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

[Figure: see text].

Physiological criteria for functioning of hands in the cold: a review

Hands are important instruments in daily life. Without hands man is hardly able to function independently. Proper functioning of the hands is determined by several physiological parameters. These physiological parameters in turn are influenced by environmental factors. In this view of the literature, physiological processes in manual dexterity are described and the influence of a cold environment on separate physiological processes is studied. In general, cold means loss of dexterity. For reasons of safety and performance, it is important to restrict the loss of manual dexterity. For this purpose, in this study minimum criteria are given for all separate physiological components. Most important minimum criteria are: a local skin temperature of 15 degrees C, a nerve temperature of 20 degrees C and a muscle temperature of 28 degrees C. Only during maximum dynamic work is a muscle temperature of 38 degrees C recommended. These temperatures are average values, and of course individual differences are evident.

Pain, thermal sensation and cooling rates of hands while touching cold materials

Hand cooling and resulting comfort and pain were studied in 12 subjects, while touching six different materials (polyurethane foam, wood, nylon, rustproof steel, aluminium, and temperature-controlled metal) which were initially at ambient temperature. This was done for three ambient temperatures (-10 degrees, 0 degree and 10 degrees C), after pre-exposure exercise or rest, with bare hands or while wearing gloves. The observed cooling curves were analysed as Newtonian cooling curves. The observed time constants appeared to be significantly related to the materials' contact coefficients, the presence of hand protection, the preceding activity, and the interaction between contact coefficient and the presence of hand protection. These parameters also allowed a good description of the time constant (r2 = 0.8) of the related cooling curves. Thermal and pain sensation could be described in terms of the local skin temperature, ambient temperature and hand protection. Equal pain and thermal levels were associated with lower temperatures of the back of the hand than of the contact side. The slightly painful condition was associated with a skin temperature of 16 degrees C for the back and 19 degrees C for the palm of the hand. The pain level appeared to be inversely related to cooling speed. Skin freezing occurred at higher skin temperatures when touching cold objects than when exposed to cold air as a result of reduced supercooling. The regression equations determined allowed calculations to be made of safety limits for hand cooling while in contact with a wide range of materials.

Effects of temperature on electromyogram and muscle function

The effects of 30 min of cooling (15 degrees C water) and warming (40 degrees C water) on arm muscle function were measured. A reference condition (24 degrees C air) was included. Of nine young male subjects the maximal grip force (Fmax), the time to reach 66% of Fmax (rate of force buildup) and the maximal rhythmic grip frequency were determined, together with surface electromyographic activity (EMG) of a forearm muscle (flexor digitorum superficialis). The results showed that in contrast to warming, cooling resulted in a significant decrease of 20% in the Fmax and a significant 50% decrease in force build-up time and the maximal rhythmic grip frequency. The relationship between the root mean square value (rms) of the EMG and the static grip force did not change due to temperature changes. The median power frequency (MPF) in the power spectrum of the EMG signal decreased by 50% due to cooling but remained unchanged with heating. During a sustained contraction at 15% of Fmax (Fmax depending on the temperature) the increase in the rms value with contraction time was 90% larger in the warm condition and 80% smaller in the cold condition compared to the increase in the reference condition. The MPF value remained constant during the warm and reference conditions but in the cold it started at a 50% lower value and increased with contraction time.(ABSTRACT TRUNCATED AT 250 WORDS)

