Psychotic Symptoms Associated with Poor Renal Function in Mild Cognitive Impairment and Dementias

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.

Neuropsychiatric Disorders in Chronic Kidney Disease

Neuropsychiatric conditions including depression, anxiety disorders, and cognitive impairment are prevalent in patients with chronic kidney disease (CKD). These conditions often make worse the quality of life and also lead to longer hospitalizations and higher mortality. Over the past decades, some hypotheses have tried to explain the connection between CKD and neuropsychiatric disorders. The most common hypothesis is based on the occurrence of cerebrovascular disease and accumulated uremic toxins in adult patients with CKD. However, the lack of a direct association between known vascular risk factors (e.g., diabetes and hypertension) with CKD-related cognitive deficits suggests that other mechanisms may also play a role in the pathophysiology shared by renal and neuropsychiatric diseases. This hypothesis is corroborated by the occurrence of neuropsychiatric comorbidities in pediatric patients with CKD preceding vascular damage, and the inconsistent findings on neuroprotective effects of antihypertensives. The aim of this narrative review was to summarize clinical evidence and potential mechanisms that links CKD and brain disorders, specifically in regard to cognitive impairment, anxiety, and depression.

Multitarget-directed cotreatment with cilostazol and aripiprazole for augmented neuroprotection against oxidative stress-induced toxicity in HT22 mouse hippocampal cells

Cerebrovascular dysfunction is crucially associated with cognitive impairment and a high prevalence of psychotic symptoms in the vascular dementia characterized by oxidative stress and multifactorial neurodegeneration. In this study, the significant decrease in BDNF expression in HT22 cells due to H₂O₂ (0.25 mM) was little affected by either aripiprazole (1 μM) or cilostazol (1 μM) alone, but significantly increased by cotreatment with both drugs. Even in the presence of H₂O₂, P-CK2α (Tyr 255), nuclear P-CREB (Ser 133), and nuclear P-β-catenin (Ser 675) levels were significantly increased in a synergistic manner by aripiprazole plus cilostazol cotreatment. Aripiprazole and cilostazol cotreatment synergistically increased P-GSK-3β (Ser 9) level. Nrf2/HO-1 expression was significantly elevated time- and concentration-dependently by either aripiprazole or cilostazol. In line with these, concurrent treatment with aripiprazole (1 μM) plus cilostazol (1 μM) significantly increased Nrf2 and HO-1 expression in a synergistic manner, accompanying with increased ARE luciferase activity, while each drug monotherapy showed little effects. Consequently, this cotreatment synergistically ameliorated the attenuated neurite outgrowth induced by H₂O₂ in the HT22 cells, and these were inhibited by K252A (inhibitor of BDNF receptor), TBCA (CK2 inhibitor), imatinib (β-catenin inhibitor) and ZnPP (inhibitor of HO-1), indicating that BDNF, P-CK2α, β-catenin and HO-1 activation are implicated in the enhanced neurite outgrowth. This study highlights that cotreatment with low concentrations of aripiprazole and cilostazol synergistically elicits neuroprotective effects by overcoming oxidative stress-evoked neurotoxicity associated with increased neurite outgrowth, providing a rationale for the use of this combinatorial treatment in vascular dementia.

Augmented improvement of cognition and memory by aripiprazole add-on for cilostazol treatment in the chronic cerebral hypoperfusion mouse model

Cerebrovascular dysfunction is associated with cognitive impairment in vascular dementia patients. This study aimed to explore augmented improvement of cognition and memory by aripiprazole add-on for cilostazol treatment in vascular dementia model. Male C57BL/6 mice were subjected to BCAS, and spatial probe and memory retention were examined using the Morris water maze (MWM) test. In the present study, the escape latency on the first day after 3rd week was 21.4 ± 4.0 s in sham-operated mice, and 76.3 ± 4.2 s in the vehicle-treated BCAS mice. In the spatial probe tests in the 3rd week, aripiprazole (1 mg/kg/day) showed time-dependently amelioration in spatial learning and memory impairments in contrast to 0.5 mg/kg/day. After treatment with 20 mg/kg/day of cilostazol for 3 weeks, the escape latency significantly decreased to 26.6 ± 5.8 s on the first day and further shortened to 21.6 ± 6.8 s on the fourth day. When the BCAS mice were concurrently treated with 0.5 mg/kg/day aripiprazole plus 20 mg/kg/day of cilostazol for 3 weeks, the escape latency was more shortened from 20.4 ± 1.2 s (1st day) to 14.9 ± 1.7 s on the 4th day of the 3-week trials. Furthermore, decreased spatial memory retention in BCAS mice was significantly alleviated by aripiprazole plus cilostazol cotreatment, indicating the benefit of aripiprazole add-on therapy. In line with these, significantly increased mBDNF and P-CREB levels and reduced apoptosis were identified in the BCAS mouse brain dentate gyrus by cotreatment as contrasted to each monotherapy. These results may provide the synergistic therapeutic avenues for augmented improvement of cognition and memory by cotreatment with aripiprazole plus cilostazol in cases of vascular dementia.

Use of psychotropic medication in women with psychotic disorders at menopause and beyond

PURPOSE OF REVIEW

Drugs have been extensively prescribed for the treatment of psychotic symptoms in schizophrenia and related disorders, as well as for the management of psychotic features in delirium, dementia and affective disorders. The aim of this narrative review is to focus on the recent literature on drug treatment in women with psychosis at the transition to menopause and subsequently.

RECENT FINDINGS

The recent literature emphasizes the following points: the efficacy of antipsychotic medication in psychosis is largely confined to the alleviation of delusions and hallucinations; menopause and ageing alter the kinetics and dynamics of drug action; drugs other than antipsychotics are currently being tested to address the cognitive, affective and negative symptoms of psychotic illnesses; menopausal symptoms add to comorbidities and require simultaneous treatment, raising the probability of deleterious drug interactions; antipsychotic drugs have many side effects and contribute to high mortality rates in the older psychosis population.

SUMMARY

A major implication for research is that antipsychotic drugs with a wider range of action and with fewer side effects are urgently needed. The clinical implications of the pharmacotherapy of psychotic illness are: older women's needs must be assessed through a comprehensive history and review of systems and physical and mental examination. To avoid adverse effects, drug dosages are best kept low and polypharmacy avoided wherever possible. It is important to frequently reassess older patients, as their pharmacotherapy requirements change with age and with comorbidity.