 to -0.01) and marginally associated with lower memory function (-0.09; 95% CI, -0.20 to 0.01). These effects on cognitive performance are equivalent to ≈3 additional years of aging. In conclusion, greater very short-term to mid-term diastolic and, to a lesser extent, systolic BPV may be a modifiable risk factor for cognitive deterioration in 40- to 75-year-old, community-dwelling individuals.

Interaction between apolipoprotein E genotype and hypertension on cognitive function in older women in the Nurses' Health Study

OBJECTIVE

To examine the interaction between APOE genotypes and both treated and untreated hypertension on cognitive function in an updated analysis of Nurses' Health Study (NHS) data.

DESIGN

At baseline (1995-2001) and 3 biennial follow-up assessments over ~6 years, cognitive function was assessed.

SETTING AND PARTICIPANTS

8300 NHS participants aged 70+ years underwent a cognitive battery, which comprised 6 tests including the Telephone Interview for Cognitive Status (TICS) and tests of verbal memory, category fluency, and working memory.

MEASURES

We estimated the mean differences in average cognitive scores across up to 4 assessments using multiple linear regression. We also tested for interaction between APOE e4 allele carrier status and hypertension overall, as well as for apparently untreated and treated hypertension.

RESULTS

We confirmed that, compared with those with APOE e3/3 genotype, APOE e4 allele carriers scored lower by 0.55 units on the average TICS score (95%CI:-0.67,-0.43). We also observed a significantly worse average TICS score among women with untreated hypertension compared with women without hypertension (difference = -0.23, 95%CI:-0.37,-0.09), while no significant difference was observed for women with treated hypertension. Significant interaction was detected between the APOE e4 allele and untreated hypertension (p-int = 0.02 for the TICS; p-int = 0.045 for global score), but not with treated hypertension. Specifically, compared with normotensive women with the APOE e3/3 genotype, APOE e4 allele carriers with treated hypertension scored lower by 0.50 units (95%CI:-0.69,-0.31); however, the APOE e4 allele carriers with untreated hypertension scored lower by 1.02 units on the TICS score (95%CI:-1.29, -0.76). This interaction of APOE e4 and untreated hypertension was also consistently observed for the global score.

CONCLUSIONS

Women with hypertension and at least one APOE e4 allele had worse average cognitive function compared with women without hypertension with the e3/3 genotype; this difference was amplified among APOE e4 allele carriers with untreated hypertension.

Cognitive Function and Atrial Fibrillation: From the Strength of Relationship to the Dark Side of Prevention. Is There a Contribution from Sinus Rhythm Restoration and Maintenance?

Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia with an increasing prevalence over time mainly because of population aging. It is well established that the presence of AF increases the risk of stroke, heart failure, sudden death, and cardiovascular morbidity. In the last two decades several reports have shown an association between AF and cognitive function, ranging from impairment to dementia. Ischemic stroke linked to AF is a well-known risk factor and predictor of cognitive decline. In this clinical scenario, the risk of stroke might be reduced by oral anticoagulation. However, recent data suggest that AF may be a predictor of cognitive impairment and dementia also in the absence of stroke. Cerebral hypoperfusion, reduced brain volume, microbleeds, white matter hyperintensity, neuroinflammation, and genetic factors have been considered as potential mechanisms involved in the pathogenesis of AF-related cognitive dysfunction. However, a cause-effect relationship remains still controversial. Consequently, no therapeutic strategies are available to prevent AF-related cognitive decline in stroke-free patients. This review will analyze the potential mechanisms leading to cognitive dysfunction in AF patients and examine the available data on the impact of a sinus rhythm restoration and maintenance strategy in reducing the risk of cognitive decline.

Blood pressure variability and brain morphology in elderly women without cardiovascular disease

OBJECTIVE

To examine the relationship between blood pressure (BP) variability (BPV), brain volumes, and cognitive functioning in postmenopausal women with few modifiable cardiovascular risk factors.

