Low systolic blood pressure is associated with impaired cognitive function in the oldest old: longitudinal observations in a population-based sample 80 years and older

Blood Pressure and Cognitive Function in Older Adults

This review explores the extensive evidence linking hypertension with vascular cognitive impairment and dementia, emphasizing its role as a treatable risk factor. Drawing on observational data, it will elucidate how the chronicity of hypertension at different life stages amplifies cognitive decline risk. It explores the mechanisms underlying hypertension's association with dementia, assesses the neuroprotective properties of antihypertensive therapy, and evaluates novel blood pressure metrics and monitoring methods for their diagnostic and therapeutic potential in dementia management.

What have observational studies taught us about brain health? An exploration of select cardiovascular risks and cognitive function

Observational research studies serve as the cornerstone for gathering evidence on risk factors and contributors to cognitive decline and impairment. The evidence can then be combined with data from preclinical studies and randomized controlled trials to ultimately inform the development of effective interventions and the content of guidance statements. Observational cohort designs on modifiable risk factors and brain health can be particularly beneficial for studying questions that are unethical or impractical for a clinical trial setting, associations with dementia which may develop over decades, and underrepresented populations typically not included in clinical trials. This chapter will review the major observational, epidemiologic studies pertaining to the traditional vascular risk factors - hypertension, diabetes mellitus, hypercholesterolemia, smoking, and physical inactivity - and how they may impact brain health.

Estimated Pulse Wave Velocity and Cognitive Outcomes: A Post hoc Analysis of SPRINT-MIND

BACKGROUND

Arterial stiffness has been confirmed to be associated with cognitive impairment. Carotid-femoral pulse wave velocity (cfPWV) is widely regarded as the gold standard for assessing arterial stiffness, yet it is not readily accessible. In response, the use of estimated pulse wave velocity (ePWV) has been proposed as a more accessible and cost-effective alternative. ePWV not only offers ease of calculation but also covers a broader spectrum of vascular aging processes, some of which may be distinct from those detected by cfPWV. The aim of our study was to investigate the association between ePWV and cognitive outcomes in SPRINT-MIND (Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension).

METHODS

This study was a post hoc analysis of the SPRINT-MIND. The primary endpoint was a composite outcome including probable dementia and mild cognitive impairment (MCI). The calculation of ePWV was based on age and mean blood pressure. The association between ePWV and cognitive outcomes was assessed Using Cox regression analysis. The response of ePWV to antihypertensive treatment at 12 months was used to define treatment efficacy.

RESULTS

8,563 patients were enrolled. The ePWV was found to be independently associated with risk of probable dementia (Tertile 3 vs. Tertile 1: HR, 95% CI: 1.70, 1.08-2.68, P = 0.023, P for trend = 0.013), MCI (Tertile 3 vs. Tertile 1: HR, 95% CI: 2.35, 1.71-3.23, P < 0.001, P for trend < 0.001), and the composite outcome of probable dementia or MCI (Tertile 3 vs. Tertile 1: HR, 95% CI: 2.17, 1.65-2.86, P < 0.001, P for trend < 0.001). The combined effect of treatment allocation and the response of ePWV to treatment exhibited that intensive/ePWV responders had the lowest risk of the primary outcome (Log-rank P = 0.002).

CONCLUSIONS

EPWV demonstrated independent predictive value for cognitive outcomes in SPRINT-MIND.

Correlation between low handgrip strength and metabolic syndrome in older adults: a systematic review

Muscle weakness has been associated to insulin resistance and metabolic syndrome in the general population. However, it is still unclear whether this association is maintained in older adults. This study investigated correlations between low handgrip strength (HGS) and metabolic syndrome, or some of its components, in older adults through a systematic review of the literature. Searches were conducted in the Virtual Health Library Regional Portal, Scopus, Cochrane, Embase, MEDLINE/ PubMed, SciELO, and Web of Science databases for relevant studiesinvestigating muscle weakness (measured by hand dynamometer) and metabolic syndrome or its components in older adult populations, published up to September 2023. From the 2050 references initially identified, 20 studies, comprising a total of 31,264 older adults of both genders, completely met the inclusion/exclusion criteria. Eighteen studies showed that lower HGS was associated with metabolic syndrome or some of its risk factors, such as abdominal obesity, hyperglycemia, insulin resistance, dyslipidemia, or high blood pressure. Two studies found that older men with high blood pressure had increased HGS. Most studies included in this systematic review revealed a significant correlation between reduced HGS and metabolic syndrome or some of its components, especially abdominal obesity and insulin resistance. We conclude that below-average HGS can be associated with metabolic syndrome in older adults.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Change in cardiovascular health and rate of cognitive decline in older adults: a 15-year population-based study

BACKGROUND

Previous research on associations between cardiovascular health, measured at a single timepoint, and rate of age-related cognitive decline shows divergent findings dependent on the participants' age and the health metric studied. The aim of this study was to add to the knowledge in this field by investigating whether change in cardiovascular health, assessed with Life's Simple 7 (LS7) score, is associated with rate of cognitive change in young-old and old-old adults.

METHODS

The study included 1022 participants aged ≥ 60 years from the Swedish National Study on Aging and Care-Kungsholmen (SNAC-K), who underwent repeated neuropsychological testing (episodic memory, semantic memory, verbal fluency, and perceptual speed) across up to 15 years. LS7, composed of seven cardiovascular health metrics (smoking, diet, physical activity, body mass index, plasma glucose, total serum cholesterol, and blood pressure), was assessed at baseline and at the 6-year follow-up. Change in LS7 was calculated as the difference between baseline and 6 years (range - 5 to 8 points) and categorised into worse (-5 to -2 points), stable (-1 to 1 points), and improved (2 to 8 points). Change in cognitive performance as a function of LS7 change categories was estimated using linear mixed-effects models.

RESULTS

Participants were classified as stable (67.1%), improved (21.0%), or worse (11.8%) according to changes in LS7 score. Both the worse and improved categories were associated with faster cognitive decline. Age-stratified analyses revealed that worsening of LS7 was clearly associated with faster cognitive decline in the old-old (≥ 78 years), whereas improvement tended be associated with faster cognitive decline in the young-old (< 78 years) group.

CONCLUSIONS

Change in cardiovascular health in old age may lead to accelerated cognitive decline, particularly in late senescence. These results suggest that it is important to monitor and maintain cardiovascular health status in very old adults.

Hypertension & dementia: Pathophysiology & potential utility of antihypertensives in reducing disease burden

Dementia is a common cause of disability and dependency among the elderly due to its progressive neurodegenerative nature. As there is currently no curative therapy, it is of major importance to identify new ways to reduce its prevalence. Hypertension is recognised as a modifiable risk factor for dementia, particularly for the two most common subtypes; vascular dementia (VaD) and Alzheimer's disease (AD). From the current literature, identified through a comprehensive literature search of PubMed and Cochrane Library, this review aims to establish the stage in adulthood when hypertension becomes a risk for cognitive decline and dementia, and whether antihypertensive treatment is effective as a preventative therapy. Observational studies generally found hypertension in mid-life (age 45-64) to be correlated with an increased risk of cognitive decline and dementia incidence, including both VaD and AD. Hypertension manifesting in late life (age ≥ 65) was demonstrated to be less of a risk, to the extent that incidences of high blood pressure (BP) in the very elderly (age ≥ 75) may even be related to reduced incidence of dementias. Despite the evidence linking hypertension to dementia, there were conflicting findings as to whether the use of antihypertensives was beneficial for its prevention and this conflicting evidence and inconsistent results could be due to the methodological differences between the reviewed observational and randomised controlled trials. Furthermore, dihydropyridine calcium channel blockers and potassium-sparing diuretics were proposed to have neuroprotective properties in addition to BP lowering. Overall, if antihypertensives are confirmed to be beneficial by larger-scale homogenous trials with longer follow-up durations, treatment of hypertension, particularly in mid-life, could be an effective strategy to considerably lower the prevalence of dementia. Furthermore, greater clarification of the neuroprotective properties that some antihypertensives possess will allow for better clinical practice guidance on the choice of antihypertensive class for both BP lowering and dementia prevention.

