Clinical correlates of low blood pressure in very old people: the importance of cognitive impairment

Kidney Function and Risk of Physical and Cognitive Impairment in Older Persons with Type 2 Diabetes at an Outpatient Clinic with Geriatric Assessment Implementation

PURPOSE

Diabetes is associated with an increased risk of cognitive and physical functional decline that may impede disease self-management. By incorporating cognitive and physical function assessment, this study aimed to evaluate prevalence and factors associated with cognitive and physical dysfunction in older diabetic people.

METHODS

The cross-sectional study was performed from August 1, 2017 to November 30, 2018. The patients aged 65 years or older with type 2 diabetes mellitus were enrolled and the disease was routinely evaluated by blood hemoglobin A1c (A1C), blood pressure, lipids, and kidney function measured by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine rate (UACR). Besides, cognitive dysfunction through Mini-mental State Examination (MMSE), and functional disabilities by Activities of Daily Living (ADL) questionnaire were assessed simultaneously.

RESULTS

Among 863 patients (48.3% men) with a median age of 72.0 years (interquartile range or IQR: 67.0-78.0 years), 159 (18.5%) had cognitive impairment assessed by MMSE, while 40 (4.6%) experienced at least one problem in ADL. With different A1C stratifications, it was shown that both MMSE and ADL scores were associated with glycemic control. Patients with impaired MMSE and ADL scores were older, had lower eGFR, lower blood pressure, and higher UACR levels. After adjustment of possible confounders, it was shown that age and eGFR predicted MMSE and ADL score impairment.

CONCLUSION

By incorporating physical and cognitive function screening program into routine care at a diabetes outpatient clinic, our study found that both cognitive and physical function impairment were common in older diabetic patients, and their relevant factors, including older age, and lower eGFR. It was recommended that in older individuals with diabetes, particularly those with risk factors, an additional assessment of cognitive and physical functions can be integrated into routine clinical process to provide more comprehensive management plans.

High blood pressure predicts hippocampal atrophy rate in cognitively impaired elders

INTRODUCTION

Understanding relationships among blood pressure (BP), cognition, and brain volume could inform Alzheimer's disease (AD) management.

METHODS

We investigated Alzheimer's Disease Neuroimaging Initiative (ADNI) participants: 200 controls, 346 mild cognitive impairment (MCI), and 154 AD. National Alzheimer's Co-ordinating Center (NACC) participants were separately analyzed: 1098 controls, 2297 MCI, and 4845 AD. Relationships between cognition and BP were assessed in both cohorts and BP and atrophy rates in ADNI. Multivariate mixed linear-regression models were fitted with joint outcomes of BP (systolic, diastolic, and pulse pressure), cognition (Mini-Mental State Examination, Logical Memory, and Digit Symbol) and atrophy rate (whole-brain, hippocampus).

RESULTS

ADNI MCI and AD patients with greater baseline systolic BP had higher hippocampal atrophy rates ([r, P value]; 0.2, 0.005 and 0.2, 0.04, respectively). NACC AD patients with lower systolic BP had lower cognitive scores (0.1, 0.0003).

DISCUSSION

Higher late-life BP may be associated with faster decline in cognitively impaired elders.

Hypertension in patients with Alzheimer's disease--prevalence, characteristics, and impact on clinical outcome. Experience of one neurology center in Poland

The aim of the study was to evaluate hypertension (HT) prevalence, characteristics, and impact on clinical outcome in patients with Alzheimer's disease (AD). We evaluated 701 patients with AD (249 males, 452 females, and mean age 74.9 ± 7.5 years). As a group representing general population matched with regard to age, education level, and place of residence, we included 762 subjects (438 males, 324 females, and mean age 74.7 ± 4.4 years) from the Polish National Multicenter Health Survey (WOBASZ) studies. The patients with AD were characterized by lower systolic blood pressure (BP) and diastolic BP values (134 ± 21 vs. 151 ± 23 mm Hg, P < .001 and 77 ± 11 vs. 86 ± 12 mm Hg, P < .001, respectively) as well as lower HT prevalence (66% vs. 78.6%, P < .001) compared with the WOBASZ group. In long-term follow-up of AD group, HT and BP levels were not associated with the decline in cognitive functions nor the increased risk of death. Patients with AD were characterized by lower prevalence of HT and other vascular risk factors. BP levels and HT had no impact on clinical outcome.