Dynamic Regulation of Cerebral Blood Flow in Patients With Alzheimer Disease

Cerebral autoregulation and baroreflex sensitivity are key mechanisms that maintain cerebral blood flow. This study assessed whether these control mechanisms are affected in patients with dementia and mild cognitive impairment due to Alzheimer disease, as this would increase the risks of antihypertensive treatment. We studied 53 patients with dementia (73.1 years [95% confidence interval (CI), 71.4–74.8]), 37 patients with mild cognitive impairment (69.2 years [95% CI, 66.4–72.0]), and 47 controls (69.4 years [95% CI, 68.3–70.5]). Beat-to-beat blood pressure (photoplethysmography), heart rate, and cerebral blood flow velocity (transcranial Doppler) were measured during 5-minute rest (sitting) and 5 minutes of orthostatic challenges, using repeated sit-to-stand maneuvers. Cerebral autoregulation was assessed using transfer function analysis and the autoregulatory index. Baroreflex sensitivity was estimated with transfer function analysis and by calculating the heart rate response to blood pressure changes during the orthostatic challenges. Dementia patients had the lowest cerebral blood flow velocity ( P =0.004). During rest, neither transfer function analysis nor the autoregulatory index indicated impairments in cerebral autoregulation. During the orthostatic challenges, higher autoregulatory index ( P =0.011) and lower transfer function gain ( P =0.017), indicating better cerebral autoregulation, were found in dementia (4.56 arb. unit [95% CI, 4.14–4.97]; 0.59 cm/s per mm Hg [95% CI, 0.51–0.66]) and mild cognitive impairment (4.59 arb. unit [95% CI, 4.04–5.13]; 0.51 cm/s per mm Hg [95% CI, 0.44–0.59]) compared with controls (3.71 arb. unit [95% CI, 3.35–4.07]; 0.67 cm/s per mm Hg [95% CI, 0.59–0.74]). Baroreflex sensitivity measures did not differ between groups. In conclusion, the key mechanisms to control blood pressure and cerebral blood flow are not reduced in 2 stages of Alzheimer disease compared with controls, both in rest and during orthostatic changes that reflect daily life challenges.

Blood Pressure Variability and Progression of Clinical Alzheimer Disease

Blood pressure variability (BPV) has been shown to have predictive value over blood pressure (BP) levels alone in stroke patients. We assessed whether BPV predicts cognitive and functional decline in Alzheimer disease, using data from a randomized trial (NILVAD [A European Multicentre Double-blind Placebo-controlled Phase III Trial of Nilvadipine in Mild to Moderate Alzheimer’s Disease]). Patients with mild-to-moderate Alzheimer disease were included if they had ≥3 office BP measurements available to determine visit-to-visit BPV. Day-to-day BPV was assessed using home BP measurements in a subsample. The variation independent of mean was used to calculate BPV. Outcomes were change in Alzheimer’s Disease Assessment Scale–cognitive subscale-12 and Disability Assessment for Dementia after 1 and 1.5 years. A total of 460 patients aged 72.1 (SD=8.1) years, with mean BP of 134.0/75.1 (10.9/6.3) mm Hg were included. After 1 year, patients in the highest quartile of BPV had deteriorated more on Alzheimer’s Disease Assessment Scale–cognitive subscale compared with patients in the lowest quartile (systolic: β, 2.24 [95% CI, 0.11–4.38], P =0.040; diastolic: β, 2.54 [95% CI, 0.33–4.75] P =0.024). This association was still present after 1.5 years (systolic: β, 2.86 [95% CI, 0.35–5.36], P =0.026; diastolic: β, 3.30 [95% CI, 0.67–5.93], P =0.014). There was no effect of visit-to-visit BPV on Disability Assessment for Dementia. Day-to-day BPV was available for 46 patients. Significant associations were observed between day-to-day BPV and deterioration on Alzheimer’s Disease Assessment Scale–cognitive subscale (systolic: P =0.036) and Disability Assessment for Dementia (systolic: P =0.020; diastolic: P =0.007) after 1 year, but not after 1.5 years. All associations were adjusted for potential confounders, including intervention group. In conclusion, this post hoc analysis indicates that higher visit-to-visit and day-to-day BPV might be associated with progression of Alzheimer disease. Targeting BPV may be a future target to slow decline in patients with Alzheimer disease.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov . Unique identifier: NCT02017340.

Physiological strain due to load carrying in heavy footwear

To determine the effects of wearing heavy footwear on physiological responses five male and five female subjects were measured while walking on a treadmill (4, 5.25, and 6.5 km.h-1) with different external loads (barefooted, combat boots, and waist pack). While walking without an external load the oxygen uptake, as a percentage of maximal oxygen uptake (%VO2max) of the men increased from 25% VO2max at 4 km.h-1 to 31% VO2max at 5.25 km.h-1 and to 42% VO2max at 6.5 km.h-1. The women had a significantly higher oxygen uptake of 30%, 40%, and 55% VO2max, respectively. In the most strenuous condition, walking at 6.5 km.h-1 with combat boots and waist pack (12 kg), the oxygen uptake for the men and women amounted to 53% and 75% VO2max, respectively. The heart rate showed a similar response to the oxygen uptake, the women having a heart rate which was 15-40 beats.min-1 higher than that of the men, depending on the experimental condition. The perceived exertion was shown to be greatly dependent on the oxygen uptake. From the results a regression formula was calculated predicting the oxygen uptake depending on the mass of the footwear, walking speed and body mass. It was concluded that the mass of footwear resulted in an increase in the energy expenditure which was a factor 1.9-4.7 times greater than that of a kilogram of body mass, depending on sex and walking speed.