Systolic blood pressure, antihypertensive treatment, and cardiovascular and mortality risk in VA nursing home residents

BACKGROUND

Optimal systolic BP (SBP) control in nursing home residents is uncertain, largely because this population has been excluded from clinical trials. We examined the association of SBP levels with the risk of cardiovascular (CV) events and mortality in Veterans Affairs (VA) nursing home residents on different numbers of antihypertensive medications.

METHODS

Our study included 36,634 residents aged ≥65 years with a VA nursing home stay of ≥90 days from October 2006-June 2019. SBP was averaged over the first week after admission and divided into categories. Cause-specific hazard ratios (HRs) of SBP categories with CV events (primary outcome) and all-cause mortality (secondary outcome) were examined using Cox regression and multistate modeling stratified by the number of antihypertensive medications used at admission (0, 1 or 2, and ≥3 medications).

RESULTS

More than 76% of residents were on antihypertensive therapy and 20% received ≥3 medications. In residents on antihypertensive therapy, a low SBP < 110 mmHg (compared with SBP 130 ~ 149 mmHg) was associated with a greater CV risk (adjusted HR [95% confidence interval]: 1.47 [1.28-1.68] in 1 or 2 medications group, and 1.41 [1.19-1.67] in ≥3 medications group). In residents on no antihypertensives, both low SBP < 110 mmHg and high SBP ≥ 150 mmHg were associated with higher mortality; while in residents receiving any antihypertensives, a low SBP was associated with higher mortality and the highest point estimates were for SBP < 110 mmHg (1.36 [1.28-1.45] in 1 or 2 medications group, and 1.47 [1.31-1.64] in ≥3 medications group).

CONCLUSIONS

The associations of SBP with CV and mortality risk varied by the intensity of antihypertensive treatment among VA nursing home residents. A low SBP among those receiving antihypertensives was associated with increased CV and mortality risk, and untreated high SBP was associated with higher mortality. More research is needed on the benefits and harms of SBP lowering in long-term care populations.

Elevated late-life blood pressure may maintain brain oxygenation and slow amyloid-β accumulation at the expense of cerebral vascular damage

Hypertension in midlife contributes to cognitive decline and is a modifiable risk factor for dementia. The relationship between late-life hypertension and dementia is less clear. We have investigated the relationship of blood pressure and hypertensive status during late life (after 65 years) to post-mortem markers of Alzheimer's disease (amyloid-β and tau loads); arteriolosclerosis and cerebral amyloid angiopathy; and to biochemical measures of ante-mortem cerebral oxygenation (the myelin-associated glycoprotein:proteolipid protein-1 ratio, which is reduced in chronically hypoperfused brain tissue, and the level of vascular endothelial growth factor-A, which is upregulated by tissue hypoxia); blood-brain barrier damage (indicated by an increase in parenchymal fibrinogen); and pericyte content (platelet-derived growth factor receptor β, which declines with pericyte loss), in Alzheimer's disease (n = 75), vascular (n = 20) and mixed dementia (n = 31) cohorts. Systolic and diastolic blood pressure measurements were obtained retrospectively from clinical records. Non-amyloid small vessel disease and cerebral amyloid angiopathy were scored semiquantitatively. Amyloid-β and tau loads were assessed by field fraction measurement in immunolabelled sections of frontal and parietal lobes. Homogenates of frozen tissue from the contralateral frontal and parietal lobes (cortex and white matter) were used to measure markers of vascular function by enzyme-linked immunosorbent assay. Diastolic (but not systolic) blood pressure was associated with the preservation of cerebral oxygenation, correlating positively with the ratio of myelin-associated glycoprotein to proteolipid protein-1 and negatively with vascular endothelial growth factor-A in both the frontal and parietal cortices. Diastolic blood pressure correlated negatively with parenchymal amyloid-β in the parietal cortex. In dementia cases, elevated late-life diastolic blood pressure was associated with more severe arteriolosclerosis and cerebral amyloid angiopathy, and diastolic blood pressure correlated positively with parenchymal fibrinogen, indicating blood-brain barrier breakdown in both regions of the cortex. Systolic blood pressure was related to lower platelet-derived growth factor receptor β in controls in the frontal cortex and in dementia cases in the superficial white matter. We found no association between blood pressure and tau. Our findings demonstrate a complex relationship between late-life blood pressure, disease pathology and vascular function in dementia. We suggest that hypertension helps to reduce cerebral ischaemia (and may slow amyloid-β accumulation) in the face of increasing cerebral vascular resistance, but exacerbates vascular pathology.

Hypertension management in patients with cardiovascular comorbidities

Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.

Hypertension and cognitive function: a review of life-course factors and disparities

PURPOSE OF REVIEW

Dementia is a life-course condition with modifiable risk factors many from cardiovascular (CV) origin, and disproportionally affects some race/ethnic groups and underserved communities in the USA. Hypertension (HTN) is the most common preventable and treatable condition that increases the risk for dementia and exacerbates dementia pathology. Epidemiological studies beginning in midlife provide strong evidence for this association. This study provides an overview of the differences in the associations across the lifespan, and the role of social determinants of health (SDoH).

RECENT FINDINGS

Clinical trials support HTN management in midlife as an avenue to lower the risk for late-life cognitive decline. However, the association between HTN and cognition differs over the life course. SDoH including higher education modify the association between HTN and cognition which may differ by race and ethnicity. The role of blood pressure (BP) variability, interactions among CV risk factors, and cognitive assessment modalities may provide information to better understand the relationship between HTN and cognition.

SUMMARY

Adopting a life-course approach that considers SDoH, may help develop tailored interventions to manage HTN and prevent dementia syndromes. Where clinical trials to assess BP management from childhood to late-life are not feasible, observational studies remain the best available evidence.

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.

Effects of the FNDC5/Irisin on Elderly Dementia and Cognitive Impairment

Population aging is an inevitable problem nowadays, and the elderly are going through a lot of geriatric symptoms, especially cognitive impairment. Irisin, an exercise-stimulating cleaved product from transmembrane fibronectin type III domain-containing protein 5 (FNDC5), has been linked with favorable effects on many metabolic diseases. Recently, mounting studies also highlighted the neuroprotective effects of irisin on dementia. The current evidence remains uncertain, and few clinical trials have been undertaken to limit its clinical practice. Therefore, we provided an overview of current scientific knowledge focusing on the preventive mechanisms of irisin on senile cognitive decline and dementia, in terms of the possible connections between irisin and neurogenesis, neuroinflammation, oxidative stress, and dementia-related diseases. This study summarized the recent advances and ongoing studies, aiming to provide a better scope into the effectiveness of irisin on dementia progression, as well as a mediator of muscle brain cross talk to provide theoretical support for exercise therapy for patients with dementia. Whether irisin is a diagnostic or prognostic factor for dementia needs more researches.

Cardiovascular Physiology and Pathophysiology in Down Syndrome

Down Syndrome (Ds) is the most common chromosomal cause of intellectual disability that results from triplication of chromosome 21 genes. Individuals with Ds demonstrate cognitive deficits in addition to comorbidities including cardiac defects, pulmonary arterial hypertension (PAH), low blood pressure (BP), and differences in autonomic regulation. Many individuals with Ds are born with heart malformations and some can be surgically corrected. Lower BP at rest and in response to exercise and other stressors are a prevalent feature in Ds. These reduced cardiovascular responses may be due to underlying autonomic dysfunction and have been implicated in lower exercise/work capacity in Ds, which is an important correlate of morbidity, mortality and quality of life. Exercise therapy can be beneficial to normalize autonomic function and may help prevent the development of co-morbidities in Ds. We will review cardiovascular physiology and pathophysiology in individuals with Ds, along with exercise therapy and special considerations for these individuals.