METHODS

Study participants consisted of postmenopausal women enrolled in the Women's Health Initiative Memory MRI study (WHIMS-MRI) without cardiovascular disease, diabetes mellitus, hypertension, or current smoking at baseline (1996-1999). BP readings were taken at baseline and each annual follow-up visit. BPV was defined as the SD associated with a participant's mean BP across visits and the SD associated with the participant's regression line with BP regressed across visits. Brain MRI scans were performed between 2004 and 2006. Cognitive functioning was assessed at baseline and annually thereafter with the Modified Mini-Mental State Examination (3MSE) scoring until 2008. The final sample consisted of 558 women (mean age 69 years, median follow-up time [interquartile range] 8 [0.8] years).

RESULTS

In adjusted models including mean systolic BP, women in the highest tertile of systolic BPV had lower hippocampal volumes and higher lesion volumes compared to women in the lowest tertile. No relationship between BPV and 3MSE scoring was detected.

CONCLUSIONS

In postmenopausal women with few modifiable cardiovascular risk factors, greater visit-to-visit systolic BPV was associated with reductions in hippocampal volume and increases in lesion volumes at later life. These data add evidence to the emerging importance of BPV as a prognostic indicator even in the absence of documented cardiovascular risk factors.

Randomised controlled trial of a Calcium Channel or Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker Regime to Reduce Blood Pressure Variability following Ischaemic Stroke (CAARBS): a protocol for a feasibility study

INTRODUCTION

Raised blood pressure (BP) is common after stroke and is associated with a poor prognosis, yet trials of BP lowering in the immediate poststroke period have not demonstrated a benefit. One possible explanation for this may be that BP variability (BPV) rather than absolute levels predicts outcome, as BPV is increased after stroke and is associated with poor outcomes. Furthermore, there is evidence of distinct antihypertensive class effects on BPV despite similar BP-lowering effects. However, whether BPV in the immediate poststroke period is a therapeutic target has not been prospectively investigated.The objectives of this trial are to assess the feasibility and safety of recruiting patients following an acute ischaemic stroke or transient ischaemic attack (TIA) to an interventional randomised controlled trial comparing the effects of two different antihypertensive drug classes on BPV. Secondary exploratory objectives are to assess if different therapeutic strategies have diverse effects on levels of BPV and if this has an impact on outcomes.

METHODS

150 adult patients with first-ever ischaemic stroke or TIA who require antihypertensive therapy for secondary prevention will be recruited within 7 days of the event from stroke services across three sites. After baseline assessments they will be randomly assigned to treatment with a calcium channel blocker or ACE inhibitor/angiotensin receptor blocker-based regimen and followed up for a period of three months.

ETHICS AND DISSEMINATION

Ethical and regulatory approvals have been granted. Dissemination is planned via publication in peer-reviewed medical journals and presentation at relevant conferences.

TRIAL REGISTRATION NUMBER

ISRCTN10853487.

Locus Coeruleus Degeneration Induces Forebrain Vascular Pathology in a Transgenic Rat Model of Alzheimer's Disease

Noradrenergic locus coeruleus (LC) neuron loss is a significant feature of mild cognitive impairment and Alzheimer's disease (AD). The LC is the primary source of norepinephrine in the forebrain, where it modulates attention and memory in vulnerable cognitive regions such as prefrontal cortex (PFC) and hippocampus. Furthermore, LC-mediated norepinephrine signaling is thought to play a role in blood-brain barrier (BBB) maintenance and neurovascular coupling, suggesting that LC degeneration may impact the high comorbidity of cerebrovascular disease and AD. However, the extent to which LC projection system degeneration influences vascular pathology is not fully understood. To address this question in vivo, we stereotactically lesioned LC projection neurons innervating the PFC of six-month-old Tg344-19 AD rats using the noradrenergic immunotoxin, dopamine-β-hydroxylase IgG-saporin (DBH-sap), or an untargeted control IgG-saporin (IgG-sap). DBH-sap-lesioned animals performed significantly worse than IgG-sap animals on the Barnes maze task in measures of both spatial and working memory. DBH-sap-lesioned rats also displayed increased amyloid and inflammation pathology compared to IgG-sap controls. However, we also discovered prominent parenchymal albumin extravasation with DBH-sap lesions indicative of BBB breakdown. Moreover, microvessel wall-to-lumen ratios were increased in the PFC of DBH-sap compared to IgG-sap rats, suggesting that LC deafferentation results in vascular remodeling. Finally, we noted an early emergence of amyloid angiopathy in the DBH-sap-lesioned Tg344-19 AD rats. Taken together, these data indicate that LC projection system degeneration is a nexus lesion that compromises both vascular and neuronal function in cognitive brain areas during the prodromal stages of AD.

