1
|
Schroevers JL, Hoevenaar-Blom MP, Busschers WB, Hollander M, Van Gool WA, Richard E, Van Dalen JW, Moll van Charante EP. Antihypertensive medication classes and risk of incident dementia in primary care patients: a longitudinal cohort study in the Netherlands. THE LANCET REGIONAL HEALTH. EUROPE 2024; 42:100927. [PMID: 38800111 PMCID: PMC11126814 DOI: 10.1016/j.lanepe.2024.100927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 04/19/2024] [Accepted: 04/19/2024] [Indexed: 05/29/2024]
Abstract
Background Hypertension is a modifiable risk factor for dementia affecting over 70% of individuals older than 60. Lowering dementia risk through preferential treatment with antihypertensive medication (AHM) classes that are otherwise equivalent in indication could offer a cost-effective, safe, and accessible approach to reducing dementia incidence globally. Certain AHM-classes have been associated with lower dementia risk, potentially attributable to angiotensin-II-receptor (Ang-II) stimulating properties. Previous study results have been inconclusive, possibly due to heterogeneous methodology and limited power. We aimed to comprehensively investigate associations between AHM (sub-)classes and dementia risk using large-scale continuous, real-world prescription and outcome data from primary care. Methods We used data from three Dutch General Practice Registration Networks. Primary endpoints were clinical diagnosis of incident all-cause dementia and mortality. Using Cox regression analysis with time-dependent covariates, we compared the use of angiotensin-converting enzyme inhibitors (ACEi) to angiotensin receptor blockers (ARBs), beta blockers, calcium channel blockers (CCBs), and diuretics; and Ang-II-stimulating- to Ang-II-inhibiting AHM. Findings Of 133,355 AHM-using participants, 5877 (4.4%) developed dementia, and 14,079 (10.6%) died during a median follow-up of 7.6 [interquartile range = 4.1-11.0] years. Compared to ACEi, ARBs [HR = 0.86 (95% CI = 0.80-0.92)], beta blockers [HR = 0.81 (95% CI = 0.75-0.87)], CCBs [HR = 0.77 (95% CI = 0.71-0.84)], and diuretics [HR = 0.65 (95% CI = 0.61-0.70)] were associated with significantly lower dementia risks. Regarding competing risk of death, beta blockers [HR = 1.21 (95% CI = 1.15-1.27)] and diuretics [HR = 1.69 (95% CI = 1.60-1.78)] were associated with higher, CCBs with similar, and ARBs with lower [HR = 0.83 (95% CI = 0.80-0.87)] mortality risk. Dementia [HR = 0.88 (95% CI = 0.82-0.95)] and mortality risk [HR = 0.86 (95% CI = 0.82-0.91)] were lower for Ang-II-stimulating versus Ang-II-inhibiting AHM. There were no interactions with sex, diabetes, cardiovascular disease, and number of AHM used. Interpretation Among patients receiving AHM, ARBs, CCBs, and Ang-II-stimulating AHM were associated with lower dementia risk, without excess mortality explaining these results. Extensive subgroup and sensitivity analyses suggested that confounding by indication did not importantly influence our findings. Dementia risk may be influenced by AHM-classes' angiotensin-II-receptor stimulating properties. An RCT comparing BP treatment with different AHM classes with dementia as outcome is warranted. Funding Netherlands Organisation for Health, Research and Development (ZonMw); Stoffels-Hornstra Foundation.
Collapse
Affiliation(s)
- Jakob L. Schroevers
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Marieke P. Hoevenaar-Blom
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Wim B. Busschers
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Monika Hollander
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG, Utrecht, the Netherlands
| | - Willem A. Van Gool
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Edo Richard
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
| | - Jan Willem Van Dalen
- Department of Neurology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - Eric P. Moll van Charante
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
- Department of Public & Occupational Health, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| |
Collapse
|
2
|
Wei W, Ma D, Li L, Zhang L. Cognitive impairment in cerebral small vessel disease induced by hypertension. Neural Regen Res 2024; 19:1454-1462. [PMID: 38051887 PMCID: PMC10883517 DOI: 10.4103/1673-5374.385841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 08/22/2023] [Indexed: 12/07/2023] Open
Abstract
ABSTRACT Hypertension is a primary risk factor for the progression of cognitive impairment caused by cerebral small vessel disease, the most common cerebrovascular disease. However, the causal relationship between hypertension and cerebral small vessel disease remains unclear. Hypertension has substantial negative impacts on brain health and is recognized as a risk factor for cerebrovascular disease. Chronic hypertension and lifestyle factors are associated with risks for stroke and dementia, and cerebral small vessel disease can cause dementia and stroke. Hypertension is the main driver of cerebral small vessel disease, which changes the structure and function of cerebral vessels via various mechanisms and leads to lacunar infarction, leukoaraiosis, white matter lesions, and intracerebral hemorrhage, ultimately resulting in cognitive decline and demonstrating that the brain is the target organ of hypertension. This review updates our understanding of the pathogenesis of hypertension-induced cerebral small vessel disease and the resulting changes in brain structure and function and declines in cognitive ability. We also discuss drugs to treat cerebral small vessel disease and cognitive impairment.
Collapse
Affiliation(s)
- Weipeng Wei
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
- Beijing Geriatric Medical Research Center; Beijing Engineering Research Center for Nervous System Drugs; National Center for Neurological Disorders; National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Denglei Ma
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
- Beijing Geriatric Medical Research Center; Beijing Engineering Research Center for Nervous System Drugs; National Center for Neurological Disorders; National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Lin Li
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
- Beijing Geriatric Medical Research Center; Beijing Engineering Research Center for Nervous System Drugs; National Center for Neurological Disorders; National Clinical Research Center for Geriatric Diseases, Beijing, China
| | - Lan Zhang
- Department of Pharmacy, Xuanwu Hospital of Capital Medical University, Beijing, China
- Beijing Geriatric Medical Research Center; Beijing Engineering Research Center for Nervous System Drugs; National Center for Neurological Disorders; National Clinical Research Center for Geriatric Diseases, Beijing, China
| |
Collapse
|
3
|
Sprague BN, Tu W, Unverzagt FW, Moser LR, Adams M, Carter A, Dawkins E, Keith NR, Reinoso DR, Clark DO. Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol. Contemp Clin Trials 2024; 141:107533. [PMID: 38621517 DOI: 10.1016/j.cct.2024.107533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/21/2024] [Accepted: 04/10/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults. METHODS AND STUDY DESIGN The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition. DISCUSSION This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.
Collapse
Affiliation(s)
- Briana N Sprague
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA.
| | - Wanzhu Tu
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Frederick W Unverzagt
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Lyndsi R Moser
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mariah Adams
- Department of Kinesiology, Indiana University Bloomington, Bloomington, IN, USA
| | - Amy Carter
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Emily Dawkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - NiCole R Keith
- Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA; Department of Kinesiology, Indiana University Bloomington, Bloomington, IN, USA
| | - Deanna R Reinoso
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA; Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Daniel O Clark
- Department of Medicine, Division of General Internal Medicine and Geriatrics, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc, Indianapolis, IN, USA
| |
Collapse
|
4
|
Morgan AE, Mc Auley MT. Vascular dementia: From pathobiology to emerging perspectives. Ageing Res Rev 2024; 96:102278. [PMID: 38513772 DOI: 10.1016/j.arr.2024.102278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/16/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
Vascular dementia (VaD) is the second most common type of dementia. VaD is synonymous with ageing, and its symptoms place a significant burden on the health and wellbeing of older people. Despite the identification of a substantial number of risk factors for VaD, the pathological mechanisms underpinning this disease remain to be fully elucidated. Consequently, a biogerontological imperative exists to highlight the modifiable lifestyle factors which can mitigate against the risk of developing VaD. This review will critically examine some of the factors which have been revealed to modulate VaD risk. The survey commences by providing an overview of the putative mechanisms which are associated with the pathobiology of VaD. Next, the factors which influence the risk of developing VaD are examined. Finally, emerging treatment avenues including epigenetics, the gut microbiome, and pro-longevity pharmaceuticals are discussed. By drawing this key evidence together, it is our hope that it can be used to inform future experimental investigations in this field.
