Treatment of hypertension reduces cognitive decline in older adults: a systematic review and meta-analysis

The Association Between Type of Insurance Plan, Out-of-Pocket Cost, and Adherence to Antihypertensive Medications in Medicare Supplement Insurance Enrollees

BACKGROUND

Medicare supplement insurance, or Medigap, covers 21% of Medicare beneficiaries. Despite offsetting some out-of-pocket (OOP) expenses, remaining OOP costs may pose a barrier to medication adherence. This study aims to evaluate how OOP costs and insurance plan types influence medication adherence among beneficiaries covered by Medicare supplement plans.

METHODS

We conducted a retrospective analysis of the Merative MarketScan Medicare Supplement Database (2017-2019) in Medigap enrollees (≥65 years) with hypertension. The proportion of days covered (PDC) was a continuous measure of medication adherence and was also dichotomized (PDC ≥0.8) to quantify adequate adherence. Beta-binomial and logistic regression models were used to estimate associations between these outcomes and insurance plan type and log-transformed OOP costs, adjusting for patient characteristics.

RESULTS

Among 27,407 patients with hypertension, the average PDC was 0.68 ± 0.31; 47.5% achieved adequate adherence. A mean $1 higher in 30-day OOP costs were associated with a 0.06 (95% confidence intervals [CIs]: -0.09 to -0.03) lower probability of adequate adherence, or a 5% (95% CI: 4%-7%) decrease in PDC. Compared with comprehensive plan enrollees, the odds of adequate adherence were lower among those with point-of-service plans (odds ratio [OR]: 0.69, 95% CI: 0.62-0.77), but higher among those with preferred provider organization (PPO) plans (OR: 1.08, 95% CI: 1.01-1.15). Moreover, the association between OOP costs and PDC was significantly greater for PPO enrollees.

CONCLUSIONS

While Medicare supplement insurance alleviates some OOP costs, different insurance plans and remaining OOP costs influence medication adherence. Reducing patient cost-sharing may improve medication adherence.

Hypertension and Mild Cognitive Impairment: State-of-the-Art Review

BACKGROUND

Mid-life hypertension is associated with cognitive decline and dementia in later life. Reducing high blood pressure (BP) with antihypertensive agents is a well-researched strategy to prevent dementia and mild cognitive impairment (MCI). However, there is still limited direct evidence to support the approach, and particularly for the treatment of the very old and those with existing MCI.

METHODS

This review presents an overview of the current evidence for the relationship between MCI and hypertension, and of the potential pathophysiological mechanisms related to cognitive decline and incidence dementia in relation to aging.

RESULTS

Although observational data are near consistent in showing an association between mid-life hypertension and MCI and/or dementia, the evidence in relation to hypertension in younger adults and the very old (age >80 years) is much more limited. Most of the commonly available antihypertensive agents appear to provide beneficial effects in reducing the risk dementia, but there is limited evidence to support such treatment in those with existing MCI.

CONCLUSIONS

Further studies are needed to determine the optimal levels of BP control across different age groups, especially in adults with MCI, and which class(es) of antihypertensive agents and duration of treatment best preserve cognitive function in those at risk of, or with established, MCI.

Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement

Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.

Current perspectives on prevention of vascular cognitive impairment and promotion of vascular brain health

INTRODUCTION

The true global burden of vascular cognitive impairment (VCI) is unknown. Reducing risk factors for stroke and cardiovascular disease would inevitably curtail VCI.

AREAS COVERED

The authors review current diagnosis, epidemiology, and risk factors for VCI. VCI increases in older age and by inheritance of known genetic traits. They emphasize modifiable risk factors identified by the 2020 Lancet Dementia Commission. The most profound risks for VCI also include lower education, cardiometabolic factors, and compromised cognitive reserve. Finally, they discuss pharmacological and non-pharmacological interventions.