Effect of Antihypertensive Treatment on Cerebral Blood Flow in Older Adults: a Systematic Review and Meta-Analysis

BACKGROUND

In older age, the benefits of antihypertensive treatment (AHT) become less evident, with greater associated risk. Of particular concern is compromising cerebral blood flow (CBF), especially in those with cognitive impairment.

METHODS

We created a synthesis of the published evidence by searching multiple electronic databases from 1970 to May 2021. Included studies had participants with mean age ≥50 years, hypertension or cognitive impairment, and assessed CBF before and after initiating AHT. Two authors independently determined eligibility and extracted data. Study quality was assessed using The Risk of Bias in Nonrandomized Studies of Interventions tool. We summarized study characteristics (qualitative synthesis) and performed random-effects meta-analyses (quantitative synthesis).

RESULTS

Thirty-two studies (total n=1306) were included, of which 23 were eligible for meta-analysis. In line with the qualitative synthesis, the meta-analysis indicated no effect of AHT initiation on CBF (standardized mean difference, 0.08 [95% CI, -0.07 to 0.22]; P=0.31, I2=42%). This was consistent across subgroups of acute versus chronic AHT, drug class, study design, and CBF measurement. Subgroups by age demonstrated an increase in CBF after AHT in those aged >70 years (standardized mean difference, 4.15 [95% CI, 0.16-8.15]; P=0.04, I2=42%), but not in those aged 50 to 65 and 65 to 70 years (standardized mean difference, 0.18 [95% CI,-2.02 to 2.38]; P=0.87, I2=49%; standardized mean difference, 1.22 [95% CI, -0.45 to 2.88]; P=0.15, I2=68%). Overall, risk of bias was moderate-to-high and quality of evidence (Grading of Recommendations Assessment, Development and Evaluation) was very low, reflecting the observational nature of the data.

CONCLUSIONS

Accepting the observed limitations, current evidence does not suggest a harmful effect of AHT on CBF. Concerns over CBF should not preclude treatment of hypertension.

Human energy expenditure when walking on a moving platform

The assumption that working on board ship is more strenuous than comparable work ashore was investigated in this study. Various physiological parameters (VO2, VCO2, VE and HR) have been measured to determine the energy expenditure of subjects walking slowly on a moving platform (ship motion simulator). Twelve subjects (eight men and four women) walked either freely on the floor or on a treadmill at a speed of 1 m x s(-1). Platform motion was either in a heave, pitch or roll mode. These three conditions were compared with a control condition in which the platform remained stationary. The results showed that during pitch and roll movements of the platform, the energy expenditure for the same walking task was about 30% higher than under the stationary control condition (3.6 J x kg[-1] x m[-1] vs 2.5 J x kg[-1] x m[-1], P < 0.05) for both walking on a treadmill and free walking. The heart rate data supported the higher energy expenditure results with an elevation of the heart rate (112 beats x min[-1] vs 103 beats x min[-1], P < 0.05). The heave condition did not differ significantly from the stationary control condition. Pitch and roll were not significantly different from each other. During all experimental conditions free walking resulted in a higher energy cost of walking than treadmill walking (3.5 J x kg[-1] x m[-1] vs 2.7 J x kg[-1] x m[-1], P < 0.05) at the same average speed. The results of this experiment were interpreted as indicating that the muscular effort, needed for maintaining balance when walking on a pitching or rolling platform, resulted in a significantly higher work load than similar walking on a stable or a heaving floor, independent of the mode of walking. These results explain in part the increased fatigue observed when a task is performed on a moving platform.