Collapse
Affiliation(s)
- Amy Elizabeth Morgan
- School of Health and Sports Sciences, Hope Park, Liverpool Hope University, Liverpool L16 9JD, United Kingdom.
| | - Mark Tomás Mc Auley
- School of Science, Engineering and Environment, University of Salford Manchester, Salford M5 4NT, United Kingdom
| |
Collapse
|
5
|
Regnault V, Lacolley P, Laurent S. Arterial Stiffness: From Basic Primers to Integrative Physiology. Annu Rev Physiol 2024; 86:99-121. [PMID: 38345905 DOI: 10.1146/annurev-physiol-042022-031925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
The elastic properties of conductance arteries are one of the most important hemodynamic functions in the body, and data continue to emerge regarding the importance of their dysfunction in vascular aging and a range of cardiovascular diseases. Here, we provide new insight into the integrative physiology of arterial stiffening and its clinical consequence. We also comprehensively review progress made on pathways/molecules that appear today as important basic determinants of arterial stiffness, particularly those mediating the vascular smooth muscle cell (VSMC) contractility, plasticity and stiffness. We focus on membrane and nuclear mechanotransduction, clearance function of the vascular wall, phenotypic switching of VSMCs, immunoinflammatory stimuli and epigenetic mechanisms. Finally, we discuss the most important advances of the latest clinical studies that revisit the classical therapeutic concepts of arterial stiffness and lead to a patient-by-patient strategy according to cardiovascular risk exposure and underlying disease.
Collapse
|
6
|
Santisteban MM, Schaeffer S, Anfray A, Faraco G, Brea D, Wang G, Sobanko MJ, Sciortino R, Racchumi G, Waisman A, Park L, Anrather J, Iadecola C. Meningeal interleukin-17-producing T cells mediate cognitive impairment in a mouse model of salt-sensitive hypertension. Nat Neurosci 2024; 27:63-77. [PMID: 38049579 PMCID: PMC10999222 DOI: 10.1038/s41593-023-01497-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/16/2023] [Indexed: 12/06/2023]
Abstract
Hypertension (HTN), a disease afflicting over one billion individuals worldwide, is a leading cause of cognitive impairment, the mechanisms of which remain poorly understood. In the present study, in a mouse model of HTN, we find that the neurovascular and cognitive dysfunction depends on interleukin (IL)-17, a cytokine elevated in individuals with HTN. However, neither circulating IL-17 nor brain angiotensin signaling can account for the dysfunction. Rather, IL-17 produced by T cells in the dura mater is the mediator released in the cerebrospinal fluid and activating IL-17 receptors on border-associated macrophages (BAMs). Accordingly, depleting BAMs, deleting IL-17 receptor A in brain macrophages or suppressing meningeal T cells rescues cognitive function without attenuating blood pressure elevation, circulating IL-17 or brain angiotensin signaling. Our data unveil a critical role of meningeal T cells and macrophage IL-17 signaling in the neurovascular and cognitive dysfunction in a mouse model of HTN.
Collapse
Affiliation(s)
- Monica M Santisteban
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Samantha Schaeffer
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Antoine Anfray
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Giuseppe Faraco
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - David Brea
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
- Department of Neuroscience and Experimental Therapeutics, Instituto de Investigaciones Biomédicas de Barcelona, Barcelona, Spain
| | - Gang Wang
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Melissa J Sobanko
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Rose Sciortino
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Gianfranco Racchumi
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Ari Waisman
- Institute for Molecular Medicine, University Medical Center, Mainz, Germany
| | - Laibaik Park
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Josef Anrather
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Costantino Iadecola
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
| |
Collapse
|
7
|
Dhami P, Alagiakrishnan K, Senthilselvan A. Association between use of antihypertensives and cognitive decline in the elderly-A retrospective observational study. PLoS One 2023; 18:e0295658. [PMID: 38117779 PMCID: PMC10732389 DOI: 10.1371/journal.pone.0295658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/24/2023] [Indexed: 12/22/2023] Open
Abstract
AIM Mild cognitive impairment (MCI) is the prodromal phase of dementia. The objective of this study was to determine whether specific antihypertensives were associated with conversion from MCI to dementia. METHODS In this retrospective study, a chart review was conducted on 335 older adults seen at the University of Alberta Hospital, Kaye Edmonton Seniors Clinic who were diagnosed with MCI. At the point of diagnosis, data was collected on demographic and lifestyle characteristics, measures of cognitive function, blood pressure measurements, use of antihypertensives, and other known or suspected risk factors for cognitive decline. Patients were followed for 5.5 years for dementia diagnoses. A logistic regression analysis was then conducted to determine the factors associated with conversion from MCI to dementia. RESULTS Mean age (± standard deviation) of the study participants was 76.5 ± 7.3 years. Patients who converted from MCI to dementia were significantly older and were more likely to have a family history of dementia. After controlling for potential confounders including age, sex, Mini Mental Status Exam scores and family history of dementia, patients who were on beta-blockers (BBs) had a 57% reduction in the odds of converting to dementia (OR: 0.43, 95% CI: 0.23, 0.81). CONCLUSIONS In this study, BB use was protective against conversion from MCI to dementia. Further studies are required to confirm the findings of our study and to elucidate the effect of BBs on cognitive decline.
Collapse
Affiliation(s)
- Prabhpaul Dhami
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kannayiram Alagiakrishnan
- Division of Geriatric Medicine, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | | |
Collapse
|
8
|
Alghamdi A, Bijlsma MJ, de Vos S, Schuiling-Veninga CC, Bos JHJ, Hak E. Association between Incidence of Prescriptions for Alzheimer's Disease and Beta-Adrenoceptor Antagonists: A Prescription Sequence Symmetry Analysis. Pharmaceuticals (Basel) 2023; 16:1694. [PMID: 38139820 PMCID: PMC10748070 DOI: 10.3390/ph16121694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/29/2023] [Accepted: 12/03/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is the most common cause of dementia, with a growing number of patients worldwide. The association between AD and treatment with drugs targeting the beta-adrenergic receptor is controversial. The aim of this study is to assess the association between the initiation of AD medication and beta-adrenoceptor antagonists (beta-blockers) in adults. MATERIALS AND METHODS We conducted a prescription sequence symmetry analysis using the University of Groningen IADB.nl prescription database. We determined the order of the first prescription for treating AD and the first prescription for beta-blockers, with the dispensing date of the first prescription for AD defined as the index date. Participants were adults over 45 years old starting any AD medication and beta-blockers within two years. We calculated adjusted sequence ratios with corresponding 95% confidence intervals. RESULTS We identified 510 users of both AD and beta-blockers, and 145 participants were eligible. The results were compatible with either a significant decrease in the incidence of AD after using beta-blockers (adjusted sequence ratio (aSR) = 0.52; 95% CI: 0.35-0.72) or, conversely, an increase in beta-blockers after AD medication (aSR = 1.96; 95% CI: 1.61-2.30). CONCLUSIONS There is a relationship between the use of beta-blockers and AD medications. Further research is needed with larger populations to determine whether drug therapy for AD increases the risk of hypertension or whether beta-blockers have potential protective properties against AD development.