Relationships between residual blood pressure variability and cognitive function in the general population of the PAMELA study

The present study was aimed at assessing the relationships between absolute and individual residual blood pressure (BP) variability and cognitive function in a general population. This cross-sectional study evaluated cognitive function using minimental state evaluation (MMSE) in 471 subjects enrolled in the PAMELA study. MMSE was calculated 10 years after initial enrollment of the subjects in the PAMELA study. Measurements included office, home, and 24-hour ambulatory BP monitoring. BP variability was obtained by calculating: (a) 24-hour standard deviation (SD) for systolic and diastolic BP and (b) individual residual BP variability. Mean age (±SD) of the subjects enrolled was 63 ± 5.7 years at the initial evaluation, with a 10-year increase when MMSE was performed. There was no significant difference in BP or heart rate values measured at office, home, or during 24-h BP monitoring between subjects with MMSE < 24 and those with ≥24. BP variability measured by SBP and DBP SD was also similar between these two groups. However, individual residual BP variability was significantly greater in subjects with lower MMSE and this difference became more pronounced when the study population was divided in three groups according to MMSE score (10-20, 21-23, 24-30). Individual residual SBP and DBP variability gradually decreased with the increase in MMSE score. Our data show that a sensitive parameter for the development of cognitive impairment is not BP or absolute BP variability but rather its short-term erratic component, which has been previously shown to be an important prognostic marker for organ damage, cardiovascular, and all-cause mortality.

Extent of, and variables associated with, blood pressure variability among older subjects

BACKGROUND

Blood pressure variability (BPV) may have prognostic implications for cardiovascular risk and cognitive decline; however, BPV has yet to be studied in old and very old people.

AIMS

Aim of the present study was to evaluate the extent of BPV and to identify variables associated with BPV among older subjects.

METHODS

A retrospective study of patients aged ≥ 65 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) was carried out. Three different BPV indexes were calculated for systolic and diastolic blood pressure (SBP and DBP): standard deviation (SD), coefficient of variation (CV), and average real variability (ARV). Demographic variables and use of antihypertensive medications were considered.

RESULTS

The study included 738 patients. Mean age was 74.8 ± 6.8 years. Mean SBP and DBP SD were 20.5 ± 4.4 and 14.6 ± 3.4 mmHg. Mean SBP and DBP CV were 16 ± 3 and 20 ± 5%. Mean SBP and DBP ARV were 15.7 ± 3.9 and 11.8 ± 3.6 mmHg. At multivariate analysis older age, female sex and uncontrolled mean blood pressure were associated with both systolic and diastolic BPV indexes. The use of calcium channel blockers and alpha-adrenergic antagonists was associated with lower systolic and diastolic BPV indexes, respectively.

CONCLUSIONS

Among elderly subjects undergoing 24-h ABPM, we observed remarkably high indexes of BPV, which were associated with older age, female sex, and uncontrolled blood pressure values.