Monitoring core temperature of firefighters to validate a wearable non-invasive core thermometer in different types of protective clothing: Concurrent in-vivo validation

This study aims (1) to test the validity of a new non-invasive core thermometer, Cosinuss°, in rest and (2) during firefighting simulation tasks, against invasive temperature pill and inner-ear temperature and (3) to compare the change in core temperature of firefighters when working in two types of protective clothing (traditional turnout gear versus new concept). 11 active firefighters performed twice a selection of tasks during their periodic preventive medical examination and a fire-extinguishing task. Without correction no correlation between the Cosinuss° and thermometer pill (ICC≤0.09, p ≥ 0.154, LoA≥1.37) and a moderate correlation between Cosinuss° and inner-ear infrared (ICC = 0.40, p = 0.044, LoA±1.20) was observed. With individual correction both correlations were excellent (ICC≥0.84, p = 0.000, LoA≤0.30). However, during and after working all correlations were poor and non-significant (ICC≤0.38, p ≥ 0.091, LoA≥1.71). During firefighting tasks, the Cosinuss° is invalid for measuring the core temperature. No differences in heat development in the two types of protective clothing was proven.

Day-To-Day Home Blood Pressure Variability and All-Cause Mortality in a Memory Clinic Population

BACKGROUND

High day-to-day blood pressure variability (BPV) has been associated with an increased risk for cognitive decline and mortality in the general population. Whether BPV is associated with increased all-cause mortality in older people with cognitive impairment is unknown.

OBJECTIVE

To investigate the association between day-to-day home BPV and all-cause mortality in older patients attending a memory clinic.

METHODS

We included 279 patients attending a memory clinic, who measured home blood pressure (BP) for 7 consecutive days in the morning and evening. Within-subject BPV was defined as the variation independent of the mean (VIM). Time-to-death was verified through the Dutch population registry. Cox proportional hazard regression was used. Separate analyses were performed for morning-to-morning and evening-to-evening BPV.

RESULTS

Mean age was 73±9 years, dementia and mild cognitive impairment were diagnosed in 35% and 34% respectively, and mean home BP was 139/79 mmHg. After a mean follow-up of 3.2 years, 52 patients had died. Neither day-to-day systolic nor diastolic VIM were associated with mortality (adjusted hazard ratio [HR] systolic VIM: 0.99, 95% -CI 0.92-1.06, p = 0.770, HR diastolic VIM: 1.04, 95% -CI 0.93-1.17, p = 0.517). When morning and evening measurements were analyzed separately, systolic morning-to-morning VIM was associated with mortality (adjusted HR: 1.09, 95% -CI 1.01-1.18, p = 0.033).

CONCLUSION

In this study, day-to-day BPV was not associated with all-cause mortality in patients attending a memory clinic. However, morning-to-morning BPV was. Due to the short assessment window, there is still a lack of clarity; hence future research is warranted to clarify the role of all BPV components in aging.

Positive pressure breathing during rest and exercise

The requirements to maintain a positive pressure with respiratory protection during heavy exercise and the effects on ventilation and feelings of discomfort were investigated. Eight male subjects participated, using the respirator system during rest and exercise at about 80% of their individual maximum power. A blower was used at maximum and medium capacity and at two pressure levels (3 and 15 mbar). Additionally, the mouth pressure was used as a feedback for the blower. The blower decreased the fraction of the breathing cycle with negative pressures from 50% (SD 4%) to 15% (SD 10%) during exercise. Negative pressures occurred at all settings of the blower during exercise. Thus, the currently available commercial blower systems do not supply a sufficient airflow to maintain a positive pressure during heavy exercise. Positive pressure breathing did not affect the ventilation and the circulation. But the oxygen consumption was higher with the blower and respirator than without.

Maximal oxygen uptake during cycling is reduced in moving environments; consequences for motion-induced fatigue

In previous studies on physical fatigue during simulated ship movements, the apparent exhaustion of subjects after experimentation suggested that the traditional index of physical workload, oxygen consumption expressed as the percentage of peak oxygen consumption (VO2-peak) measured in a separate graded exercise test (GXT), underestimates workload in a moving environment. In these studies, the GXT was carried out in a stationary environment, as is standard practice. To explain the underestimation, it was hypothesized that VO2-peak might have been less if the GXT had been carried out in the moving environment. This paper reports on three experimental tests of this hypothesis, performed with a ship motion simulator and aboard a ship at sea. In all three experiments, VO2-peak was indeed significantly reduced when the GXT was carried out in the moving environment. Theoretical reasons for this phenomenon are discussed and investigated, but a clear explanation is still lacking.