Collapse
Affiliation(s)
- Ali Alghamdi
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
| | - Maarten J. Bijlsma
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
- Laboratory of Population Health, Max Planck Institute for Demographic Research, 18057 Rostock, Germany
| | - Stijn de Vos
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
| | - Catharina C.M. Schuiling-Veninga
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
| | - Jens H. J. Bos
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
| | - Eelko Hak
- Groningen Research Institute of Pharmacy, Pharmaco Therapy, Epidemiology & Economics, University of Groningen, 9713 AV Groningen, The Netherlands (S.d.V.); (C.C.M.S.-V.); (E.H.)
- Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
9
|
Mateo‐Arriero I, Lalovic A, Dowden G, Markey L, Cox KL, Flicker L, Bessarab D, Thompson S, Kickett C, Woods D, Pestell CF, Edgill P, Etherton‐Beer C, Smith K. Co-design of dementia prevention program for Aboriginal Australians (DAMPAA). Alzheimers Dement 2023; 19:4564-4571. [PMID: 36933191 PMCID: PMC10955769 DOI: 10.1002/alz.13032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Dementia is highly prevalent in older Aboriginal Australians, with several modifiable risk factors. Currently, there is limited evidence on how to prevent cognitive decline in Aboriginal Australians. METHODS Based on our Theory of Change (ToC) framework, we co-developed the Dementia risk management and prevention program for Aboriginal Australians (DAMPAA) aged over 45 years in partnership with Aboriginal community-controlled organizations (ACCOs) and Elders. Qualitative data were collected through ACCO staff workshops, Elders yarning, and governance groups to inform the protocol. Additionally, we conducted a small pilot study. RESULTS Expected DAMPAA ToC outcomes are: (1) improved daily function, (2) better cardiovascular risk management, (3) falls reduction, (4) improved quality of life, and (5) reduced cognitive decline. Attendance enablers are social interaction, environment, exercise type/level, and logistics. DISCUSSION Findings suggest that ToC is an effective collaborative approach for co-designing Aboriginal health programs.
Collapse
Affiliation(s)
- Irene Mateo‐Arriero
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Alexander Lalovic
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Glennette Dowden
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Lesley Markey
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Kay L. Cox
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
- West Australian Centre for Health and AgeingUniversity of Western AustraliaPerthWAAustralia
| | - Leon Flicker
- West Australian Centre for Health and AgeingUniversity of Western AustraliaPerthWAAustralia
| | - Dawn Bessarab
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| | - Sandra Thompson
- Western Australian Centre for Rural HealthUniversity of Western AustraliaGeraldtonWAAustralia
| | | | - Deborah Woods
- Geraldton Regional Aboriginal Medical ServiceGeraldtonWAAustralia
| | - Carmela F. Pestell
- School of Psychological ScienceUniversity of Western AustraliaPerthWAAustralia
| | - Paula Edgill
- Derbarl Yerrigan Health ServiceEast PerthWAAustralia
| | | | - Kate Smith
- Centre for Aboriginal Medical and Dental HealthUniversity of Western AustraliaPerthWAAustralia
| |
Collapse
|
10
|
Upadhyaya P, Ling Y, Chen L, Kim Y, Jiang X. Inferring Personalized Treatment Effect of Antihypertensives on Alzheimer's Disease Using Deep Learning. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS. IEEE INTERNATIONAL CONFERENCE ON HEALTHCARE INFORMATICS 2023; 2023:49-57. [PMID: 38516035 PMCID: PMC10956734 DOI: 10.1109/ichi57859.2023.00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Alzheimer's disease (AD) is one of the leading causes of death in the United States, especially among the elderly. Recent studies have shown how hypertension is related to cognitive decline in elderly patients, which in turn leads to increased mortality as well as morbidity. There have been various studies that have looked at the effect of antihypertensive drugs in reducing cognitive decline, and their results have proved inconclusive. However, most of these studies assume the treatment effect is similar for all patients, thus considering only the average treatment effects of antihypertensive drugs. In this paper, we assume that the effect of antihypertensives on the onset of AD depends on patient characteristics. We develop a deep learning method called LASSO-Dragonnet to estimate the individualized treatment effects of each patient. We considered six antihypertensive drugs, and each of the six models considered one of the drugs as the treatment and the remaining as control. Our studies showed that although many antihypertensives have a positive impact in delaying AD onset on average, the impact varies from individual to individual, depending on their various characteristics. We also analyzed the importance of various covariates in such an estimation. Our results showed that the individualized treatment effects of each patient could be estimated accurately using a deep learning method, and that the importance of various covariates could be determined.
Collapse
Affiliation(s)
| | - Yaobin Ling
- School of Biomedical Informatics, UT Health, Houston, USA
| | - Luyao Chen
- School of Biomedical Informatics, UT Health, Houston, USA
| | - Yejin Kim
- School of Biomedical Informatics, UT Health, Houston, USA
| | - Xiaoqian Jiang
- School of Biomedical Informatics, UT Health, Houston, USA
| |
Collapse
|
11
|
Prajjwal P, Marsool MDM, Inban P, Sharma B, Asharaf S, Aleti S, Gadam S, Al Sakini AS, Hadi DD. Vascular dementia subtypes, pathophysiology, genetics, neuroimaging, biomarkers, and treatment updates along with its association with Alzheimer's dementia and diabetes mellitus. Dis Mon 2023; 69:101557. [PMID: 37031059 DOI: 10.1016/j.disamonth.2023.101557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2023]
Abstract
Dementia is a chronic progressive cognitive decline illness that results in functional impairment. Vascular dementia (VaD), second only to Alzheimer's disease (AD), is one of the most prevalent forms of dementia in the elderly (aged over 65 years), with a varied presentation and unpredictable disease development caused by cerebrovascular or cardiovascular illness. To get a better understanding of the changes occurring in the brain and to drive therapy efforts, new biomarkers for early and precise diagnosis of AD and VaD are required. In this review, Firstly, we describe the subtypes of vascular dementia, their clinical features, pathogenesis, genetics implemented, and their associated neuroimaging and biomarkers, while describing extensively the recent biomarkers discovered in the literature. Secondly, we describe some of the well-documented and other less-defined risk factors and their association and pathophysiology in relation to vascular dementia. Finally, we follow recent updates in the management of vascular dementia along with its association and differentiation from Alzheimer's disease. The aim of this review is to gather the scattered updates and the most recent changes in blood, CSF, and neuroimaging biomarkers related to the multiple subtypes of vascular dementia along with its association with Alzheimer's dementia and diabetes mellitus.
Collapse
Affiliation(s)
| | | | - Pugazhendi Inban
- Internal Medicine, Government Medical College, Omandurar, Chennai, India
| | | | - Shahnaz Asharaf
- Internal Medicine, Travancore Medical College, Kollam, Kerala, India
| | - Soumya Aleti
- PGY-2, Internal Medicine, Berkshire Medical Center, Pittsfield, MA, USA
| | - Srikanth Gadam
- Internal Medicine, Postdoctoral Research Fellow, Mayo Clinic, USA
| | | | - Dalia Dhia Hadi
- University of Baghdad, Al-Kindy College of Medicine, Baghdad, Iraq
| |
Collapse
|
12
|
Jung JH, Na HK, Jeong SH, Chung SJ, Yoo HS, Lee YH, Baik K, Kim SJ, Sohn YH, Lee PH. Effects of Dihydropyridines on the Motor and Cognitive Outcomes of Patients with Parkinson's Disease. Mov Disord 2023. [PMID: 36825772 DOI: 10.1002/mds.29367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Dihydropyridines (DHPs) may have neuroprotective effects against Parkinson's disease (PD). OBJECTIVE This study investigated the effects of DHPs on nigrostriatal dopaminergic denervation and longitudinal motor and cognitive outcomes in PD. METHODS We classified 476 patients with drug-naive PD who had undergone dopamine transporter imaging into three groups. They were selected according to a prior diagnosis of hypertension and use of DHPs and were matched using propensity scores: patients without hypertension (HTN-; n = 50) and patients with hypertension treated without DHP (HTN+/DHP-; n = 50) or with DHP (HTN+/DHP+; n = 50). Multiple linear regression and linear mixed model analyses were performed to determine intergroup differences in baseline dopamine transporter availability and longitudinal changes in the levodopa-equivalent dose, respectively. Using Kaplan-Meier analyses, we compared the risks of levodopa-induced dyskinesia, wearing off, and dementia-free survival during the 5.06 years of the mean follow-up period. The Cox regression model determined the independent effects of DHPs on dementia conversion. RESULTS Dopamine transporter availability in all striatal subregions was comparable between the HTN-, HTN+/DHP-, and HTN+/DHP+ groups. The risks of levodopa-induced dyskinesia and wearing off, as well as longitudinal changes in the levodopa-equivalent dose, did not differ between the groups. The HTN+/DHP+ group had a lower risk of developing dementia than the HTN+/DHP- (Bonferroni-corrected Plog-rank = 0.036) group. The use of DHP was independently associated with a lower risk of dementia conversion after controlling for other antihypertensive drugs and confounding factors (hazard ratio, 0.242; 95% confidence interval, 0.087-0.668; P = 0.006). CONCLUSIONS DHPs may be associated with better long-term cognitive outcomes in hypertensive patients with PD. © 2023 International Parkinson and Movement Disorder Society.