Sleep duration and 24-hour ambulatory blood pressure in adults not on antihypertensive medications

Short sleep duration has been widely linked to increased cardiovascular morbidity and mortality. We performed a post hoc analysis of 24-hour ambulatory blood pressure monitoring (ABPM) in the Lifestyle Modification in Blood Pressure Lowering Study (LIMBS) and Penn Icelandic Sleep Apnea (PISA) Study. The 24-hour mean systolic blood pressure (BP) was 12.7 mm Hg higher in LIMBS (P < 0.001; n = 66) and 4.7 mm Hg higher in PISA (P = 0.005; n = 153) among participants with shorter sleep duration (less than 7 hours) compared to those with longer sleep duration (at least 7 hours). In multivariable adjusted models, shorter sleep duration was strongly associated with higher systolic BP on 24-hour ABPM, independent of nocturnal BP and in-office BP. There was no effect modification by obstructive sleep apnea. Adults with shorter sleep duration may benefit from screening with 24-hour ABPM to promote earlier detection of hypertension and potentially mitigate their increased risk for future cardiovascular disease.

Variability in metabolic parameters and risk of dementia: a nationwide population-based study

Background

Variability in biological parameters has been reported to be associated with adverse health outcomes. We aimed to investigate the composite effect of the visit-to-visit variability in blood pressure, glucose, cholesterol, and body mass index on the risk of dementia.

Methods

A population-based cohort study including 2,930,816 subjects without a history of dementia, hypertension, diabetes mellitus, and dyslipidemia who underwent ≥ 3 health examinations was performed. The coefficient of variation (CV), standard deviation, and variability independent of the mean were calculated as variability indices. High variability was defined as having values in the highest quartile for each parameter.

Results

A total of 32,901 (1.12%) participants developed dementia, of which 74.4% and 11.0% were attributable to Alzheimer’s disease and vascular dementia, respectively, during the median follow-up of 5.5 years. Individuals with higher variability of each parameter were at higher risk of future dementia. In the multivariable adjusted model, the hazard ratios and 95% confidence intervals of all-cause dementia were 1.22 (1.19–1.26) for one parameter, 1.39 (1.35–1.43) for two parameters, 1.54 (1.48–1.60) for three parameters, and 1.73 (1.60–1.88) for four parameters compared with subjects having no parameters of high variability measured as the CV. Consistent results were noted for Alzheimer’s disease and vascular dementia, using other indices of variability and in various sensitivity and subgroup analyses.

Conclusions

There was a linear association between the number of high variability parameters and risk of dementia. Reducing variability of metabolic parameters would be a target to preserve cognitive reserve in the general population.

Electronic supplementary material

The online version of this article (10.1186/s13195-018-0442-3) contains supplementary material, which is available to authorized users.

Ambulatory blood pressure monitoring and neurocognitive function in children with primary hypertension

BACKGROUND

Children with primary hypertension have been reported to have diminished scores in measures of cognition. However, little is known about the relative correlation between office and ambulatory blood pressure (BP) and neurocognitive test performance, and whether short-term BP variability is associated with decreased neurocognitive function. We sought to determine whether ambulatory BP monitoring (ABPM) was more strongly associated with neurocognitive test performance compared with office BP, and whether increased short-term BP variability was associated with lower neurocognitive scores.

METHODS

Seventy-five subjects ages 10-18 years, with untreated primary hypertension, and 75 matched normotensive controls completed neurocognitive testing. All subjects had office BP and ABPM prior to neurocognitive testing.

RESULTS

On multivariate analyses, there was no significant association between office BP and neurocognitive tests. However, several ABPM parameters were significantly associated with neurocognitive test scores in the lower quartile, in particular 24 h SBP load and wake systolic blood pressure (SBP) index [Rey Auditory Verbal learning Test (RAVLT) List A Trial 1, 24 h SBP load, odds ratio (OR) = 1.02, wake SBP index, OR = 1.06; List A Total, 24 h SBP load, OR = 1.02, wake SBP index, OR = 1.06; Short Delay Recall, wake SBP index, OR = 1.06; CogState Maze delayed recall, 24 h SBP load, OR = 1.03, wake SBP index, OR = 1.08; Grooved Pegboard, 24 h SBP load, OR = 1.02; all p < 0.05]. In contrast, short-term BP variability measures were not associated with neurocognitive test performance.

CONCLUSIONS

ABPM is superior to office BP in distinguishing hypertensive youth with lower neurocognitive test performance.