Hypertension-induced cognitive impairment: from pathophysiology to public health

Hypertension affects two-thirds of people aged >60 years and significantly increases the risk of both vascular cognitive impairment and Alzheimer's disease. Hypertension compromises the structural and functional integrity of the cerebral microcirculation, promoting microvascular rarefaction, cerebromicrovascular endothelial dysfunction and neurovascular uncoupling, which impair cerebral blood supply. In addition, hypertension disrupts the blood-brain barrier, promoting neuroinflammation and exacerbation of amyloid pathologies. Ageing is characterized by multifaceted homeostatic dysfunction and impaired cellular stress resilience, which exacerbate the deleterious cerebromicrovascular effects of hypertension. Neuroradiological markers of hypertension-induced cerebral small vessel disease include white matter hyperintensities, lacunar infarcts and microhaemorrhages, all of which are associated with cognitive decline. Use of pharmaceutical and lifestyle interventions that reduce blood pressure, in combination with treatments that promote microvascular health, have the potential to prevent or delay the pathogenesis of vascular cognitive impairment and Alzheimer's disease in patients with hypertension.

Oxidative Stress in the Pathogenesis of Alzheimer's Disease and Cerebrovascular Disease with Therapeutic Implications

The significant gain in life expectancy led to an increase in the incidence and prevalence of dementia. Although vascular risk factors have long and repeatedly been shown to increase the risk of Alzheimer's Disease (AD), translating these findings into effective preventive measures has failed. In addition, the finding that incident ischemic stroke approximately doubles the risk of a patient to develop AD has been recently reinforced. Current knowledge and pathogenetic hypotheses of AD are discussed. The implication of oxidative stress in the development of AD is reviewed, with special emphasis on its sudden burst in the setting of acute ischemic stroke and the possible link between this increase in oxidative stress and consequent cognitive impairment. Current knowledge and future directions in the prevention and treatment of AD are discussed outlining the hypothesis of a possible beneficial effect of antioxidant treatment in acute ischemic stroke in delaying the onset/progression of dementia.

Does Antihypertensive Use Moderate the Effect of Blood Pressure on Cognitive Decline in Older People?

BACKGROUND

While midlife hypertension is deleterious, late-life hypertension has been associated with better cognitive outcomes in several studies. Many questions remain, including the relative benefit or harm of a blood pressure (BP) target and antihypertensive therapy of <120 in very old individuals.

METHODS

The Sydney Memory and Aging Study (n = 1015) comprises a cohort of 70- to 90-year-olds, who were followed biennially for 8 years. Global cognition was assessed with a battery of 10 neuropsychological tests. Blood pressure was measured at Waves 1 and 2 and classified into 3 systolic groupings: group 1 (≤120 mmHg), group 2 (121-140 mmHg), and group 3 (>140 mmHg). Multiple regression, linear mixed modeling, and Cox regression examined the effect of BP and antihypertensives.

RESULTS

There were no overall significant differences in global cognition or dementia between the disparate BP groups. However, in those not taking antihypertensives, the systolic BP (SBP) > 140 mmHg group had a significantly worse global cognitive trajectory compared to SBP ≤ 120 mmHg (b = -0.067, 95% CI [-0.129, -0.006], p = .030). Within the SBP ≤ 120 mmHg group those taking antihypertensives had significantly worse global cognition trajectories compared to those not taking antihypertensives even when controlling for past history of hypertension (b = -0.077, 95% CI [-0.147, -0.007], p = .030).

CONCLUSIONS

Untreated hypertension in old age is related to worse global cognitive decline. However, ongoing treatment at new recommendations of lower SBP targets may be related to poorer cognitive decline and should be considered carefully in older populations.

Cardiovascular Risk Factors Across the Life Course and Cognitive Decline: A Pooled Cohort Study

OBJECTIVE

Cardiovascular risk factors (CVRFs) are associated with increased risk of cognitive decline, but little is known about how early adult CVRFs and those across the life course might influence late-life cognition. To test the hypothesis that CVRFs across the adult life course are associated with late-life cognitive changes, we pooled data from 4 prospective cohorts (n = 15,001, ages 18-95).

METHODS

We imputed trajectories of body mass index (BMI), fasting glucose (FG), systolic blood pressure (SBP), and total cholesterol (TC) for older adults. We used linear mixed models to determine the association of early adult, midlife, and late-life CVRFs with late-life decline on global cognition (Modified Mini-Mental State Examination [3MS]) and processing speed (Digit Symbol Substitution Test [DSST]), adjusting for demographics, education, and cohort.

RESULTS

Elevated BMI, FG, and SBP (but not TC) at each time period were associated with greater late-life decline. Early life CVRFs were associated with the greatest change, an approximate doubling of mean 10-year decline (an additional 3-4 points for 3MS or DSST). Late-life CVRFs were associated with declines in early late life (<80 years) but with gains in very late life (≥80 years). After adjusting for CVRF exposures at all time periods, the associations for early adult and late-life CVRFs persisted.

CONCLUSIONS

We found that imputed CVRFs across the life course, especially in early adulthood, were associated with greater late-life cognitive decline. Our results suggest that CVRF treatment in early adulthood could benefit late-life cognition, but that treatment in very late life may not be as helpful for these outcomes.

The Relationship Between Cardiovascular Health and Rate of Cognitive Decline in Young-Old and Old-Old Adults: A Population-Based Study

BACKGROUND

Modifiable vascular risk factors have been associated with late-life cognitive impairment. The Life Simple 7 (LS7) score comprises seven cardiovascular health metrics: smoking, diet, physical activity, body mass index, plasma glucose, total serum cholesterol, and blood pressure.

OBJECTIVE

To investigate the association between individual and composite LS7 metrics and rate of cognitive decline, and potential differences in these associations between young-old and old-old individuals.

METHODS

This cohort study included 1,950 participants aged≥60 years (M = 70.7 years) from the Swedish National Study on Aging and Care-Kungsholmen (SNAC-K), who underwent repeated neuropsychological testing (episodic and semantic memory, verbal fluency, processing speed, global cognition) across 12 years. The LS7 score was assessed at baseline and categorized as poor, intermediate, or optimal. Level and change in cognitive performance as a function of LS7 categories were estimated using linear mixed-effects models.

RESULTS

Having an optimal LS7 total score was associated with better performance (expressed in standard deviation units) at baseline for perceptual speed (β= 0.21, 95%CI 0.12-0.29), verbal fluency (β= 0.08, 0.00-0.16), and global cognition (β= 0.06, 0.00-0.12) compared to the poor group. Age-stratified analyses revealed associations for cognitive level and change only in the young-old (< 78 years) group. For the specific metrics, diverging patterns were observed for young-old and old-old individuals.

CONCLUSION

Meeting the LS7 criteria for ideal cardiovascular health in younger old age is associated with slower rate of cognitive decline. However, the LS7 criteria may have a different meaning for cognitive function in very old adults.

Associations between vascular risk factors and subsequent Alzheimer's disease in older adults

Background

The clinical guidelines related to the primary prevention of Alzheimer’s disease (AD) have focused on the management of vascular risk factors. However, the link between vascular risk factors and AD in older adults remains unclear. This study aimed to determine the association between vascular risk factors and subsequent AD in 178,586 older adults (age ≥ 65 years).