Collapse
Affiliation(s)
- Jin Ho Jung
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea.,Dementia and Neurodegenerative Disease Research Center, Inje University, Busan, South Korea
| | - Han Kyu Na
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Seong Ho Jeong
- Department of Neurology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, South Korea
| | - Seok Jong Chung
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Yongin Severance Hospital, Yonsei University Health System, Yongin, South Korea
| | - Han Soo Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Yang Hyun Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyoungwon Baik
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Sang Jin Kim
- Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea.,Dementia and Neurodegenerative Disease Research Center, Inje University, Busan, South Korea
| | - Young H Sohn
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea
| | - Phil Hyu Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea.,Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, South Korea
| |
Collapse
|
13
|
Schroevers JL, Eggink E, Hoevenaar-Blom MP, Van Dalen JW, Van Middelaar T, Van Gool WA, Richard E, Moll Van Charante EP. Antihypertensive medication classes and the risk of dementia over a decade of follow-up. J Hypertens 2023; 41:262-270. [PMID: 36394298 PMCID: PMC9799049 DOI: 10.1097/hjh.0000000000003324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/27/2022] [Accepted: 10/18/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Use of angiotensin II (ATII)-stimulating antihypertensive medication (AHM), including angiotensin receptor blockers (ARBs) and dihydropyridine calcium channel blockers (CCBs), has been associated with lower dementia risk. Previous studies had relatively short follow-up periods. The aim of this study is to investigate if these effects are sustained over longer periods. METHODS This post hoc observational analysis was based on data from a dementia prevention trial (preDIVA and its observational extension), among Dutch community-dwelling older adults without prior diagnosis of dementia. Differential associations between AHM classes and incident dementia were studied after 7.0 and 10.4 years, based on the median follow-up durations of dementia cases and all participants. RESULTS After 7 years, use of ATII-stimulating antihypertensives [hazard ratio = 0.68, 95% confidence interval (CI) = 0.47-1.00], ARBs (hazard ratio = 0.54, 95% CI = 0.31-0.94) and dihydropyridine CCBs (hazard ratio = 0.52, 95% CI = 0.30-0.91) was associated with lower dementia risk. After 10.4 years, associations for ATII-stimulating antihypertensives, ARBs and dihydropyridine CCBs attenuated (hazard ratio = 0.80, 95% CI = 0.61-1.04; hazard ratio = 0.75, 95% CI = 0.53-1.07; hazard ratio = 0.73, 95% CI = 0.51-1.04 respectively), but still suggested lower dementia risk when compared with use of other AHM classes. Results could not be explained by competing risk of mortality. CONCLUSION Our results suggest that use of ARBs, dihydropyridine CCBs and ATII-stimulating antihypertensives is associated with lower dementia risk over a decade, although associations attenuate over time. Apart from methodological aspects, differential effects of antihypertensive medication classes on incident dementia may in part be temporary, or decrease with ageing.
Collapse
Affiliation(s)
| | - Esmé Eggink
- Department of General Practice/Family Medicine
| | - Marieke P. Hoevenaar-Blom
- Department of Public and Occupational Health, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam
| | - Jan Willem Van Dalen
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen
| | - Tessa Van Middelaar
- Department of Neurology, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Willem A. Van Gool
- Department of Public and Occupational Health, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam
| | - Edo Richard
- Department of Public and Occupational Health, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen
| | - Eric P. Moll Van Charante
- Department of General Practice/Family Medicine
- Department of Public and Occupational Health, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam
| |
Collapse
|
14
|
Chrysant SG. Superior stroke prevention with angiotensin receptor blockers compared with other antihypertensive drugs. Expert Opin Drug Saf 2023; 22:125-131. [PMID: 36882886 DOI: 10.1080/14740338.2023.2189236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Stroke is a major cause of death and disability and its incidence is linearly increased with the elevation of blood pressure (BP) and the advancement of age in both men and women, with its incidence being higher in older subjects, the blacks and women. AREAS COVERED The annual worldwide incidence of stroke is 7.6 million for subjects ≥ 20 years of age with the average direct and indirect annual costs of stroke care, is expected to be $94.3 billion between 2014 and 2015. With respect to the cause of stroke, this is multifactorial, due to atherosclerotic heart disease, inflammation, atrial fibrillation, and hypertension with the latter being the most important cause. Therefore, control of BP is the major factor for its prevention. In order to get a better perspective on the current management of stroke, a Medline search of the English literature was conducted between 2014 and 2022 and 26 pertinent papers were selected. EXPERT OPINION Review of data from the selected papers demonstrated that control of SSBP < 130 mmHg was better in stroke prevention than SBP 130-140 mmHg for primary and secondary strokes. Among the drugs used, angiotensin receptor blockers provided superior stroke prevention compared to angiotensin converting enzyme inhibitors and other antihypertensive drugs.