Physical Predictors of Cognitive Function in Individuals With Hypertension: Evidence from the CHARLS Basline Survey

The purpose of the study was to examine the independent associations of each individual physical performance measure (i.e., grip strength, walking speed, repeated chair stands, and balance test) with subdomains of cognitive function and to determine predictors for each subdomain of cognitive function. A secondary data analysis was performed using a nationally representative middle-aged and older sample of hypertensive population. The findings showed that after adding all four physical performance measures, stronger grip strength was significantly associated with better visuospatial abilities, episodic memory, orientation/attention, and overall cognitive function. In addition, faster walking speed and faster repeated chair stands were strongly associated with better episodic memory and overall cognitive function, respectively. Because grip strength was significantly associated with several subdomains of cognitive functioning, it seems conceivable that increasing physical activity would improve both grip strength and cognitive function in patients with hypertension.

[Antihypertensive therapy in the elderly]

Arterial hypertension is the most common modifiable risk factor for cerebrovascular and cardiovascular morbidity and mortality in old age. The prevention of cognitive brain disorders is also a therapeutic goal of long-term treatment of hypertension. Older patients also have a higher risk of developing cardiovascular diseases and therefore benefit from a relatively moderate reduction in blood pressure. With respect to the high prevalence of hypertension in old age and the increasing incidence with time, the therapy of hypertension is becoming increasingly more important to achieve an improved prognosis for patients along with a reduction of costs. The accurate blood pressure measurement for elderly patients includes repeated measurements while standing and sitting. Additionally, the measurements should also be conducted by the patient or by a family member. The most accurate method for assessing the daily blood pressure level, e.g. practice hypertension, non-dipping and intermittent hypertension, is the 24-h blood pressure measurement by ambulatory blood pressure monitoring (ABPM). General measures and lifestyle interventions are effective for reducing blood pressure of elderly patients with hypertension and a low salt diet is scientifically proven to be superior. The same drugs used for young people are also recommended for older patients and most give preference to diuretics, renin-angiotensin-aldosterone system (RAAS) inhibitors and calcium antagonists. The target blood pressure in elderly patients is repeatedly the focus of scientific discussions. The current recommendations are presented in the text and the characteristics which must be particularly considered in the therapy of elderly patients are presented in detail.

Cardiovascular Pharmacogenomics and Cognitive Function in Patients with Schizophrenia

The authors sought to examine the impact of multiple risk alleles for cognitive dysfunction and cardiovascular disease risk on cognitive function and to determine if these relationships varied by cognitive reserve (CR) or concomitant medication use in patients with schizophrenia. They conducted a cross-sectional study in ambulatory mental health centers. A total of 122 adults with a schizophrenia spectrum diagnosis who were maintained on a stable antipsychotic regimen for at least 6 months before study enrollment were included. Patients were divided into three CR groups based on years of formal education: no high school completion or equivalent (low-education group [18 patients]), completion of high school or equivalent (moderate-education group [36 patients], or any degree of post-high school education (high-education group [68 patients]). The following pharmacogenomic variants were genotyped for each patient: AGT M268T (rs699), ACE insertion/deletion (or ACE I/D, rs1799752), and APOE ε2, ε3, and ε4 (rs429358 and rs7412). Risk allele carrier status (identified per gene as AGT M268 T carriers, ACE D carriers, and APOE ε4 carriers) was not significantly different among CR groups. The Brief Assessment of Cognition in Schizophrenia (BACS) scale was used to assess cognitive function. The mean ± SD patient age was 43.9 ± 11.6 years. Cardiovascular risk factors such as hypertension and hyperlipidemia diagnoses, and use of antihypertensive and lipid-lowering agents, did not significantly differ among CR groups. Mixed modeling revealed that risk allele carrier status was significantly associated with lower verbal memory scores for ACE D and APOE ε4 carriers, but AGT T carrier status was significantly associated with higher verbal memory scores (p=0.0188, p=0.0055, and p=0.0058, respectively). These results were only significant in the low-education group. In addition, medication-gene interactions were not significant predictors of BACS scores. ACE D and APOE ε4 carrier status, independent of medication use, was associated with lower verbal memory scores in patients with schizophrenia who had relatively lower CR, as identified by formal education. These results suggest that increasing CR may be protective against cognitive impairment that may be worsened by select cardiovascular risk alleles in patients with schizophrenia.