Impact of diabetes on cognitive impairment and disability in elderly hospitalized patients with heart failure

AIM

Heart failure (HF) and diabetes mellitus (DM) are each associated with cognitive impairment and disability. The aim of the present study was to evaluate the impact of DM on cognitive impairment and functional status in elderly hospitalized patients affected by HF.

METHODS

A total of 79 elderly hospitalized patients with HF were enrolled in the present study. They underwent physical and instrumental examination, and geriatric multidimensional assessment including Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS), activities of daily living (ADL) and instrumental activities of daily living (IADL). Differences between groups were established by t-test, Spearman's correlation coefficient was searched to examine the relation between variables. All results were considered significant if P was <0.05.

RESULTS

HF and DM coexisted in 43 patients (54.4% of cases); when they occurred together patients showed, compared with non diabetic patients, a greater clinical severity of HF (44.2% were in New York Heart Association class IV vs 16.7%, P = 0.017), a lower MMSE score (20.4 ± 3.6 vs 23 ± 3.8, P = 0.004), and a lower number of preserved functions in ADL (3 ± 1.6 vs 4 ± 1.8, P = 0.008) and in IADL (3.2 ± 1.7 vs 4.6 ± 2.3, P = 0.003). The correlation between DM and cognitive impairment, and disability was confirmed by multivariate and univariate analysis.

CONCLUSIONS

We confirm that DM is frequent in elderly hospitalized patients with HF, and we report that it has a negative impact on cognitive functions and functional status, worsening cognitive impairment, and disability observed in these patients. Comprehensive geriatric assessment is necessary for older adults with HF, especially when DM coexists.

Phenotypic profiling of cognitive impairment risk among patients with heart failure: a literature review of the usefulness of cardiac-related variables

BACKGROUND

Mild cognitive impairment among patients with heart failure can be subtle. Heart failure-related variables such as ejection fraction, low systolic blood pressure and functional status are reportedly associated with cognitive impairment among heart failure patients. The purpose of this literature review was to examine the value of cardiac variables commonly assessed during heart failure-related hospitalizations for a phenotypic profile of the risk of cognitive impairment.

METHOD

A literature review of primary research studies was conducted. Electronic databases (PubMed and CINAHL) were searched using the keywords heart failure, blood pressure, ejection fraction, functional status, and B-type natriuretic peptide (BNP) in combination with the terms cognition, cognitive function, cognitive dysfunction, and cognitive impairment.

RESULTS

Thirty-seven studies met the inclusion criteria. Evidence supports the potential utility of lower ejection fraction, lower blood pressure and functional status and elevated B-type natriuretic peptide as a phenotypic profile for an increased risk of cognitive impairment.

IMPLICATIONS

If the risk for cognitive impairment is suspected, specific evaluations of cognition can be performed. For community-dwelling heart failure patients with mild cognitive impairment, more intense interventions to support self-care, increased family involvement and more frequent follow up may be necessary.

Longitudinal trajectories of cognitive decline among older adults with cardiovascular disease

BACKGROUND

The long-term course of cognitive impairments secondary to cardiovascular disease (CVD) is unclear. In this study, we prospectively investigated the temporal pattern, rate and hierarchy of cognitive decline attributable to CVD--a risk factor for the development of vascular cognitive impairment (VCI)--and examined the influence of cardiac surgery and heart failure on cognitive decline.

METHODS

A total of 172 older adults with CVD were administered a comprehensive battery of neuropsychological tests at study entry, and at 12 and 36 months thereafter. Random coefficient regressions were used to investigate the temporal course, rate and hierarchy of cognitive decline, as well as to examine the effect of heart failure (reported by 21% of the sample) and cardiac surgery (reported by 44% of the sample) on trajectories of cognitive change.