Collapse
Affiliation(s)
- Steven G Chrysant
- Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Department of Cardiology, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| |
Collapse
|
15
|
Tayler HM, MacLachlan R, Güzel Ö, Miners JS, Love S. Elevated late-life blood pressure may maintain brain oxygenation and slow amyloid-β accumulation at the expense of cerebral vascular damage. Brain Commun 2023; 5:fcad112. [PMID: 37113314 PMCID: PMC10128877 DOI: 10.1093/braincomms/fcad112] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 02/16/2023] [Accepted: 04/03/2023] [Indexed: 04/29/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Hannah M Tayler
- Dementia Research Group, Institute of Clinical Neurosciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK
| | - Robert MacLachlan
- Dementia Research Group, Institute of Clinical Neurosciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK
| | - Özge Güzel
- Dementia Research Group, Institute of Clinical Neurosciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK
| | - J Scott Miners
- Dementia Research Group, Institute of Clinical Neurosciences, Bristol Medical School, University of Bristol, Bristol, BS10 5NB, UK
| | - Seth Love
- Correspondence to: Seth Love South West Dementia Brain Bank, University of Bristol Learning & Research Level 1, Southmead Hospital, Bristol, BS10 5NB, UK E-mail:
| |
Collapse
|
16
|
Peters R, Xu Y, Fitzgerald O, Aung HL, Beckett N, Bulpitt C, Chalmers J, Forette F, Gong J, Harris K, Humburg P, Matthews FE, Staessen JA, Thijs L, Tzourio C, Warwick J, Woodward M, Anderson CS. Blood pressure lowering and prevention of dementia: an individual patient data meta-analysis. Eur Heart J 2022; 43:4980-4990. [PMID: 36282295 DOI: 10.1093/eurheartj/ehac584] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/22/2022] [Accepted: 10/03/2022] [Indexed: 01/12/2023] Open
Abstract
AIMS Observational studies indicate U-shaped associations of blood pressure (BP) and incident dementia in older age, but randomized controlled trials of BP-lowering treatment show mixed results on this outcome in hypertensive patients. A pooled individual participant data analysis of five seminal randomized double-blind placebo-controlled trials was undertaken to better define the effects of BP-lowering treatment for the prevention of dementia. METHODS AND RESULTS Multilevel logistic regression was used to evaluate the treatment effect on incident dementia. Effect modification was assessed for key population characteristics including age, baseline systolic BP, sex, and presence of prior stroke. Mediation analysis was used to quantify the contribution of trial medication and changes in systolic and diastolic BP on risk of dementia. The total sample included 28 008 individuals recruited from 20 countries. After a median follow-up of 4.3 years, there were 861 cases of incident dementia. Multilevel logistic regression reported an adjusted odds ratio 0.87 (95% confidence interval: 0.75, 0.99) in favour of antihypertensive treatment reducing risk of incident dementia with a mean BP lowering of 10/4 mmHg. Further multinomial regression taking account of death as a competing risk found similar results. There was no effect modification by age or sex. Mediation analysis confirmed the greater fall in BP in the actively treated group was associated with a greater reduction in dementia risk. CONCLUSION The first single-stage individual patient data meta-analysis from randomized double-blind placebo-controlled clinical trials provides evidence to support benefits of antihypertensive treatment in late-mid and later life to lower the risk of dementia. Questions remain as to the potential for additional BP lowering in those with already well-controlled hypertension and of antihypertensive treatment commenced earlier in the life-course to reduce the long-term risk of dementia. CLASSIFICATION OF EVIDENCE Class I evidence in favour of antihypertensive treatment reducing risk of incident dementia compared with placebo.
Collapse
Affiliation(s)
- Ruth Peters
- Neuroscience Research Australia, Barker Street, Randwick, Sydney, New South Wales 2031, Australia
- Faculty of Science, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Imperial College London, Exhibition Road, London SW7 2AZ, UK
| | - Ying Xu
- Neuroscience Research Australia, Barker Street, Randwick, Sydney, New South Wales 2031, Australia
- Faculty of Science, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
| | - Oisin Fitzgerald
- Neuroscience Research Australia, Barker Street, Randwick, Sydney, New South Wales 2031, Australia
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | - Htein Linn Aung
- Neuroscience Research Australia, Barker Street, Randwick, Sydney, New South Wales 2031, Australia
| | - Nigel Beckett
- Guys and St Thomas' NHS Foundation Trust, Westminster Bridge Road, Lambeth, London SE1 7EH, UK
| | | | - John Chalmers
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | - Francoise Forette
- International Longevity Centre, 11 Rue Jean Mermoz, Paris 75008, France
| | - Jessica Gong
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | - Katie Harris
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | - Peter Humburg
- Neuroscience Research Australia, Barker Street, Randwick, Sydney, New South Wales 2031, Australia
| | - Fiona E Matthews
- Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne NE4 5PL, UK
| | - Jan A Staessen
- Research Institute Alliance for the Promotion of Preventive Medicine, 59 Leopold Straat, 2800 Mechelen, Belgium
- Biomedical Sciences Group, Faculty of Medicine, University of Leuven, 13 Oude Market, 3000 Leuven, Belgium
| | - Lutgarde Thijs
- Biomedical Sciences Group, Faculty of Medicine, University of Leuven, 13 Oude Market, 3000 Leuven, Belgium
| | - Christophe Tzourio
- Inserm, Bordeaux Population Health Research Center, University of Bordeaux, U1219, CHU Bordeaux, F-33000 Bordeaux, France
| | | | - Mark Woodward
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Imperial College London, Exhibition Road, London SW7 2AZ, UK
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | - Craig S Anderson
- The George Institute for Global Health, 5 King Street, Sydney, New South Wales 2042, Australia
- Faculty of Medicine, University of New South Wales, High Street Kensington, Sydney, New South Wales 2052, Australia
| | | |
Collapse
|
17
|
Zhang B, Hu M, Sun Y, Lin Y, Zhu C. Associations Between the Prevalence, Treatment, Control of Hypertension and Cognitive Trajectories Among Chinese Middle-Aged and Older Adults. Am J Geriatr Psychiatry 2022; 30:1123-1134. [PMID: 35466016 DOI: 10.1016/j.jagp.2022.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/26/2022] [Accepted: 03/27/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To investigate the associations between the prevalence, treatment, control of hypertension, and trajectories of cognitive performance among Chinese middle-aged and older adults. DESIGN An 8-year longitudinal study. SETTING China. PARTICIPANTS Chinese middle-aged and older adults. MEASUREMENTS Data from the China Health and Retirement Longitudinal Study were utilized. Group-based trajectory modeling was performed to identify heterogeneous trajectories of episodic memory and executive function. Multinomial logistic regression models were established to examine the relationships between hypertension status and cognitive trajectories, stratified by sex. RESULTS Three episodic memory trajectories and four executive function trajectories were identified in males and females. Hypertension prevalence was associated with worse episodic memory and executive function trajectories in females. Compared with treated hypertensives, untreated hypertensives were more likely to have worse executive function trajectories, both in males and females. Among male treated hypertensives, those with uncontrolled blood pressure (BP) had worse episodic memory trajectories compared with their counterparts with controlled at standard targets, while females with uncontrolled BP demonstrated worse executive function trajectories compared with females controlled at standard targets. There was basically no significant difference in cognitive trajectory memberships between individuals with controlled hypertension corresponding to intensive or standard BP targets. CONCLUSIONS The prevalence of hypertension was associated with worse cognitive trajectories, and the treatment and control of hypertension were related to more favorable cognitive trajectories. Intensive BP control target was not associated with additional benefit beyond the recognized protective effect of standard BP targets on cognitive trajectories.
Collapse
Affiliation(s)
- Baiyang Zhang
- Department of epidemiology and health statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Meijing Hu
- Department of epidemiology and health statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yue Sun
- Department of epidemiology and health statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Yidie Lin
- Department of epidemiology and health statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Cairong Zhu
- Department of epidemiology and health statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
| |
Collapse
|
18
|
Zheng J, Xu M, Walker V, Yuan J, Korologou-Linden R, Robinson J, Huang P, Burgess S, Au Yeung SL, Luo S, Holmes MV, Davey Smith G, Ning G, Wang W, Gaunt TR, Bi Y. Evaluating the efficacy and mechanism of metformin targets on reducing Alzheimer's disease risk in the general population: a Mendelian randomisation study. Diabetologia 2022; 65:1664-1675. [PMID: 35902387 PMCID: PMC9477943 DOI: 10.1007/s00125-022-05743-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/08/2022] [Indexed: 02/05/2023]
Abstract
AIMS/HYPOTHESIS Metformin use has been associated with reduced incidence of dementia in diabetic individuals in observational studies. However, the causality between the two in the general population is unclear. This study uses Mendelian randomisation (MR) to investigate the causal effect of metformin targets on Alzheimer's disease and potential causal mechanisms in the brain linking the two. METHODS Genetic proxies for the effects of metformin drug targets were identified as variants in the gene for the corresponding target that associated with HbA1c level (N=344,182) and expression level of the corresponding gene (N≤31,684). The cognitive outcomes were derived from genome-wide association studies comprising 527,138 middle-aged Europeans, including 71,880 with Alzheimer's disease or Alzheimer's disease-by-proxy. MR estimates representing lifelong metformin use on Alzheimer's disease and cognitive function in the general population were generated. Effect of expression level of 22 metformin-related genes in brain cortex (N=6601 donors) on Alzheimer's disease was further estimated. RESULTS Genetically proxied metformin use, equivalent to a 6.75 mmol/mol (1.09%) reduction on HbA1c, was associated with 4% lower odds of Alzheimer's disease (OR 0.96 [95% CI 0.95, 0.98], p=1.06×10-4) in non-diabetic individuals. One metformin target, mitochondrial complex 1 (MCI), showed a robust effect on Alzheimer's disease (OR 0.88, p=4.73×10-4) that was independent of AMP-activated protein kinase. MR of expression in brain cortex tissue showed that decreased MCI-related gene (NDUFA2) expression was associated with lower Alzheimer's disease risk (OR 0.95, p=4.64×10-4) and favourable cognitive function. CONCLUSIONS/INTERPRETATION Metformin use may cause reduced Alzheimer's disease risk in the general population. Mitochondrial function and the NDUFA2 gene are plausible mechanisms of action in dementia protection.