EXPERT OPINION

By virtue of the high frequencies of stroke and cardiovascular disease the global prevalence of VCI is expectedly higher than prevalent neurodegenerative disorders causing dementia. Since ~ 90% of the global burden of stroke can be attributed to modifiable risk factors, a formidable opportunity arises to reduce the burden of not only stroke but VCI outcomes including progression from mild to the major in form of vascular dementia. Strict control of vascular risk factors and secondary prevention of cerebrovascular disease via pharmacological interventions will impact on burden of VCI. Non-pharmacological measures by adopting healthy diets and encouraging physical and cognitive activities and urging multidomain approaches are important for prevention of VCI and preservation of vascular brain health.

Mechanisms underlying HIV-associated cognitive impairment and emerging therapies for its management

People living with HIV are affected by the chronic consequences of neurocognitive impairment (NCI) despite antiretroviral therapies that suppress viral replication, improve health and extend life. Furthermore, viral suppression does not eliminate the virus, and remaining infected cells may continue to produce viral proteins that trigger neurodegeneration. Comorbidities such as diabetes mellitus are likely to contribute substantially to CNS injury in people living with HIV, and some components of antiretroviral therapy exert undesirable side effects on the nervous system. No treatment for HIV-associated NCI has been approved by the European Medicines Agency or the US Food and Drug Administration. Historically, roadblocks to developing effective treatments have included a limited understanding of the pathophysiology of HIV-associated NCI and heterogeneity in its clinical manifestations. This heterogeneity might reflect multiple underlying causes that differ among individuals, rather than a single unifying neuropathogenesis. Despite these complexities, accelerating discoveries in HIV neuropathogenesis are yielding potentially druggable targets, including excessive immune activation, metabolic alterations culminating in mitochondrial dysfunction, dysregulation of metal ion homeostasis and lysosomal function, and microbiome alterations. In addition to drug treatments, we also highlight the importance of non-pharmacological interventions. By revisiting mechanisms implicated in NCI and potential interventions addressing these mechanisms, we hope to supply reasons for optimism in people living with HIV affected by NCI and their care providers.

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.

Hypertension differentially impacts cognition in men and women in early midlife

The current study aimed to understand how sex differences in the timing of hypertension onset contribute to early midlife risk for cognitive decline that may differ by sex and whether sex-dependent advantages in normotensive populations are influenced by the presence of hypertension. One hundred and ninety-five adults aged 45-55 from the New England Family Study underwent neuropsychological testing to assess attention, executive function, and memory. Physician-diagnosed hypertension status was self-reported via questionnaire. Mid-adulthood hypertension was associated with worse performance on measures of attention and memory, but the cognitive domains impacted varied by sex. Hypertension was associated with only attention in men, whereas in women it was associated with attention and associative and working memory. Sex differences in midlife cognitive performance found in normotensive adults were attenuated in those with hypertension. Our results underscore the importance of accounting for sex when assessing the impact of hypertension on midlife cognition that could be indicative of later decline and risk for cognitive impairment and dementia, given hypertension is an independent risk factor.

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.

Influence of Baseline Diastolic Blood Pressure on the Effects of Systolic Blood Pressure Lowering on Cognitive Function in Type 2 Diabetes Mellitus

BACKGROUND

Lowering of systolic blood pressure (SBP) in patients with low diastolic blood pressure (DBP), can further lower DBP. This can potentially decrease cerebral perfusion and cognition. We examined the influence of baseline DBP on the effect of lowering SBP on cognition.

METHODS

This is a post hoc analysis of the Memory in Diabetes (MIND) substudy (N = 1,430) of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study (NCT00000620). Standard neuropsychological tests (Digit Symbol Substitution Test [DSST], Mini-Mental State Examination [MMSE], Rey Auditory Verbal Learning Test [RAVLT], and Stroop test) were performed at baseline and months 20 and 40. We compared the effects of intensive (goal SBP <120 mm Hg) vs. standard (goal SBP <140 mm Hg) SBP control on the changes in the 4 test scores from baseline to the averages of months 20 and 40 across the range of baseline DBP using cubic spline terms.