Methods

Participants were recruited from 2009 through 2010 and followed up for 6 years. We assessed various vascular risk factors (total cholesterol [TC], low-density lipoprotein cholesterol [LDL-C], high-density lipoprotein cholesterol [HDL-C], triglycerides [TG], fasting glucose [FG], systolic blood pressure [SBP], diastolic blood pressure [DBP], pulse pressure [PP], and body mass index [BMI]) and their association with AD incidence, categorizing each vascular factor using current clinical guidelines.

Results

AD was observed in 6.0% of participants at follow-up. All lipid profiles (TC, LDL-C, HDL-C and TG) were positively associated with the risk of AD. SBP and PP were in negative associations with AD, and DBP was positively associated with AD. BMI exhibited a negative association with AD incidence. We found no significant association between FG and AD risk. The sex difference was observed to have effects on vascular risk factors.

Conclusions

In this study, we comprehensively investigated the association between eight vascular risk factors and the risk of incident AD. Our findings suggest that multiple vascular risk factors are related to the development of AD in older adults. These results can help inform future guidelines for reducing AD risk.

Chronic stress and age-related pattern of blood pressure: A cross-sectional study in rural China

OBJECTIVE

Chronic stress is a risk factor for hypertension in adults. However, there is conflicting evidence for older adults. We hypothesized that age-related arterial stiffening, which leads to a lower blood pressure (especially diastolic blood pressure [DBP]), is more pronounced among older adults with high vs low stress. The objectives of this study were (a) to investigate age-related trends in systolic and DBPs among adults in rural Fujian, China, and (b) to examine differences in age-related blood pressure trends according to levels of stress by using Epstein-Barr virus (EBV) antibody titer as a marker of chronic stress status.

METHODS

We collected cross-sectional data from 764 rural community-dwelling adults in rural Fujian, China (mean age = 59.4). Participants were categorized into high and low stress groups by median split of EBV antibody titer. A least-squares regression analysis was used to investigate the association between age and blood pressures.

RESULTS

We observed an inverted U-shaped association between age and DBP, while there was a linear association between age and systolic blood pressure in the overall sample. When stratified by stress, the inverted U-shaped associations with age (both systolic and DBPs) were seen only among those with high stress; DBP peaked at the age of ~68 years, and the declining trend later in life was more clearly observed among those with high chronic stress.

DISCUSSION

Decrease of DBP was more pronounced among older adults with high vs low chronic stress in rural China.

Hypertension and the Risk of Dementia

Hypertension, particularly midlife high blood pressure, has been related to a higher risk of cognitive decline and dementia, including Alzheimer disease. However, these associations are complex and not fully elucidated. Cerebral small vessel disease emerges as one of the most important causes. Several observational studies have shown the potential beneficial role of antihypertensive treatment in preventing cognitive decline. However, randomized clinical trials (RCTs) have shown controversial results without proving nor disproving the association. On the other hand, in very elderly or frail people some studies have observed a relationship between low blood pressure and worse cognitive function. The optimal systolic and diastolic blood pressure values for protecting cognitive function, especially in elderly people, are not known.

Hypertension and Its Impact on Stroke Recovery: From a Vascular to a Parenchymal Overview

Hypertension is the first modifiable vascular risk factor accounting for 10.4 million deaths worldwide; it is strongly and independently associated with the risk of stroke and is related to worse prognosis. In addition, hypertension seems to be a key player in the implementation of vascular cognitive impairment. Long-term hypertension, complicated or not by the occurrence of ischemic stroke, is often reviewed on its vascular side, and parenchymal consequences are put aside. Here, we sought to review the impact of isolated hypertension or hypertension associated to stroke on brain atrophy, neuron connectivity and neurogenesis, and phenotype modification of microglia and astrocytes. Finally, we discuss the impact of antihypertensive therapies on cell responses to hypertension and functional recovery. This attractive topic remains a focus of continued investigation and stresses the relevance of including this vascular risk factor in preclinical investigations of stroke outcome.

Heart rate and blood pressure in male Ts65Dn mice: a model to investigate cardiovascular responses in Down syndrome

Down syndrome (Ds) is the most common chromosomal cause of intellectual disability that results from triplication of chromosome 21 genes. Lower blood pressure (BP) and heart rate (HR) in response to exercise and other stressors are prevalent in Ds, and are mediated by autonomic dysfunction. The Ts65Dn mouse is a model of Ds that is commonly used in preclinical studies, but has not been formally investigated for cardiovascular responses in conscious mice. Based on human studies of Ds, we hypothesized Ts65Dn would have lower BP and HR, but similar arterial stiffness. BP was quantified in conscious wild-type (WT) and Ts65Dn. A main effect for strain was observed for all BP measures (systolic, diastolic, mean, pulse pressure), with WT higher than Ts65Dn. Pulse wave velocity was similar between WT and Ts65Dn. High-frequency power spectra was higher in WT suggesting autonomic differences between strains. Freely moving HR was higher in WT versus Ts65Dn in both the dark and light cycles, although a main effect of circadian cycle was also present (dark> light). Similar to what is observed in humans, Ts65Dn has a lower BP which may be attributed to autonomic differences and result in preservation of arterial function with advancing age. Ts65Dn thus appears to capture the Ds cardiovascular phenotype across the lifespan. These data support further use of Ts65Dn to investigate mechanisms that may lead to altered BP and HR responses in Ds.

Small vessel disease to subcortical dementia: a dynamic model, which interfaces aging, cholinergic dysregulation and the neurovascular unit

BACKGROUND

Small vessels have the pivotal role for the brain's autoregulation. The arteriosclerosis-dependent alteration of the brain perfusion is one of the major determinants in small vessel disease. Endothelium distress can potentiate the flow dysregulation and lead to subcortical vascular dementia (sVAD). sVAD increases morbidity and disability. Epidemiological studies have shown that sVAD shares with cerebrovascular disease most of the common risk factors. The molecular basis of this pathology remains controversial.

PURPOSE

To detect the possible mechanisms between small vessel disease and sVAD, giving a broad vision on the topic, including pathological aspects, clinical and laboratory findings, metabolic process and cholinergic dysfunction.

METHODS

We searched MEDLINE using different search terms ("vascular dementia", "subcortical vascular dementia", "small vessel disease", "cholinergic afferents", etc). Publications were selected from the past 20 years. Searches were extended to Embase, Cochrane Library, and LILIACS databases. All searches were done from January 1, 1998 up to January 31, 2018.

RESULTS

A total of 560 studies showed up, and appropriate studies were included. Associations between traditional vascular risk factors have been isolated. We remarked that SVD and white matter abnormalities are seen frequently with aging and also that vascular and endothelium changes are related with age; the changes can be accelerated by different vascular risk factors. Vascular function changes can be heavily influenced by genetic and epigenetic factors.

CONCLUSION

Small vessel disease and the related dementia are two pathologies that deserve attention for their relevance and impact in clinical practice. Hypertension might be a historical problem for SVD and SVAD, but low pressure might be even more dangerous; CBF regional selective decrease seems to be a critical factor for small vessel disease-related dementia. In those patients, endothelium damage is a super-imposed condition. Several issues are still debatable, and more research is needed.

Cardiovascular health and cognitive functioning among centenarians: a comparison between the Tokyo and Georgia centenarian studies

ABSTRACTObjectives:Centenarians have survived into very late life, but whether they reach very old age in good health remains unclear. The purpose of this study was to compare the cardiovascular health status and cognitive functioning of centenarians in the United States with centenarians in Japan.

DESIGN, SETTING, AND PARTICIPANTS

This cross-national design compared centenarians from the United States and Japan. The sample of U.S. centenarians was recruited from the Georgia Centenarian Study and included 287 centenarians. The sample of Japanese centenarians was recruited from the Tokyo Centenarian Study and included 304 centenarians.