Collapse
Affiliation(s)
- Jie Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK.
| | - Min Xu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Venexia Walker
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
- Center for Digestive Disease, The Seventh Affiliated Hospital, Sun Yat-sen University, Shenzhen, Guangdong, China
- Guangzhou Women and Children Medical Center, Guangzhou, Guangdong, China
- Division of Epidemiology, the JC School of Public Health & Primary Care, the Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Roxanna Korologou-Linden
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - Jamie Robinson
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - Peiyuan Huang
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
| | - Stephen Burgess
- MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge, UK
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Shiu Lun Au Yeung
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Shan Luo
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong, SAR, China
| | - Michael V Holmes
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
- Clinical Trial Service Unit & Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford University Hospital, Oxford, UK
| | - George Davey Smith
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK
- NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK
| | - Guang Ning
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiqing Wang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tom R Gaunt
- MRC Integrative Epidemiology Unit (IEU), Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, UK.
- NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol, Bristol, UK.
| | - Yufang Bi
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
- Shanghai National Clinical Research Center for Metabolic Diseases, Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission of the PR China, Shanghai Key Laboratory for Endocrine Tumor, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| |
Collapse
|
19
|
Colbourne L, Harrison PJ. Brain-penetrant calcium channel blockers are associated with a reduced incidence of neuropsychiatric disorders. Mol Psychiatry 2022; 27:3904-3912. [PMID: 35618884 PMCID: PMC9708561 DOI: 10.1038/s41380-022-01615-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 04/14/2022] [Accepted: 05/06/2022] [Indexed: 02/08/2023]
Abstract
Calcium channel blockers (CCBs) differ in their ability to penetrate into the brain. Pharmacoepidemiological studies suggest that CCBs as a class may have beneficial effects on the risks and outcomes of some psychiatric and neurological disorders. It is plausible but unknown whether this effect relates to their brain penetrance. To address this, we used the TriNetX electronic health records network to identify people prescribed a brain-penetrant CCB (BP-CCB), or those given amlodipine, a CCB with low brain penetrability. We created cohorts of patients who, prior to first CCB exposure, either had to have, or could not have had, a recorded ICD-10 diagnosis in any of the following categories: psychotic disorder; affective disorder (including bipolar disorder and major depressive disorder); anxiety disorder; substance use disorder; sleep disorder; delirium; dementia, or movement disorder. Cohort pairs were propensity score matched for age, sex, race, blood pressure, body mass index, and a range of other variables. The outcomes were the incidence of these disorders measured over a two-year exposure period. Matched cohort sizes ranged from 17,896 to 49,987. In people with no prior history of psychiatric or neurodegenerative disorder, there was a significantly lower incidence of most disorders with BP-CCBs compared to amlodipine, with risk ratios ranging from 0.64 to 0.88 and an overall risk ratio of 0.88, i.e. a risk reduction of 12%. In people who did have a prior psychiatric or neurodegenerative diagnosis, differences were much smaller, but again showed lower risks for several disorders with BP-CCBs compared to amlodipine. The differences were somewhat more marked in women and in people less than 60 years old. Results were similar when comparing BP-CCBs with verapamil and diltiazem. We also compared BP-CCBs with angiotensin receptor blockers, and found an overall risk ratio of 0.94 in favour of BP-CCBs, but with differential effects across disorders including a higher risk of psychotic disorder and dementia, but a lower risk for anxiety and sleep disorders. In some analyses, there was evidence of residual confounding even after the extensive matching, in that negative control outcomes showed a reduced incidence with BP-CCBs relative to the comparator cohort. In summary, CCBs that readily penetrate the brain are associated with a lower incidence of neuropsychiatric disorders, especially first diagnoses, compared to CCBs which do not. This may reflect their blockade of neuronal voltage-gated calcium channels. The findings encourage repurposing trials using existing BP-CCBs, and suggest that novel BP-CCBs with enhanced and more selective central actions might have greater therapeutic potential for psychiatric and neurodegenerative disorders.
Collapse
Affiliation(s)
- Lucy Colbourne
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK
| | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford, OX3 7JX, UK.
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, OX3 7JX, UK.
| |
Collapse
|
20
|
Margrett JA, Schofield T, Martin P, Poon LW, Masaki K, Donlon TA, Kallianpur KJ, Willcox BJ. Novel Functional, Health, and Genetic Determinants of Cognitive Terminal Decline: Kuakini Honolulu Heart Program/Honolulu-Asia Aging Study. J Gerontol A Biol Sci Med Sci 2022; 77:1525-1533. [PMID: 34918073 PMCID: PMC9373950 DOI: 10.1093/gerona/glab327] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Indexed: 11/13/2022] Open
Abstract
To investigate interindividual differences in cognitive terminal decline and identify determinants including functional, health, and genetic risk and protective factors, data from the Honolulu Heart Program/Honolulu-Asia Aging Study, a prospective cohort study of Japanese American men, were analyzed. The sample was recruited in 1965-1968 (ages 45-68 years). Longitudinal performance of cognitive abilities and mortality status were assessed from Exam 4 (1991-1993) through June 2014. Latent class analysis revealed 2 groups: maintainers retained relatively high levels of cognitive functioning until death and decliners demonstrated significant cognitive waning several years prior to death. Maintainers were more likely to have greater education, diagnosed coronary heart disease, and presence of the apolipoprotein E (APOE) ε2 allele and FOXO3 G allele (SNP rs2802292). Decliners were more likely to be older and have prior stroke, Parkinson's disease, dementia, and greater depressive symptoms at Exam 4, and the APOE ε4 allele. Findings support terminal decline using distance to death as the basis for modeling change. Significant differences were observed between maintainers and decliners 15 years prior to death, a finding much earlier compared to the majority of previous investigations.