RESULTS

Mean age was 63 ± 6 years, 55% were women and 66% White. Participates with lower baseline DBP were older, had more cardiovascular events and a longer duration of diabetes. There was no difference in the change in DSST (-0.22; 95% CI -0.97, 0.52), MMSE (-0.14; 95% CI -0.34, 0.06), RAVLT (-0.12; 95% CI -0.29, 0.06), and Stroop interference (-0.47; 95% CI -1.76, 0.82) in the intensive vs. standard SBP intervention. There was no interaction between baseline DBP and change in scores with the SBP intervention.

CONCLUSIONS

Intensive SBP reduction does not adversely affect cognition, even in those with low baseline DBP.

Depression interacts with allostatic load to predict cognitive decline in middle age

BACKGROUND

Allostatic load (AL) indicates the cumulative impact of stress on homeostatic mechanisms. Depression and AL have been associated with cognitive deficits, but it is unclear if they do so independently.

METHODS

Using data from middle-aged participants in the observational longitudinal Midlife in the United States (MIDUS) study (n = 704, 57.5 % female, 63.8 ± 10.6 years old in 2014), we assessed whether the effect of prior depression (Composite International Diagnostic Interview Short-Form in 1995) on cognitive decline between 2004 and 2013 (composite Z-scores derived from the Brief Test of Adult Cognition by Telephone and the Stop & Go Switch Task) was moderated by AL Z-scores in 2004 (calculated from biomarkers in blood, urine, and electrocardiography).

RESULTS

A significant depression × AL interaction predicted a decline in a composite cognitive score (β = -0.066, SE=0.029, p = 0.024) and executive function (β = -0.068, SE=0.025, p = 0.007). Depression predicted a decline in composite cognition among those with AL Z-scores above - 0.055. AL subdomains of inflammation and lipid metabolism showed evidence of moderation.

CONCLUSION

Middle-aged adults with depression who had higher allostatic load were at greater risk of cognitive decline. Future studies should evaluate whether the interaction predicts incident dementia, and whether interventions targeting depression or elevated AL in people who have both can attenuate cognitive decline.

Associations Between the Prevalence, Treatment, Control of Hypertension and Cognitive Trajectories Among Chinese Middle-Aged and Older Adults

OBJECTIVE

To investigate the associations between the prevalence, treatment, control of hypertension, and trajectories of cognitive performance among Chinese middle-aged and older adults.

DESIGN

An 8-year longitudinal study.

SETTING

China.

PARTICIPANTS

Chinese middle-aged and older adults.

MEASUREMENTS

Data from the China Health and Retirement Longitudinal Study were utilized. Group-based trajectory modeling was performed to identify heterogeneous trajectories of episodic memory and executive function. Multinomial logistic regression models were established to examine the relationships between hypertension status and cognitive trajectories, stratified by sex.

RESULTS

Three episodic memory trajectories and four executive function trajectories were identified in males and females. Hypertension prevalence was associated with worse episodic memory and executive function trajectories in females. Compared with treated hypertensives, untreated hypertensives were more likely to have worse executive function trajectories, both in males and females. Among male treated hypertensives, those with uncontrolled blood pressure (BP) had worse episodic memory trajectories compared with their counterparts with controlled at standard targets, while females with uncontrolled BP demonstrated worse executive function trajectories compared with females controlled at standard targets. There was basically no significant difference in cognitive trajectory memberships between individuals with controlled hypertension corresponding to intensive or standard BP targets.

CONCLUSIONS

The prevalence of hypertension was associated with worse cognitive trajectories, and the treatment and control of hypertension were related to more favorable cognitive trajectories. Intensive BP control target was not associated with additional benefit beyond the recognized protective effect of standard BP targets on cognitive trajectories.