MEASUREMENTS

Cognitive functioning was assessed with a mental status questionnaire, and cardiovascular disease by a health history assessment, blood pressure, and selected blood parameters.

RESULTS

The results suggest that Tokyo centenarians had lower disease experiences and BMI values, when compared to Georgia centenarians, but blood pressure was higher among Japanese centenarians. Lower levels of hemoglobin in Japanese centenarians and higher levels of C-reactive protein in Georgia were also found. The positive association of hypertension and albumin levels with cognitive functioning and the negative association of stroke occurrence with cognitive functioning were replicated in both countries. Differential effects were obtained for heart problems, BMI, and C-reactive protein (with positive effects for Tokyo centenarians, except for C-reactive protein).

CONCLUSION

For extremely old individuals, some markers of cardiovascular disease are replicable across countries, whereas differential effects for cardiovascular health also need to be considered in cardiovascular health.

Systolic Blood Pressure and Cognitive Decline in Older Adults With Hypertension

PURPOSE

Hypertension trials often exclude patients with complex health problems and lack generalizability. We aimed to determine if systolic blood pressure (SBP) in patients undergoing antihypertensive treatment is associated with 1-year changes in cognitive/daily functioning or quality of life (QoL) in persons aged ≥75 years with or without complex health problems.

METHODS

We analyzed data from a population-based prospective cohort study (Integrated Systematic Care for Older Persons [ISCOPE]) with a 1-year follow-up. Stratified by SBP level in the year before baseline, we used mixed-effects linear regression models to evaluate the change from baseline to 1-year follow-up in outcome measures (Mini-Mental State Examination [MMSE], Groningen Activity Restriction Scale [GARS], and EQ-5D-3L). We adjusted for age, sex, and baseline MMSE/GARS/EQ-5D-3L scores and stratified for complex health problems as a proxy for frailty.

RESULTS

Participant (n = 1,266) age averaged 82.4 (SD 5) years, and 874 (69%) were women. For participants undergoing antihypertensive therapy (1,057; 83.5%) and with SBP <130 mm Hg, crude cognitive decline was 0.90 points MMSE, whereas in those with SBP >150 mm Hg, it was 0.14 points MMSE (ie, 0.76-point less decline; P for trend = .013). Complex health problems modified the association of SBP with cognition; the association was seen in those with antihypertensive treatment (P for trend <.001), not in those without (P for trend = .13). Daily functioning/QoL did not differ across the strata of SBP or antihypertensive treatment.

CONCLUSIONS

Participants aged ≥75 years undergoing antihypertensive treatment, with SBP ≥130 mm Hg compared to <130 mm Hg, showed less cognitive decline after 1 year, without loss of daily functioning or QoL. This effect was strongest in participants with complex health problems. More studies should be conducted to determine if there is a causal relation and to understand the mechanism of the association observed.

Effect of Intensive vs Standard Blood Pressure Control on Probable Dementia: A Randomized Clinical Trial

IMPORTANCE

There are currently no proven treatments to reduce the risk of mild cognitive impairment and dementia.

OBJECTIVE

To evaluate the effect of intensive blood pressure control on risk of dementia.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at 102 sites in the United States and Puerto Rico among adults aged 50 years or older with hypertension but without diabetes or history of stroke. Randomization began on November 8, 2010. The trial was stopped early for benefit on its primary outcome (a composite of cardiovascular events) and all-cause mortality on August 20, 2015. The final date for follow-up of cognitive outcomes was July 22, 2018.

INTERVENTIONS

Participants were randomized to a systolic blood pressure goal of either less than 120 mm Hg (intensive treatment group; n = 4678) or less than 140 mm Hg (standard treatment group; n = 4683).

MAIN OUTCOMES AND MEASURES

The primary cognitive outcome was occurrence of adjudicated probable dementia. Secondary cognitive outcomes included adjudicated mild cognitive impairment and a composite outcome of mild cognitive impairment or probable dementia.

RESULTS

Among 9361 randomized participants (mean age, 67.9 years; 3332 women [35.6%]), 8563 (91.5%) completed at least 1 follow-up cognitive assessment. The median intervention period was 3.34 years. During a total median follow-up of 5.11 years, adjudicated probable dementia occurred in 149 participants in the intensive treatment group vs 176 in the standard treatment group (7.2 vs 8.6 cases per 1000 person-years; hazard ratio [HR], 0.83; 95% CI, 0.67-1.04). Intensive BP control significantly reduced the risk of mild cognitive impairment (14.6 vs 18.3 cases per 1000 person-years; HR, 0.81; 95% CI, 0.69-0.95) and the combined rate of mild cognitive impairment or probable dementia (20.2 vs 24.1 cases per 1000 person-years; HR, 0.85; 95% CI, 0.74-0.97).

CONCLUSIONS AND RELEVANCE

Among ambulatory adults with hypertension, treating to a systolic blood pressure goal of less than 120 mm Hg compared with a goal of less than 140 mm Hg did not result in a significant reduction in the risk of probable dementia. Because of early study termination and fewer than expected cases of dementia, the study may have been underpowered for this end point.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01206062.

Lower blood pressure during antihypertensive treatment is associated with higher all-cause mortality and accelerated cognitive decline in the oldest-old. Data from the Leiden 85-plus Study

BACKGROUND

the appropriateness of lowering systolic blood pressure remains controversial in the oldest-old. We tested whether systolic blood pressure is associated with all-cause mortality and change in cognitive function for patients prescribed antihypertensive treatment and those without treatment.

METHODS

we studied participants in the population-based Leiden 85-plus cohort study. Baseline systolic blood pressure and use of antihypertensive treatment were predictors; all-cause mortality and change in cognitive function measured using the Mini-Mental State Examination were the outcomes. Grip strength was measured as a proxy for physical frailty. We used Cox proportional hazards and mixed-effects linear regression models to analyse the relationship between systolic blood pressure and both time to death and change in cognitive function. In sensitivity analyses, we excluded deaths within 1 year and restricted analyses to participants without a history of cardiovascular disease.

RESULTS

of 570 participants, 249 (44%) were prescribed antihypertensive therapy. All-cause mortality was higher in participants with lower blood pressure prescribed antihypertensive treatment (HR 1.29 per 10 mmHg lower systolic blood pressure, 95% CI 1.15-1.46, P < 0.001). Participants taking antihypertensives showed an association between accelerated cognitive decline and lower blood pressure (annual mean change -0.35 points per 10 mmHg lower systolic blood pressure, 95% CI -0.60, -0.11, P = 0.004); decline in cognition was more rapid in those with lower hand grip strength. In participants not prescribed antihypertensive treatment, no significant associations were seen between blood pressure and either mortality or cognitive decline.

CONCLUSIONS

lower systolic blood pressure in the oldest-old taking antihypertensives was associated with higher mortality and faster decline in cognitive function.

Association between Cognitive Impairment, Vascular Disease and All-Cause Mortality

OBJECTIVE

The purpose of this study was to investigate the association between elder's cognitive impairment and mortality. Additionally, interaction between cognitive impairment and cardio- and cerebrovascular diseases was considered.

METHODS

Data from the Korean Longitudinal Study of Aging (KLoSA) from 2006 to 2014 was assessed using 10,026 participants at baseline with no missing information. Chi-square test, log-rank test, and Cox proportional hazards models were used to investigate the association between cognitive impairment and mortality.

RESULTS

Cognitive impairment was significantly associated with mortality. With normal cognitive functioning group as reference: HR=2.329 (p<.0001) for severe cognitive impairment, HR=1.238 (p.009) for mild cognitive impairment. The association remained significant even after considering for cardio- and cerebrovascular diseases.