Day-to-Day Blood Pressure Variability and Risk of Dementia in a General Japanese Elderly Population: The Hisayama Study

Supplemental Digital Content is available in the text.

Several observational studies have reported that higher visit-to-visit blood pressure variability is a risk factor for cognitive impairment and dementia. However, no studies have investigated the association of day-to-day blood pressure variability assessed by home blood pressure measurement with the development of dementia.

Midterm Blood Pressure Variability Is Associated with Poststroke Cognitive Impairment: A Prospective Cohort Study

Objective

The aim of this study was to investigate the relationship between blood pressure variability (BPV) and poststroke cognitive impairment (PSCI).

Methods

Seven-hundred ninety-six patients with acute ischemic stroke were included in this study. Midterm BPV was evaluated by calculating the SD and coefficient of variation (CV, 100 × SD/mean) of systolic blood pressure (SBP) and diastolic blood pressure during the 7 days after stroke onset. Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA) at admission and at all follow-up visits. Patients with MoCA scores <26 were considered to have PSCI.

Results

The incidence of PSCI reached its peak (72%) 3 months after stroke onset and decreased to 30.3% at 12 months poststroke. After adjusting for covariables, the increase in the prevalence of PSCI at 3 months was independently associated with increases in the CV of blood pressure during the 7 days after stroke [odds ratios and 95% CI for patients in the second to fifth quintiles of SBP CV were 2.28 (1.18, 4.39), 2.33 (1.18, 4.62), 2.69 (1.31, 5.53), and 4.76 (1.95, 11.67), respectively]. Sub-analysis of the MoCA scores revealed that the patients had impairments in visuoperceptual abilities and executive functions, as well as in naming and delayed recall (p < 0.05).

Conclusion

Midterm BPV during the early phase of acute ischemic stroke is independently associated with PSCI, especially in the visuoperceptual, executive, and delayed recall domains.

Clinical Trial Registration

http://www.chictr.org.cn, identifier ChiCTR-TRC-14004804.

More accurate systolic blood pressure measurement is required for improved hypertension management: a perspective

The commonly used techniques for systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurement are the auscultatory Korotkoff-based sphygmomanometry and oscillometry. The former technique is relatively accurate but is limited to a physician's office because its automatic variant is subject to noise artifacts. Consequently, the Korotkoff-based measurement overestimates the blood pressure in some patients due to white coat effect, and because it is a single measurement, it cannot properly represent the variable blood pressure. Automatic oscillometry can be used at home by the patient and is preferred even in clinics. However, the technique's accuracy is low and errors of 10-15 mmHg are common. Recently, we have developed an automatic technique for SBP measurement, based on an arm pressure cuff and a finger photoplethysmographic probe. The technique was found to be significantly more accurate than oscillometry, and comparable to the Korotkoff-based technique, the reference-standard for non-invasive blood pressure measurements. The measurement of SBP is a mainstay for the diagnosis and follow-up of hypertension, which is a major risk factor for several adverse events, mainly cardiovascular. Lowering blood pressure evidently reduces the risk, but excessive lowering can result in hypotension and consequently hypoperfusion to vital organs, since blood pressure is the driving force for blood flow. Erroneous measurement by 10 mmHg can lead to a similar unintended reduction of SBP and may adversely affect patients treated to an SBP of 120-130 mmHg. In particular, in elderly patients, unintended excessive reduction of blood pressure due to inaccurate SBP measurement can result in cerebral hypoperfusion and consequent cognitive decline. By using a more accurate technique for automatic SBP measurement (such as the photoplethysmographic-based technique), the optimal blood pressure target can be achieved with lower risk for hypotension and its adverse events.