RESULTS

The course of decline in cognition was linear for language and attention-executive function-psychomotor speed, and curvilinear for visuospatial abilities, memory and overall cognition. The decline in attention-executive function-psychomotor speed was smaller than the decline in other domains. The greatest decline occurred in visuospatial abilities. The rate of decline in cognition was not altered by a history of heart failure. Patients who had undergone cardiac surgery exhibited slower deceleration in their rates of decline in overall cognition. At baseline, patients with a history of heart failure had comparatively poorer attention-executive function-psychomotor speed, overall cognition and, to a lesser extent, visuospatial scores.

CONCLUSION

There is measurable decline in neurocognitive function among patients with CVD. This decline is linear in some cognitive domains and curvilinear in others and is not attributable to the normal aging process. Cardiac surgery, but not heart failure, significantly affects the trajectory of cognitive decline. Because most vascular risk factors are modifiable, preventive measures such as lifestyle changes may be useful in retarding cognitive decline among patients with CVD, thus preventing the onset of VCI.

Relation of neurocardiovascular instability to cognitive, emotional and functional domains

There is bulk of evidence suggesting that blood pressure dysregulation, as low blood pressure (LBP) or hypotension, orthostatic hypotension (OH) and high blood pressure (HPB) or hypertension are associated with alterations in cognitive and emotional domains. Some studies suggest that LBP, neurocardiovascular instability, like the OH, and atherosclerosis resulting from long standing HBP, reduces cerebral blood flow, increasing the risk of cognitive impairment, morbidity and mortality. This study aims to evaluate whether patients with cognitive impairment and cardiovascular disease would show any differences in some anamnestic indicators and/or psychometric measures of cognitive performance and affective symptoms. We recruited 36 patients over 65 years of age admitted to both psycho- and cardio-geriatric ambulatories of our hospital during the last year. The population (mean age of 80.5 years, 72.2% females, 27.8% males) was divided in 2 groups, with OH (25%), and without OH (75%). The first group was subdivided in subgroups: patients with HBP, normal BP and LBP, respectively. Cognitive and depressive domains were assessed with the mini mental state examination (MMSE) and the Italian "scala di valutazione del benessere emotivo nell' anziano" (SVEBA). Information about the present status, comorbidities (cumulative illness rating scale=CIRS), functional ability (activities of daily living=ADL, instrumental ADL=IADL) and drugs were collected during clinical examination. BP was measured 4 times, at the beginning of examination, then with the patient in clinostatic and orthostatic position (1st and 3rd minute). Data were analyzed by MANCOVA, considering age and gender as covariates, MMSE, SVEBA, CIRS, ADL, IADL and drugs as dependent variables, and presence/absence of OH as factor. Covariates were not significant sources of variance, as well as overall factor. Due to the heuristic aim of the study, we considered of interest the results of subsequent ANOVAs showing significant differences in SVEBA and ADL with respect to the factor. These data give us the basis to develop a longitudinal study to confirm the detrimental effect of OH on a wide range of health domains.

The age-dependent relation of blood pressure to cognitive function and dementia

The relation of blood pressure with cognitive function and dementia has, in recent years, received much attention from epidemiological research. Some cross-sectional studies have shown an inverse association between blood pressure and the prevalence of dementia and Alzheimer's disease, whereas longitudinal studies yield mixed results that largely depend on the age at which blood pressure is measured and the time interval between blood pressure and outcome assessments. Some studies suggest that midlife high blood pressure is a risk factor for late-life cognitive impairment and dementia, and that low diastolic pressure and very high systolic pressure in older adults may be associated with subsequent development of dementia and Alzheimer's disease. Observational studies and randomised clinical trials provide limited evidence for a protective effect of antihypertensive therapy against dementia and stroke-related cognitive decline. Atherosclerosis resulting from long-standing hypertension, and cerebral hypoperfusion secondary to severe atherosclerosis and to low blood pressure may be major biological pathways linking both high blood pressure in midlife and low blood pressure in late-life to cognitive decline and dementia.