CONCLUSION

This study provided additional support to previous findings in regards to the relationship between cognitive impairment and mortality. Worse cognitive functioning increased the risk of mortality and the presence of cardio- and cerebrovascular diseases exacerbated this relationship.

Systolic blood pressure decline in very old individuals is explained by deteriorating health: Longitudinal changes from Umeå85+/GERDA

Declining systolic blood pressure (SBP) is common in very old age and is associated with adverse events, such as dementia. Knowledge of factors associated with SBP changes could explain the etiology of this decline in SBP. This study investigated longitudinal changes in socioeconomic factors, medical conditions, drug prescriptions, and assessments and their associations with SBP changes among very old followed individuals.The study was based on data from the Umeå85+/Gerontological Regional Database (GERDA) cohort study, which provided cross-sectional and longitudinal data on participants aged 85, 90, and ≥95 years from 2000 to 2015. Follow-up assessments were conducted after 5 years. The main outcome was a change in SBP. Factors associated with SBP changes were assessed using multivariate linear regression models.In the Umeå85+/GERDA study, 454 surviving individuals underwent follow-up assessment after 5 years. Of these, 297 had SBP measured at baseline and follow-up. The mean change ± standard deviation in SBP was -12 ± 25 mm Hg. SBP decline was associated independently with later investigation year (P = .009), higher baseline SBP (P < .001), baseline antidepressant prescription (P = .011), incident acute myocardial infarction during follow-up (P = .003), new diuretic prescription during follow-up (P = .044), and a decline in the Barthel Activities of Daily Living index at follow-up (P < .001).In conclusion, SBP declines among very old individuals. This decline seems to be associated with initial SBP level, investigation year, and health-related factors.

Defining the Relationship Between Hypertension, Cognitive Decline, and Dementia: a Review

Hypertension is a highly prevalent condition which has been established as a risk factor for cardiovascular and cerebrovascular disease. Although the understanding of the relationship between cardiocirculatory dysfunction and brain health has improved significantly over the last several decades, it is still unclear whether hypertension constitutes a potentially treatable risk factor for cognitive decline and dementia. While it is clear that hypertension can affect brain structure and function, recent findings suggest that the associations between blood pressure and brain health are complex and, in many cases, dependent on factors such as age, hypertension chronicity, and antihypertensive medication use. Whereas large epidemiological studies have demonstrated a consistent association between high midlife BP and late-life cognitive decline and incident dementia, associations between late-life blood pressure and cognition have been less consistent. Recent evidence suggests that hypertension may promote alterations in brain structure and function through a process of cerebral vessel remodeling, which can lead to disruptions in cerebral autoregulation, reductions in cerebral perfusion, and limit the brain's ability to clear potentially harmful proteins such as β-amyloid. The purpose of the current review is to synthesize recent findings from epidemiological, neuroimaging, physiological, genetic, and translational research to provide an overview of what is currently known about the association between blood pressure and cognitive function across the lifespan. In doing so, the current review also discusses the results of recent randomized controlled trials of antihypertensive therapy to reduce cognitive decline, highlights several methodological limitations, and provides recommendations for future clinical trial design.

"Do it-yourself": Home blood pressure as a predictor of traditional and everyday cognition in older adults

BACKGROUND

Hypertension guidelines recommend home blood pressure (HBP) monitoring in adjunct to office blood pressure (OBP) for its greater reproducibility and prognostic utility in the prevention of cardiovascular outcomes, especially stroke. To date, the relationship between HBP and cognitive function remains unexplored.

METHODS

We examined HBP as a cognitive predictor in a multi-ethnic group of community-dwelling adults aged 60 and over (N = 133) using neuropsychological measures and analyzed the data using multiple regression analyses. We also employed "everyday cognition" measures that have been found to have higher prognostic utility for real-world functioning than traditional cognitive tasks.

RESULTS

Good to perfect HBP monitoring compliance over seven days was achieved by 88.7% of the participants with superior reliability (ICC≥.96) to office readings. Higher home systolic BP and pulse pressure predicted worse processing speed, executive function, and everyday cognitive function, whereas lower home diastolic BP predicted worse everyday cognition. Office readings were similarly associated with everyday cognitive function but with no other cognitive measures.

CONCLUSION

Our findings are the first to validate HBP as a predictor of neuropsychological function in older adults beyond cognitive screening. Differential relationships among blood pressure variables and specific cognitive domains were observed. With proper standardization and training, we demonstrated that HBP can be obtained in a multi-ethnic community-dwelling older adult cohort. Our findings emphasize the importance of employing blood pressure and cognitive measures that are adequately sensitive to detect vascular-related cognitive impairment in a relatively healthy population. Implications regarding proper HBP measurement for hypertension management, cognitive health, and everyday function are discussed.

Systolic Blood Pressure Trajectory, Frailty, and All-Cause Mortality >80 Years of Age: Cohort Study Using Electronic Health Records

BACKGROUND

Clinical trials show benefit from lowering systolic blood pressure (SBP) in people ≥80 years of age, but nonrandomized epidemiological studies suggest lower SBP may be associated with higher mortality. This study aimed to evaluate associations of SBP with all-cause mortality by frailty category >80 years of age and to evaluate SBP trajectories before death.

METHODS

A population-based cohort study was conducted using electronic health records of 144 403 participants ≥80 years of age registered with family practices in the United Kingdom from 2001 to 2014. Participants were followed for ≤5 years. Clinical records of SBP were analyzed. Frailty status was classified using the e-Frailty Index into the categories of fit, mild, moderate, and severe. All-cause mortality was evaluated by frailty status and mean SBP in Cox proportional-hazards models. SBP trajectories were evaluated using person months as observations, with mean SBP and antihypertensive treatment status estimated for each person month. Fractional polynomial models were used to estimate SBP trajectories over 5 years before death.

RESULTS

During follow-up, 51 808 deaths occurred. Mortality rates increased with frailty level and were greatest at SBP <110 mm Hg. In fit women, mortality was 7.7 per 100 person years at SBP 120 to 139 mm Hg, 15.2 at SBP 110 to 119 mm Hg, and 22.7 at SBP <110 mm Hg. For women with severe frailty, rates were 16.8, 25.2, and 39.6, respectively. SBP trajectories showed an accelerated decline in the last 2 years of life. The relative odds of SBP <120 mm Hg were higher in the last 3 months of life than 5 years previously in both treated (odds ratio, 6.06; 95% confidence interval, 5.40-6.81) and untreated (odds ratio, 6.31; 95% confidence interval, 5.30-7.52) patients. There was no evidence of intensification of antihypertensive therapy in the final 2 years of life.

CONCLUSIONS

A terminal decline of SBP in the final 2 years of life suggests that nonrandomized epidemiological associations of low SBP with higher mortality may be accounted for by reverse causation if participants with lower blood pressure values are closer, on average, to the end of life.

Pathophysiologic relationship between Alzheimer's disease, cerebrovascular disease, and cardiovascular risk: A review and synthesis

As the population ages due to demographic trends and gains in life expectancy, the incidence and prevalence of dementia increases, and the need to understand the etiology and pathogenesis of dementia becomes ever more urgent. Alzheimer's disease (AD), the most common form of dementia, is a complex disease, the mechanisms of which are poorly understood. The more we learn about AD, the more questions are raised about our current conceptual models of disease. In the absence of a cure or the means by which to slow disease progress, it may be prudent to apply our current knowledge of the intersection between AD, cardiovascular disease, and cerebrovascular disease to foster efforts to delay or slow the onset of AD. This review discusses our current understanding of the epidemiology, genetics, and pathophysiology of AD, the intersection between AD and vascular causes of dementia, and proposes future directions for research and prevention.