Collapse
Affiliation(s)
- Jennifer A Margrett
- Department of Human Development and Family Studies, College of Human Sciences, Iowa State University, Ames, Iowa, USA
| | - Thomas Schofield
- Department of Human Development and Family Studies, College of Human Sciences, Iowa State University, Ames, Iowa, USA
| | - Peter Martin
- Department of Human Development and Family Studies, College of Human Sciences, Iowa State University, Ames, Iowa, USA
| | - Leonard W Poon
- Institute of Gerontology, University of Georgia, Athens, Georgia, USA
| | - Kamal Masaki
- Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
- Department of Research, Kuakini Medical Center, Honolulu, Hawaii, USA
| | - Timothy A Donlon
- Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
- Department of Research, Kuakini Medical Center, Honolulu, Hawaii, USA
| | - Kalpana J Kallianpur
- Department of Research, Kuakini Medical Center, Honolulu, Hawaii, USA
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
| | - Bradley J Willcox
- Department of Geriatric Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, Hawaii, USA
- Department of Research, Kuakini Medical Center, Honolulu, Hawaii, USA
| |
Collapse
|
21
|
Wu Z, Woods RL, Chong TTJ, Orchard SG, McNeil JJ, Shah RC, Wolfe R, Murray AM, Storey E, Ryan J. Potential modifiable factors associated with late-life cognitive trajectories. Front Neurol 2022; 13:950644. [PMID: 35989918 PMCID: PMC9381981 DOI: 10.3389/fneur.2022.950644] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/11/2022] [Indexed: 11/19/2022] Open
Abstract
Objective There is variability across individuals in cognitive aging. To investigate the associations of several modifiable factors with high and low cognitive performance. Methods Data came from 17,724 community-dwelling individuals aged 65-98 years. Global cognition, verbal fluency, episodic memory, and psychomotor speed were assessed over up to seven years. Group-based multi-trajectory modeling identified distinct cognitive trajectories. Structural equation modeling examined the direct/indirect associations of social/behavioral factors and several chronic conditions with cognitive trajectories. Results Seven trajectory subgroups were identified. In the structural equation modeling we compared two subgroups-participants with the highest (14.2%) and lowest (4.1%) cognitive performance with the average subgroup. Lower education, never alcohol intake, and frailty directly predicted increased risk of low performance, and decreased likelihood of high performance. Hypertension (RR: 0.69, 95%CI: 0.60-0.80), obesity (RR: 0.84, 95%CI: 0.73-0.97), diabetes (RR: 0.69, 95%CI: 0.56-0.86) and depression (RR: 0.68, 95%CI: 0.54-0.85) only predicted lower likelihood of high cognitive performance, while dyslipidemia was only associated with low performance (RR: 1.30, 95%CI: 1.07-1.57). Living alone predicted increased risk of low cognitive performance and several comorbidities. Smoking did not predict cognitive trajectories but was associated with increased risk of diabetes, obesity and frailty. Findings were similar when examining the direct associations between modifiable risk factors and all seven cognitive subgroups. Conclusions Although several modifiable factors were associated with high performance, and reversely with low performance, this was not observed for obesity, hypertension and dyslipidemia. Further, health behaviors may affect cognitive function indirectly, via geriatric conditions. This indicates that strategies to promote healthy cognitive aging, may be distinct from those targeting dementia prevention.
Collapse
Affiliation(s)
- Zimu Wu
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Robyn L. Woods
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Trevor T. -J. Chong
- Turner Institute for Brain and Mental Health, Monash University, Melbourne, VIC, Australia,Department of Neurology, Alfred Health, Melbourne, VIC, Australia,Department of Clinical Neurosciences, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Suzanne G. Orchard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - John J. McNeil
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Raj C. Shah
- Department of Family Medicine and Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago, IL, United States
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Anne M. Murray
- Berman Center for Outcomes and Clinical Research, Hennepin Healthcare Research Institute, Minneapolis, MN, United States
| | - Elsdon Storey
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Joanne Ryan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia,*Correspondence: Joanne Ryan
| |
Collapse
|
22
|
Akushevich I, Kolpakov S, Yashkin AP, Kravchenko J. Vulnerability to Hypertension Is a Major Determinant of Racial Disparities in Alzheimer's Disease Risk. Am J Hypertens 2022; 35:745-751. [PMID: 35581146 PMCID: PMC9340628 DOI: 10.1093/ajh/hpac063] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 04/15/2022] [Accepted: 05/17/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Higher incidence levels of Alzheimer's disease (AD) in Black Americans are well documented. However, quantitative explanations of this disparity in terms of risk-factor diseases acting through well-defined pathways are lacking. METHODS We applied a Blinder-Oaxaca-based algorithm modified for censored data to a 5% random sample of Medicare beneficiaries age 65+ to explain Black/White disparities in AD risk in terms of differences in exposure and vulnerability to morbidity profiles based on 10 major AD-risk-related diseases. RESULTS The primary contribution to racial disparities in AD risk comes from morbidity profiles that included hypertension with about 1/5th of their contribution due to differences in prevalence (exposure effect) and 4/5ths to differences in the effects of the morbidity profile on AD risk (vulnerability effect). In total, disease-related effects explained a higher proportion of AD incidence in Black Americans than in their White counterparts. CONCLUSIONS Disease-related causes may represent some of the most straightforward targets for targeted interventions aimed at the reduction of racial disparities in health among US older adults. Hypertension is a manageable and potentially preventable condition responsible for the majority of the Black/White differences in AD risk, making mitigation of the role of this disease in engendering higher AD incidence in Black Americans a prominent concern.
Collapse
Affiliation(s)
| | - Stanislav Kolpakov
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Julia Kravchenko
- Department of Surgery, Duke University School of Medicine, Duke University, Durham, North Carolina, USA
| |
Collapse
|
23
|
Lai AY, Bazzigaluppi P, Morrone CD, Hill ME, Stefanovic B, McLaurin J. Compromised Cortical-Hippocampal Network Function From Transient Hypertension: Linking Mid-Life Hypertension to Late Life Dementia Risk. Front Neurosci 2022; 16:897206. [PMID: 35812238 PMCID: PMC9260147 DOI: 10.3389/fnins.2022.897206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022] Open
Abstract
Mid-life hypertension is a major risk factor for developing dementia later in life. While anti-hypertensive drugs restore normotension, dementia risk remains above baseline suggesting that brain damage sustained during transient hypertension is irreversible. The current study characterized a rat model of transient hypertension with an extended period of normotensive recovery: F344 rats were treated with L-NG-Nitroarginine methyl ester (L-NAME) for 1 month to induce hypertension then allowed up to 4 months of recovery. With respect to cognitive deficits, comparison between 1 month and 4 months of recovery identified initial deficits in spatial memory that resolved by 4 months post-hypertension; contrastingly, loss of cognitive flexibility did not. The specific cells and brain regions underlying these cognitive deficits were investigated. Irreversible structural damage to the brain was observed in both the prefrontal cortex and the hippocampus, with decreased blood vessel density, myelin and neuronal loss. We then measured theta-gamma phase amplitude coupling as a readout for network function, a potential link between the observed cognitive and pathological deficits. Four months after hypertension, we detected decreased theta-gamma phase amplitude coupling within each brain region and a concurrent increase in baseline connectivity between the two regions reflecting an attempt to maintain function that may account for the improvement in spatial memory. Our results demonstrate that connectivity between prefrontal cortex and hippocampus is a vulnerable network affected by transient hypertension which is not rescued over time; thus demonstrating for the first time a mechanistic link between the long-term effects of transient hypertension and dementia risk.
Collapse
Affiliation(s)
- Aaron Y. Lai
- Biological Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- *Correspondence: Aaron Y. Lai,
| | - Paolo Bazzigaluppi
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| | | | - Mary E. Hill
- Biological Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Bojana Stefanovic
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
| | - JoAnne McLaurin
- Biological Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
24
|
Bueno Bergantin L. Mental disorders and poor COVID-19 prognosis: reevaluating the relationship through Ca2+/cAMP signalling. Curr Top Med Chem 2022; 22:1215-1218. [PMID: 35524666 DOI: 10.2174/1568026622666220504163811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/12/2022] [Accepted: 03/18/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Leandro Bueno Bergantin
- Department of Pharmacology - Escola Paulista de Medicina - Universidade Federal de São Paulo - SP, Brazil
| |
Collapse
|
25
|
Johnson EEH, Alexander C, Lee GJ, Angers K, Ndiaye D, Suhr J. Examination of race and gender differences in predictors of neuropsychological decline and development of Alzheimer's disease. Clin Neuropsychol 2022; 36:327-352. [PMID: 34218735 PMCID: PMC10496932 DOI: 10.1080/13854046.2021.1940299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/28/2021] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Abstract
ObjectiveBlack adults are diagnosed with Alzheimer's disease (AD) at higher rates than White adults. Biopsychosocial risk factors that differentially affect individuals by race, including health, education, and APOE e4, may explain these findings. Some research suggests that the risk for AD associated with the APOE e4 allele may differ by race. Gender differences in AD have also been identified but remain understudied. We examined race, APOE status, vascular risk factors, education, and the interaction of APOE e4 status and race as predictors of cognitive decline and the development of Alzheimer's disease between genders in a large longitudinal sample of older adults. Methods: Participants (N = 4336) were selected from the National Alzheimer's Coordinating Center's Uniform Data Set who completed measures of verbal fluency, naming, and immediate/delayed story memory across 5 years. Analyses were stratified by gender. Follow up interactions examined statistical significance of differences. Results: APOE e4 by race interactions were largely non-significant and dropped from most models. When controlling for health, education, referral source, and Uniform Data Set form (when applicable), few racial differences in cognitive performance over time emerged. Black participants obtained lower scores than White participants on a majority of baseline measures. Race findings did not differ by gender. Hypertension was more strongly predictive of decline in delayed memory among women. Conclusions: Analyses did not support that APOE e4 differentially affects Black individuals. Hypertension may be a more relevant risk factor among women. Results raise questions regarding the accuracy of baseline scores in predicting decline for Black individuals.