Neurodegenerative diseases and blood pressure variability: A comprehensive review from HOPE Asia

Asia has an enormous number of older people and is the primary contributor to the rise in neurodegenerative diseases such as Alzheimer's and Parkinson's disease. The therapy of many neurodegenerative diseases has not yet progressed to the point where it is possible to alter the course of the disease. Mid-life hypertension is an important predictor of later-life cognitive impairment and brain neurodegenerative conditions. These findings highlight the pivotal role of preventing and managing hypertension as a risk factor for neurodegenerative disease. Autonomic dysfunction, neuropsychiatric and sleep disturbances can arise in neurodegenerative diseases, resulting in blood pressure variability (BPV). The BPV itself can worsen the progression of the disease. In older people with neurodegenerative disease and hypertension, it is critical to consider 24-h blood pressure monitoring and personalized blood pressure therapy.

Insights into Cognitive Brain Health in Chronic Kidney Disease

Cognitive impairment and Chronic Kidney Disease (CKD) are common in older adults. With advances in medicine, the average lifespan is expected to increase, further increasing the prevalence of both conditions. The mechanisms underlying cognitive impairment in CKD are unclear. While mild-moderately low estimated glomerular filtration rate (eGFR) may not be associated with cognitive impairment, severely decreased eGFR and albuminuria do. Patients on dialysis have a high prevalence of cognitive impairment. Cognitive function improves after kidney transplantation. However, some residual cognitive deficits persist after transplantation, indicating that restoring the kidney function alone may not be enough to restore cognitive function, and other etiological factors may play a role. Albuminuria, another marker of CKD is also associated with cognitive impairment. However, albuminuria is often undiagnosed. Improving early identification and management of patients with albuminuria may be a good population-based dementia prevention strategy. Other factors associated with cognitive impairment in CKD include anemia and other metabolic derangements commonly observed in CKD. In this article, we reviewed the prevalence of cognitive impairment in CKD, the potential mechanisms underlying cognitive impairment in CKD, andthecurrent evidence on the association between cognitive impairment and eGFR and albuminuria.

Update on Hypertension Research in 2021

In 2021, 217 excellent manuscripts were published in Hypertension Research. Editorial teams greatly appreciate the authors' contribution to hypertension research progress. Here, our editorial members have summarized twelve topics from published work and discussed current topics in depth. We hope you enjoy our special feature, "Update on Hypertension Research in 2021".

Antihypertensive Medication Class and the Risk of Dementia and Cognitive Decline in Older Adults: A Secondary Analysis of the Prospective HELIAD Cohort

BACKGROUND

It is unclear whether the main antihypertensive medication classes (diuretics, calcium channel blockers, beta-blockers, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers (ARBs)) are associated with different risks of cognitive decline. Published evidence is conflicting and stems mainly from observational studies.

OBJECTIVE

To investigate the differential effects of antihypertensives on the risks of developing dementia and cognitive decline, with a specific focus on the vascular component of the mechanisms underlying these interactions.

METHODS

Older adults with a history of hypertension and without dementia were drawn from the population-based HELIAD cohort. Age-, gender-, education-, and antihypertensive medication- (five dichotomous exposures) adjusted Cox proportional-hazards models and generalized estimating equations were performed to appraise the associations of baseline antihypertensive therapy with dementia incidence and cognitive decline (quantified using a comprehensive neuropsychological battery). Analyses were subsequently adjusted for clinical vascular risk (dyslipidemia, diabetes mellitus, smoking, cardiovascular, and cerebrovascular history) and genetic susceptibility to stroke (using polygenic risk scores generated according to the MEGASTROKE consortium GWAS findings).