Antihypertensive withdrawal for the prevention of cognitive decline

BACKGROUND

Clinical trials and observational data have variously shown a protective, harmful or neutral effect of antihypertensives on cognitive function. In theory, withdrawal of antihypertensives could improve cerebral perfusion and reduce or delay cognitive decline. However, it is also plausible that withdrawal of antihypertensives may have a detrimental effect on cognition through increased incidence of stroke or other vascular events.

OBJECTIVES

To assess the effects of complete withdrawal of at least one antihypertensive medication on incidence of dementia, cognitive function, blood pressure and other safety outcomes in cognitively intact and cognitive impaired adults.

SEARCH METHODS

We searched ALOIS, the specialised register of the Cochrane Dementia and Cognitive Improvement Group, with additional searches conducted in MEDLINE, Embase, PsycINFO, CINAHL, LILACS, Web of Science Core Collection, ClinicalTrials.gov and the World Health Organization Portal/ICTRP on 12 December 2015. There were no language or date restrictions applied to the electronic searches, and no methodological filters were used to restrict the search.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) provided they compared withdrawal of antihypertensive medications with continuation of the medications and included an outcome measure assessing cognitive function or a clinical diagnosis of dementia. We included studies with healthy participants, but we also included studies with participants with all grades of severity of existing dementia or cognitive impairment.

DATA COLLECTION AND ANALYSIS

Two review authors examined titles and abstracts of citations identified by the search for eligibility, retrieving full texts where needed to identify studies for inclusion, with any disagreement resolved by involvement of a third author. Data were extracted independently on primary and secondary outcomes. We used standard methodological procedures expected by Cochrane.The primary outcome measures of interest were changes in global and specific cognitive function and incidence of dementia; secondary outcomes included change in systolic and diastolic blood pressure, mortality, adverse events (including cardiovascular events, hospitalisation and falls) and adherence to withdrawal. The quality of the evidence was evaluated using the GRADE approach.

MAIN RESULTS

We included two RCTs investigating withdrawal of antihypertensives in 2490 participants. There was substantial clinical heterogeneity between the included studies, therefore we did not combine data for our primary outcome. Overall, the quality of included studies was high and the risk of bias was low. Neither study investigated incident dementia.One study assessed withholding previously prescribed antihypertensive drugs for seven days following acute stroke. Cognition was assessed using telephone Mini-Mental State Examination (t-MMSE) and Telephone Interview for Cognitive Status (TICS-M) at 90 days as a secondary outcome. The t-MMSE score was a mean of 1.0 point higher in participants who withdrew antihypertensive medications compared to participants who continued them (95% confidence interval (CI) 0.35 to 1.65; 1784 participants) and the TICS-M was a mean of 2.10 points higher (95% CI 0.69 to 3.51; 1784 participants). However, in both cases the evidence was of very low quality downgraded due to risk of bias, indirectness and evidence from a single study. The other study was community based and included participants with mild cognitive impairment. Drug withdrawal was for 16 weeks. Cognitive performance was assessed using a composite of at least five out of six cognitive tests. There was no evidence of a difference comparing participants who withdrew antihypertensive medications and participants who continued (mean difference 0.02 points, 95% CI -0.19 to 0.21; 351 participants). This evidence was of low quality and was downgraded due to risk of bias and evidence from single study.In one study, the systolic blood pressure after seven days of withdrawal was 9.5 mmHg higher in the intervention compared to the control group (95% CI 7.43 to 11.57; 2095 participants) and diastolic blood pressure was 5.1 mmHg higher (95% CI 3.86 to 6.34; 2095 participants). This evidence was low quality, downgraded due to indirectness, because the data must be interpreted in the context of the wider study looking at glyceryl trinitrate administration or not, and evidence from a single study. In the other study, systolic blood pressure increased by 7.4 mmHg in the withdrawal group compared to the control group (95% CI 7.08 to 7.72; 356 participants) and diastolic blood pressure increased by 2.6 mmHg (95% CI 2.42 to 2.78; 356 participants). This was moderate quality evidence, downgraded as evidence was from a single study. We combined data for mortality and cardiovascular events. There was no clear evidence that antihypertensive medication withdrawal affected adverse events, although there was a possible trend to increased cardiovascular events in the large post-stroke study (pooled mortality risk ratio 0.88, 95% CI 0.72 to 1.08; 2485 participants; and cardiovascular events risk ratio 1.29, 95% CI 0.96 to 1.72). Certain prespecified outcomes of interest (falls, hospitalisation) were not reported.

AUTHORS' CONCLUSIONS

The effects of withdrawing antihypertensive medications on cognition or prevention of dementia are uncertain. There was a signal of a positive effect in one study looking at withdrawal after acute stroke but these results are unlikely to be generalisable to non-stroke settings and were not a primary outcome of the study. Withdrawing antihypertensive drugs was associated with increased blood pressure. It is unlikely to increase mortality at three to four months' follow-up, although there was a signal from one large study looking at withdrawal after stroke that withdrawal was associated an increase in cardiovascular events.

The association between SBP and mortality risk differs with level of cognitive function in very old individuals

Objective:

Cognitive impairment and dementia are highly prevalent in very old populations. Cardiovascular disease is a common cause of death in people with dementia.

This study investigated whether the association of blood pressure (BP) with mortality differed with respect to mini-mental state examination (MMSE) score in a representative sample of very old individuals.

Methods:

The sample consisted of 1115 participants aged 85, 90, and at least 95 years from the Umeå85+/GErontological Regional DAtabase cohort study. The main outcome was all-cause mortality within 2 years according to BP and MMSE score, using Cox proportional-hazard regression models adjusted for sociodemographic and clinical characteristics associated with death.

Results:

Mean age, MMSE score, and SBP and DBP were 89.4 ± 4.6 years, 21.1 ± 7.6, 146.1 ± 23.4 mmHg, and 74.1 ± 11.7 mmHg, respectively. Within 2 years, 293 (26%) participants died. BP was not associated independently with mortality risk, except among participants with MMSE scores of 0–10 among whom mortality risk was increased in association with SBP at least 165 mmHg and 125 mmHg or less, compared with 126–139 mmHg (adjusted hazard ratio 4.54, 95% confidence interval = 1.52–13.60 and hazard ratio 2.23, 95% confidence interval = 1.12–4.45, respectively). In age and sex-adjusted analyses, SBP 125 mmHg or less was associated with increased mortality risk in participants with MMSE scores at least 18.

Conclusion:

In people aged at least 85 years, the association of SBP with mortality appears to differ with respect to MMSE score. Very old individuals with very severe cognitive impairment and low or high BP may have increased mortality risk.

Independent and interactive impacts of hypertension and diabetes mellitus on verbal memory: A coordinated analysis of longitudinal data from England, Sweden, and the United States

The importance of preventing and controlling hypertension (HTN) and diabetes mellitus (DM) to mitigate risks to physical health has long been understood by health care professionals. More recently, a growing body of evidence implicates HTN and DM in age-related cognitive decline and risk for dementia, though consensus has yet to be reached on whether older adults living with comorbid HTN and DM are at heightened risk for cognitive impairment. The present study sought to contribute to this topic through a coordinated analysis of 3 longitudinal studies of aging from England, Sweden, and the United States (total N = 12,513). Identical multilevel linear growth models were fit to each to estimate the impact of baseline disease status on initial level and change in verbal declarative memory performance. Overall, few associations between HTN, DM, and cognition were observed. Rate of decline was steeper for Swedish participants with independent HTN but attenuated for their American counterparts. Americans with comorbid HTN and DM showed attenuated decline. Treatment with medication was substantially less prevalent in the earlier-born and lower-educated Swedish sample, which may help to explain our pattern of results. In addition, those living with multiple conditions may be more likely to receive treatment, mitigating cognitive decline. Our results present a nuanced view of the interactions between HTN, DM, and cognition, and lead us to recommend consideration of treatment status or proxies such as birth cohort and education, in combination with age at assessment and specific measure used to interpret research in this area. (PsycINFO Database Record