Falls in hospices: a cancer network observational study of fall rates and risk factors

Falls have been identified as a problem in frail patient populations, but their risk factors have not been studied prospectively in the hospice setting. We calculated fall rates in three hospices in the Yorkshire region, identified risk factors for falls based on previous studies in elderly patients, and then carried out a prospective study of inpatients in two of these hospices. We compared these risk factors in patients who subsequently fell with patients that did not fall during the study period. Information was recorded on 102 admissions. Twelve patients fell, generating 23 falls; six patients fell more than once. Significant risk factors for falling were cognitive impairment, low systolic lying and standing blood pressure, visual impairment and age over 80. Males with these risk factors fell more often than female patients with these risk factors. Strategies to prevent falls in hospice inpatients need to be directed appropriately towards patients with cognitive and visual impairment and low systolic blood pressure.

Decline in blood pressure over time and risk of dementia: a longitudinal study from the Kungsholmen project

BACKGROUND AND PURPOSE

Low blood pressure has been related to an increased risk of dementia. We sought to verify blood pressure variations before and after a dementia diagnosis and to relate blood pressure decline to subsequent Alzheimer disease and dementia.

METHODS

A community dementia-free cohort aged > or =75 years (n=947) underwent follow-up examinations twice over a period of 6 years to detect dementia cases (Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, revised [DSM-III-R] criteria, n=304). Blood pressure variation before and after dementia diagnosis was verified with linear mixed-effects models. Using the dementia-free cohort identified at first follow-up (n=719), the association between blood pressure decline from baseline to first follow-up and subsequent risk of dementia was examined.

RESULTS

Blood pressure markedly decreased over 3 years before dementia diagnosis and afterward, whereas no substantial decline was present 3 to 6 years before the diagnosis. However, among subjects with baseline systolic pressure <160 mm Hg, systolic pressure decline > or =15 mm Hg occurring 3 to 6 years before diagnosis was associated with relative risks (95% CI) of 3.1 (1.3 to 7.0) for Alzheimer disease and 3.1 (1.5 to 6.3) for dementia. There was a dose-response relationship between systolic pressure decline and dementia risk in subjects with vascular disease.

CONCLUSIONS

Blood pressure starts to decrease only 3 years before dementia diagnosis and continues to decline afterward. A greater decline in systolic pressure occurring 3 to 6 years before diagnosis is associated with an increased risk of dementia only in older people with already low blood pressure or affected by vascular disorders.

The relationship between changes in normal-range systolic blood pressure and cognitive function in middle-aged healthy women

Little is known about the effect of normal-range blood pressure (BP) on cognitive function. In previous studies investigating the relationship between BP and cognitive function in elderly subjects, underlying cerebrovascular damage has complicated the interpretation of results. To reveal the relationship between BP levels that were within an absolutely normal range and cognitive function, we examined cognitive function in normotensive, healthy middle-aged women. BP levels were measured on three separate occasions at 1-month intervals, and the subjects exhibiting normotension (< 140/90 mmHg) throughout the evaluation period were recruited as normotensive subjects. Cognitive function was assessed using subtests of the Wechsler Adult Intelligence Scale-Revised. The study demonstrated that, among the subtests examined, the scores on the Digit Symbol Test, an index of psychomotor performance, had a significant correlation with normotensive-range systolic blood pressure (SBP) (r=-0.51, p<0.05); this relation was negative-that is, higher but still normal-range SBP levels were associated with impaired Digit Symbol Test scores. In addition, the relationship adjusted by age and educational level was also significant (partial correlation = -0.56, p<0.05). In contrast, diastolic BP was not related to the Digit Symbol Test (r = -0.33, p = 0.13). Furthermore, the Digit Symbol Test was not influenced by blood glucose or serum cholesterol levels. These findings suggested that, even within the normotensive range, lower levels of SBP might be protective against impairment of psychomotor speed in middle-aged women.