RESULTS

A total of 776 predominantly female participants (73.61±4.94 years) with hypertension and a mean follow-up of 3.02±0.82 years were analyzed. Baseline treatment was not associated with the risk of incident dementia. ARB users experienced a slower yearly global cognitive [2.5% of a SD, 95% CI = (0.1, 4.9)] and language [4.4% of a SD, 95% CI = (1.4, 7.4)] decline compared to non-users. The fully adjusted model reproduced similar associations for both global cognitive [β= 0.027, 95% CI =  (-0.003, 0.057)], and language decline [β= 0.063, 95% CI = (0.023, 0.104)].

CONCLUSION

ARBs may be superior to other antihypertensive agents in the preservation of cognition, an association probably mediated by vascular-independent mechanisms.

Antihypertensive medication in frail older adults: A narrative review through a deprescribing lens

Purpose of review

The management of hypertension in frail older adults remains controversial, as these patients are underrepresented in clinical trials and practice guidelines. Overtreatment may cause harm while undertreatment may lead to greater risk of cardiovascular events. Our research aims to examine this controversy and provide guidance regarding deprescribing decisions in frail older adults.

Results

Current evidence suggests that there may be minimal cardiovascular benefit and significant harm of antihypertensive medication in the frail older adult population. A minority of hypertension guidelines provide sufficient recommendations for frail older adults, and there are limited tools available to guide clinical decision-making.

Conclusion

Randomized controlled trials and well-designed observational studies are needed to confirm the benefit-to-harm relationship of antihypertensive medication in frail older adults. Decision tools that comprehensively address antihypertensive deprescribing would be advantageous to help clinicians with hypertension management in this population. Clinicians should engage in shared decision-making with the patient and family to ensure that decisions regarding antihypertensive deprescribing best meet the needs of all involved.

Effect of diet supplemented with African Star Apple Fruit Pulp on purinergic, cholinergic and monoaminergic enzymes, TNF-α expression and redox imbalance in the brain of hypertensive rats

OBJECTIVE

This study examined whether diet supplemented with African star apple fruit pulp (FP) can mitigate the effect of high blood pressure on brain neurochemicals, histopathology and expression of genes linked with neuroinflammation.

METHODS

Rats were administered with cyclosporine (25 mg/kg.bw) to induce hypertension and were fed with or without FP supplemented diet. Purinergic (Nucleoside triphosphate diphosphohydrolases [NTPdase] and adenosine deaminase [ADA]) cholinergic (acetylcholinesterase [AChE]) and monoaminergic (monoamine oxidase-B) enzymes were assessed in treated and untreated hypertensive rats' brains. Oxidative stress biomarkers (catalase, glutathione-S-transferase, thiols, reactive oxygen species [ROS] and malondialdehyde [MDA]), as well as AChE, tumour necrosis factor and receptor (TNF-α and TNF-α-R) expression, were also determined.

RESULTS

FP supplemented diet significantly reduced NTPdase and ADA activities and increased Na⁺/K+-ATPase activities in hypertensive rats' brains compared to the untreated group. Furthermore, FP reduced acetylcholinesterase and monoamine oxidase-B activities compared to the hypertensive group. Redox imbalance was observed in hypertensive rats with inhibition of antioxidant enzymes and high levels of ROS and MDA. However, FP supplemented diet improved antioxidant enzymes, reduced ROS and MDA production in the brain of hypertensive rats. High blood pressure also triggered upregulation of AChE, TNF-α and TNF-α-R while feeding with FP supplemented diet downregulated the genes.

CONCLUSION

This study demonstrates the neuroprotective role of FP supplemented diet against alterations in neurochemicals associated with Alzheimer's disease, oxidative stress-induced neuronal damage and expression of genes linked with neuroinflammation. Moreover, studies on animal behaviour and human subjects are required to confirm these beneficial effects.