Cognitive Impairment Among the Aging Population in a Community in Southwest Nigeria

Background. Vascular risk models can be quite informative in assisting the clinician to make a prediction of an individual’s risk of cognitive impairment. Thus, a simple marker is a priority for low-capacity settings. This study examines the association of selected simple to deploy vascular markers with cognitive impairment in an elderly population. Method. This cross-sectional study assessed the cognitive functions of older persons 65 years and older in southwest Nigeria. Vascular parameters and risk factors were also measured. Analysis was done using SPSS, and logistic regression was used to explore the association between cognitive impairment and certain vascular risk factors such as elevated blood pressure, diabetes, and pulse pressure. Results. The study population comprised 623 participants (29.1% men) with mean age 73 ± 8.9 years. Having mean arterial pressure (MAP) and pulse pressure in the fourth quartiles (27% and 29.9%, respectively) was significantly associated with cognitive impairment ( p = .001, p < .001). Predicted cardiovascular risks of 10% or more was significantly associated with cognitive impairment ( p < .001). After adjusting for age, gender, educational level, and years of smoking, those with MAP in the fourth quartile were up to 3 times more likely to have cognitive impairment compared to those within the first quartile. Conclusion. Our study demonstrated that among elderly Nigerians, MAPs of 114 mmHg and more was an independent predictor of cognitive impairment. This is a simple measure that is available in low-capacity areas.

Association of late-life changes in blood pressure and cognitive status

Background

Disagreement exists on the association between changes in blood pressure and cognitive impairment. We aimed to examine whether 4-year changes in systolic and diastolic blood pressure (SBP and DBP) are associated with cognitive status in a representative sample of older men and women.

Methods

Analysis of longitudinal data from 854 participants of a population-based German sample (aged 60–87 years) was performed with standard cognitive screening and blood pressure measurements. Effects of changes in SBP and DBP (10 mmHg and 5 mmHg respectively as unit of regression effect measure) on cognitive status were evaluated using non-parametric and linear regression modeling.

Results

No clear associations were seen between changes in SBP or in DBP and cognitive scores. Small effects were found after stratification for sex and hypertension awareness. Specifically, larger decreases in SBP were associated with higher cognitive scores in those men aware of their hypertension (10 mmHg decrease in SBP, β = −0.26, 95% CI: −0.51 to −0.02) and men with controlled hypertension (10 mmHg decrease in SBP, β = −0.44, 95% CI: −0.92 to −0.03). Additionally larger increases in DBP were associated with higher cognitive scores in men with controlled hypertension (5 mmHg increase in DBP, β = 0.67, 95% CI: 0.19–1.15). For women aware of their hypertension, larger decreases in DBP were associated with higher cognitive scores (5 mmHg decrease in DBP, β = −0.26; 95%CI: −0.51 to −0.01).

Conclusions

Changes in blood pressure were only weakly associated with cognitive status. Specifically, decreases in SBP were associated with higher cognitive scores in men aware of their hypertension and especially those that were medically controlled.

Antihypertensive Therapies and Cognitive Function: a Review

Increasing life expectancy has made old age-related health problems like dementia and cognitive decline more prevalent, and these are rapidly becoming important causes of disability and poor quality of life, causing significant add-ons to health-care costs worldwide. Hypertension is the most important modifiable vascular risk factor for the development and progression of both cognitive decline and dementia. In many observational and randomized studies, antihypertensive therapies have been shown to be beneficial in slowing cognitive decline. However, due to observed discrepancies by these studies, there is a lack of consensus on the best antihypertensive strategy for the prevention or slowing of cognitive decline. It is also not clear whether the beneficial effect of antihypertensive therapy is due to the use of a specific class of agents or combination therapy. Thus, we present a comprehensive review of overall antihypertensive therapies and cognition and of the individual antihypertensive therapy classes with their specific protective mechanisms and available clinical evidence behind their effect on cognitive function.

Higher outdoor temperatures are progressively associated with lower blood pressure: a longitudinal study in 100,000 healthy individuals

This study investigated the shape of associations between climate parameters (mean daily temperature and humidity) and systolic and diastolic blood pressure in a large longitudinal cohort of healthy individuals. The study population comprised 101,377 Dutch whole blood and plasma donors (50% men), who made 691,107 visits to the blood bank between 2007 and 2009. Climate parameters were acquired from the Royal Netherlands Meteorological Institute. Associations with blood pressure, measured prior to each blood donation, were studied using (piecewise) linear regression analyses within Generalized Estimating Equation models. On average, systolic blood pressure was 0.18 mm Hg, and diastolic blood pressure was 0.11 mm Hg lower per one degree Celsius higher mean daily temperature. Higher daily temperatures were associated with lower blood pressure, independent of humidity and potentially confounding factors. These associations were stronger at older age and higher temperatures. Seasonality should therefore be taken into account when monitoring blood pressure, particularly in older individuals.

Blood pressure, brain structure, and cognition: opposite associations in men and women

BACKGROUND

Research on associations between blood pressure, brain structure, and cognitive function has produced somewhat inconsistent results. In part, this may be due to differences in age ranges studied and because of sex differences in physiology and/or exposure to risk factors, which may lead to different time course or patterns in cardiovascular disease progression. The aim of this study was to investigate the impact of sex on associations between blood pressure, regional cerebral volumes, and cognitive function in older individuals.

METHODS

In this cohort study, brachial blood pressure was measured twice at rest in 266 community-based individuals free of dementia aged 68-73 years who had also undergone a brain scan and a neuropsychological assessment. Associations between mean blood pressure (MAP), regional brain volumes, and cognition were investigated with voxel-wise regression analyses.

RESULTS

Positive associations between MAP and regional volumes were detected in men, whereas negative associations were found in women. Similarly, there were sex differences in the brain-volume cognition relationship, with a positive relationship between regional brain volumes associated with MAP in men and a negative relationship in women.

CONCLUSIONS

In this cohort of older individuals, higher MAP was associated with larger regional volume and better cognition in men, whereas opposite findings were demonstrated in women. These effects may be due to different lifetime risk exposure or because of physiological differences between men and women. Future studies investigating the relationship between blood pressure and brain structure or cognitive function should evaluate the potential for differential sex effects.

Mildly elevated blood pressure is a marker for better health status in Polish centenarians

The number of centenarians is projected to rise rapidly. However, knowledge of evidence-based health care in this group is still poor. Hypertension is the most common condition that leads to multiple organ complications, disability, and premature death. No guidelines for the management of high blood pressure (BP) in centenarians are available. We have performed a cross-sectional study to characterize clinical and functional state of Polish centenarians, with a special focus on BP. The study comprised 86 consecutive 100.9 ± 1.2 years old (mean ± SD) subjects (70 women and 16 men). The assessment included structured interview, physical examination, geriatric functional assessment, resting electrocardiography, and blood and urine sampling. The subjects were followed-up on the phone. Subjects who survived 180 days (83 %) as compared to non-survivors had higher systolic BP (SBP), diastolic BP (DPB), mean arterial pressure (MAP), pulse pressure (PP), higher mini-mental state examination, Barthel Index of Activities of Daily Living and Lawton Instrumental Activities of Daily Living Scale scores, higher serum albumin and calcium levels, and total iron-binding capacity, while lower serum creatinine, cystatin C, folate, and C-reactive protein levels. SBP ≥140 mm Hg, DBP ≥90 mm Hg, MAP ≥100 mm Hg, and PP ≥40 mm Hg were associated with higher 180-day survival probability. Results suggest that mildly elevated blood pressure is a marker for better health status in Polish centenarians.