Difficult cases in heart failure: the challenge of neurocognitive dysfunction in severe heart failure

Often ignored, neurocognitive dysfunction in chronic heart failure represents a daunting morbidity progressing to loss of self-reliance. Although the precise mechanisms arbitrating the development of this disorder remain elusive, microembolization and cerebral hypoperfusion are implicated. Other causes of cognitive decline may include prior cardiac surgery, chronic hypertension, sleep disordered breathing, hyperhomocysteinemia, dementia of aging, and more traditional causes such as Alzheimer's disease. The discovery of neurocognitive defects in heart failure must prompt a well-constructed diagnostic evaluation to search for the underlying causes since this process may be at least partially reversible in many cases.

Low blood pressure and incidence of dementia in a very old sample: dependent on initial cognition

OBJECTIVE

To examine whether initially low blood pressure is related to the incidence of dementia.

DESIGN

A population-based prospective study.

SETTING

The Kungsholmen district of Stockholm, Sweden

PARTICIPANTS

Three hundred four nondemented subjects aged 75 to 96 years at baseline.

MEASUREMENTS AND MAIN RESULTS

After an average of 3 years, 81 dementia cases were identified (67 with Alzheimer's disease cases). Compared with individuals with baseline systolic pressure of 141 to 179 mm Hg, those with systolic pressure < or = 140 mm Hg had a significantly higher risk of dementia (relative risk (RR) = 1.9, 95% confidence interval (CI), 1.2-3.2) and Alzheimer's disease (RR = 2.2, 95% CI, 1.2-3.8). However, the RR in relation to systolic pressure < or = 140 mm Hg was 1.3 (0.8-2.2) for all dementia and 1.5 (0.8-2.6) for Alzheimer's disease, when the baseline Mini-Mental State Examination (MMSE) score was included in the model as a dichotomous variable (< 24 vs > or = 24). Baseline MMSE < 24 significantly predicted the occurrence of dementia (RR = 6.9; 95% CI, 4.3-11.1). Systolic pressure < or = 140 mm Hg was significantly related to MMSE score < 24 at baseline.

CONCLUSIONS

These data suggest that low blood pressure may be an early correlate of a dementing process although a causative effect cannot be definitely ruled out.

Blood pressure and cognitive decline in the elderly

Elevated blood pressure is associated with cognitive decline in elderly people. Classically, hypertension was thought to lead to end-organ damage of the brain manifested by neuropsychological deficits. This review examines recent evidence for this hypothesis and also considers other possible causal mechanisms for the observed relationship between blood pressure and mental ability.

Systolic blood pressure tracking over 25 to 30 years and cognitive performance in older adults

OBJECTIVE

To determine the extent to which individual changes in systolic blood pressure (SBP) over a 30-year interval are associated with differential neuropsychological outcomes in old age.

METHODS

Seven hundred seventeen survivors from the Western Collaborative Group Study, a longitudinal study of cardiovascular risk factors now in its 38th year of follow-up, with blood pressures measured in middle age (mean=45 years) and in old age (mean=75 years) and neuropsychological tests administered at follow-up were included in this analysis. Participants were grouped according to 30-year change in SBP (increased, decreased, or "normal"). Analyses focused on comparisons of neuropsychological performance of "high SBP trackers" (ie, those with persistent SBP>/=140 mm Hg throughout adult life) and of SBP "decreasers" with the performance of those whose SBP was either stable or changed in an expected way over time.

RESULTS

Only 7.5% of participants had elevated SBP in middle age, but 43.8% of participants had elevated SBP in old age. After adjustment for age, education, depression, clinically defined stroke, and use of antihypertensive medications and after exclusion of individuals with impaired cognitive performance at follow-up, high SBP trackers, 5.0% (n=36), performed consistently less well than the "normal" SBP subgroups on a composite measure of verbal learning and memory (P=0.04). When compared with the "normal" SBP subgroup, the SBP decreasers, 5.3% (n=38), performed less well on speeded performance (P=0.03).

CONCLUSIONS

There is a relatively small group of people who maintain elevated SBP throughout their adult lives. These persons are at increased risk for reduced verbal learning and memory function. There is also a group of individuals who experience a decrease in SBP and who are at risk for decreased psychomotor speed. Delineation of these 2 SBP subgroups may lead to further clarification of the effects of SBP on neurobehavioral function in older adults.