Hypertension and Cognitive Impairment: A Review of Mechanisms and Key Concepts

Cognitive impairment, and dementia, are major contributors to global burden of death and disability, with projected increases in prevalence in all regions of the world, but most marked increases in low and middle-income countries. Hypertension is a risk factor for both Vascular Cognitive Impairment and Alzheimer's disease, the two most common causes of dementia, collectively accounting for 85% of cases. Key end-organ pathological mechanisms, for which hypertension is proposed to be causative, include acute and covert cerebral ischemia and hemorrhage, accelerated brain atrophy, cerebral microvascular rarefaction and endothelial dysfunction, disruption of blood-brain barrier and neuroinflammation that affects amyloid pathologies. In addition to the direct-effect of hypertension on brain structure and microvasculature, hypertension is a risk factor for other diseases associated with an increased risk of dementia, most notably chronic kidney disease and heart failure. Population-level targets to reduce the incidence of dementia are a public health priority. Meta-analyses of blood pressure lowering trials report a significant reduction in the risk of dementia, but the relative (7–11%) and absolute risk reductions (0.4% over 4 years) are modest. However, given the high lifetime prevalence of both conditions, such relative risk reduction would translate into important population-level reductions in dementia globally with effective screening and control of hypertension. Optimal blood pressure target, especially in older adults with orthostatic hypotension, and antihypertensive agent(s) are uncertain. In this review article, we will detail the observational and interventional evidence linking hypertension with cognitive impairment, summarizing the mechanisms through which hypertension causes cognitive decline.

Peak ependymal cell stretch overlaps with the onset locations of periventricular white matter lesions

Deep and periventricular white matter hyperintensities (dWMH/pvWMH) are bright appearing white matter tissue lesions in T2-weighted fluid attenuated inversion recovery magnetic resonance images and are frequent observations in the aging human brain. While early stages of these white matter lesions are only weakly associated with cognitive impairment, their progressive growth is a strong indicator for long-term functional decline. DWMHs are typically associated with vascular degeneration in diffuse white matter locations; for pvWMHs, however, no unifying theory exists to explain their consistent onset around the horns of the lateral ventricles. We use patient imaging data to create anatomically accurate finite element models of the lateral ventricles, white and gray matter, and cerebrospinal fluid, as well as to reconstruct their WMH volumes. We simulated the mechanical loading of the ependymal cells forming the primary brain-fluid interface, the ventricular wall, and its surrounding tissues at peak ventricular pressure during the hemodynamic cycle. We observe that both the maximum principal tissue strain and the largest ependymal cell stretch consistently localize in the anterior and posterior horns. Our simulations show that ependymal cells experience a loading state that causes the ventricular wall to be stretched thin. Moreover, we show that maximum wall loading coincides with the pvWMH locations observed in our patient scans. These results warrant further analysis of white matter pathology in the periventricular zone that includes a mechanics-driven deterioration model for the ventricular wall.

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.

Mild Cognitive Impairment and modifiable risk factors among Lebanese older adults in primary care

OBJECTIVE

Mild Cognitive Impairment (MCI) is an intermediate state between normal cognition and dementia. Identification of MCI and associated risk factors is important for early intervention. This study investigated the prevalence of MCI among Lebanese older adults and associated risk factors in primary care.

METHODS

For this cross-sectional study, 337 adults aged 60 years and older met inclusion criteria and were recruited at a primary care clinic associated with a tertiary medical center in Beirut, Lebanon. The validated Arabic version of the Montreal Cognitive Assessment, the 5-item Geriatric Depression Scale, and the Lawton Instrumental Activities of Daily Living Scale were administered. Data about sociodemographic, behavioral, and clinical characteristics was obtained.

RESULTS

There was no difference in the mean age between those with normal cognition and those with MCI (mean age 70.38 ± 7.4 and 72.12 ± 7.6 years, respectively). The prevalence of MCI was 14.8% (50 out of 337), 42% were males and 58% were women. Participants having more than 12 years of education (OR = 0.297; CI = 0.112-0.788; P = 0.015) were less likely to have MCI. Participants with history of smoking (OR = 2.599; CI = 1.266-5.339; P = 0.012) or at risk of depression (OR = 2.847; CI = 1.392-5.819; P = 0.004) were more likely to have MCI.

CONCLUSION

Identification of patients with history of smoking and at risk of depression may serve as an opportunity to offer intensive counseling and targeted treatment to delay the onset or progression of MCI to Alzheimer's disease.

Safety and efficacy of losartan for the reduction of brain atrophy in clinically diagnosed Alzheimer's disease (the RADAR trial): a double-blind, randomised, placebo-controlled, phase 2 trial

Background

Drugs modifying angiotensin II signalling could reduce Alzheimer's disease pathology, thus decreasing the rate of disease progression. We investigated whether the angiotensin II receptor antagonist losartan, compared with placebo, could reduce brain volume loss, as a measure of disease progression, in clinically diagnosed mild-to-moderate Alzheimer's disease.

Methods

In this double-blind, multicentre, randomised controlled trial, eligible patients aged 55 years or older, previously untreated with angiotensin II drugs and diagnosed (National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association criteria) with mild-to-moderate Alzheimer's disease, and who had capacity to consent, were recruited from 23 UK National Health Service hospital trusts. After undergoing a 4-week, open-label phase of active treatment then washout, participants were randomly assigned (1:1) oral over-encapsulated preparations of either 100 mg losartan (after an initial two-dose titration stage) or matched placebo daily for 12 months. Randomisation, minimised by age and baseline medial temporal lobe atrophy score, was undertaken online or via pin-access service by telephone. Participants, their study companions, and study personnel were masked to group assignment. The primary outcome, analysed by the intention-to-treat principle (ie, participants analysed in the group to which they were randomised, without imputation for missing data), was change in whole brain volume between baseline and 12 months, measured using volumetric MRI and determined by boundary shift interval (BSI) analysis. The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN93682878) and the European Union Drug Regulating Authorities Clinical Trials Database (EudraCT 2012–003641–15), and is completed.

Findings

Between July 22, 2014, and May 17, 2018, 261 participants entered the open-label phase. 211 were randomly assigned losartan (n=105) or placebo (n=106). Of 197 (93%) participants who completed the study, 171 (81%) had complete primary outcome data. The mean brain volume (BSI) reduction was 19·1 mL (SD 10·3) in the losartan group and 20·0 mL (10·8) in the placebo group. The difference in total volume reduction between groups was –2·29 mL (95% CI –6·46 to 0·89; p=0·14). The number of adverse events was low (22 in the losartan group and 20 in the placebo group) with no differences between treatment groups. There was one treatment-related death per treatment group.

Interpretation

12 months of treatment with losartan was well tolerated but was not effective in reducing the rate of brain atrophy in individuals with clinically diagnosed mild-to-moderate Alzheimer's disease. Further research is needed to assess the potential therapeutic benefit from earlier treatment in patients with milder cognitive impairment or from longer treatment periods.

Funding

Efficacy and Mechanism Evaluation Programme (UK Medical Research Council and National Institute for Health Research).

Metabolic Syndrome and Cognitive Function

PURPOSE OF REVIEW

Metabolic syndrome (MetS) is a cluster of cardiovascular disease risk factors that are related to several adverse health outcomes, including poor cognitive function. This review seeks to summarize and critically review select recent findings on the association between MetS and cognition.

RECENT FINDINGS

MetS was associated with lower domain-specific and global cognitive function in most cross-sectional studies, but findings from longitudinal studies are not consistent. The associations varied depending on age, sex, cognitive test, genetic susceptibility, and the duration of follow-up in prospective studies. MetS was associated with a higher risk of mild cognitive impairment (MCI) and progression from MCI to dementia, particularly vascular dementia. Among MetS components, high blood pressure, high waist circumference, and hyperglycemia were the strongest predictors of cognitive function. MetS is associated with higher risk of cognitive impairment. Research is needed on how preventing or treating MetS affects cognition.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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