Collapse
Affiliation(s)
| | | | - Grace J Lee
- Psychology, Ohio University, Athens, OH00, USA
| | | | | | - Julie Suhr
- Psychology, Ohio University, Athens, OH00, USA
| |
Collapse
|
26
|
Kivipelto M, Palmer K, Hoang TD, Yaffe K. Trials and Treatments for Vascular Brain Health: Risk Factor Modification and Cognitive Outcomes. Stroke 2022; 53:444-456. [DOI: 10.1161/strokeaha.121.032614] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is robust evidence linking vascular health to brain health, cognition, and dementia. In this article, we present evidence from trials of vascular risk factor treatment on cognitive outcomes. We summarize findings from randomized controlled trials of antihypertensives, lipid-lowering medications, diabetes treatments (including antidiabetic drugs versus placebo, and intensive versus standard glycemic control), and multidomain interventions (that target several domains simultaneously such as control of vascular and metabolic factors, nutrition, physical activity, and cognitive stimulation etc). We report that evidence on the efficacy of vascular risk reduction interventions is promising, but not yet conclusive, and several methodological limitations hamper interpretation. Evidence mainly comes from high-income countries and, as cognition and dementia have not been the primary outcomes of many trials, evaluation of cognitive changes have often been limited. As the cognitive aging process occurs over decades, it is unclear whether treatment during the late-life window is optimal for dementia prevention, yet older individuals have been the target of most trials thus far. Further, many trials have not been powered to explore interactions with modifiers such as age, race, and apolipoprotein E, even though sub-analyses from some trials indicate that the success of interventions differs depending on patient characteristics. Due to the complex multifactorial etiology of dementia, and variations in risk factors between individuals, multidomain interventions targeting several risk factors and mechanisms are likely to be needed and the long-term sustainability of preventive interventions will require personalized approaches that could be facilitated by digital health tools. This is especially relevant during the coronavirus disease 2019 (COVID-19) pandemic, where intervention strategies will need to be adapted to the new normal, when face-to-face engagement with participants is limited and public health measures may create changes in lifestyle that affect individuals’ vascular risk profiles and subsequent risk of cognitive decline.
Collapse
Affiliation(s)
- Miia Kivipelto
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden (M.K., K.P.)
- Medical Unit Aging, Karolinska University Hospital (M.K.)
- Ageing Epidemiology (AGE) Research Unit, School of Public Health, Imperial College London, United Kingdom (M.K.)
- Institute of Public Health and Clinical Nutrition and Institute of Clinical Medicine, Neurology, University of Eastern Finland, Kuopio (M.K.)
| | - Katie Palmer
- Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden (M.K., K.P.)
- FINGERS Brain Health Institute, Stockholm, Sweden (K.P.)
| | - Tina D. Hoang
- Northern California Institute for Research and Education, San Francisco, CA (T.D.H.)
- Center for Population Brain Health, University of California, San Francisco (T.D.H., K.Y.)
| | - Kristine Yaffe
- Departments of Psychiatry, Neurology, and Epidemiology; University of California, San Francisco (K.Y.)
- Center for Population Brain Health, University of California, San Francisco (T.D.H., K.Y.)
- San Francisco Veterans Affairs Healthcare System, CA (K.Y.)
| |
Collapse
|
27
|
Laurent S, Agabiti-Rosei C, Bruno RM, Rizzoni D. Microcirculation and Macrocirculation in Hypertension: A Dangerous Cross-Link? Hypertension 2022; 79:479-490. [PMID: 34984924 DOI: 10.1161/hypertensionaha.121.17962] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Microcirculation and macrocirculation are tightly interconnected into a dangerous cross-link in hypertension. Small artery damage includes functional (vasoconstriction, impaired vasodilatation) and structural abnormalities (mostly inward eutrophic remodeling). These abnormalities are major determinants of the increase in total peripheral resistance and mean blood pressure (BP) in primary hypertension, which in the long term induces large artery stiffening. In turn, large artery stiffening increases central systolic and pulse pressures, which are further augmented by wave reflection in response to the structural alterations in small resistance arteries. Finally, transmission of high BP and flow pulsatility to small resistance arteries further induces functional and structural abnormalities, thus leading to increased total peripheral resistance and mean BP, thus perpetuating the vicious circle. Hyperpulsatility, in addition to higher mean BP, exaggerates cardiac, brain, and kidney damages and leads to cardiovascular, cerebral, and renal complications. The dangerous cross-link between micro and macrocirculation can be reversed into a virtuous one by ACE (angiotensin-converting enzyme) inhibitors, sartans, and calcium channel blockers. These three pharmacological classes are more potent than β-blockers and diuretics for reducing arterial stiffness and small artery remodeling. The same ranking was observed for their effectiveness at reducing left ventricular hypertrophy, preserving glomerular filtration rate, and preventing dementia, suggesting that they can act beyond brachial BP reduction, by breaking the micro/macrocirculation vicious circle.
Collapse
Affiliation(s)
- Stephane Laurent
- Université de Paris, France (S.L., R.M.B.).,Department of Pharmacology, Georges Pompidou European Hospital, Assistance-Publique Hopitaux de Paris, France (S.L., R.M.B.).,INSERM U970, Cardiovascular Research Center-PARCC, Paris, France (S.L., R.M.B.)
| | - Claudia Agabiti-Rosei
- Department of Clinical and Experimental Sciences, Clinica Medica, University of Brescia, Italy (C.A.-R., D.R.)
| | - Rosa Maria Bruno
- Université de Paris, France (S.L., R.M.B.).,Department of Pharmacology, Georges Pompidou European Hospital, Assistance-Publique Hopitaux de Paris, France (S.L., R.M.B.).,INSERM U970, Cardiovascular Research Center-PARCC, Paris, France (S.L., R.M.B.)
| | - Damiano Rizzoni
- Department of Clinical and Experimental Sciences, Clinica Medica, University of Brescia, Italy (C.A.-R., D.R.).,Division of Medicine, Spedali Civili di Brescia, Montichiari, Italy (D.R.)
| |
Collapse
|
28
|
Ma LY, He F, Liu S, Wang XD, Gao Y, Shi Z, Niu J, Ji Y. The Association Between the Prevalence, Medication Adherence and Control of Hypertension and the Prevalence of Mild Cognitive Impairment in Rural Northern China: A Cross-Sectional Study. Patient Prefer Adherence 2022; 16:493-502. [PMID: 35228797 PMCID: PMC8882022 DOI: 10.2147/ppa.s351588] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/28/2022] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION High blood pressure is one of the main modifiable risk factors for dementia. However, it remains unclear whether lowering the blood pressure effectively prevents cognitive impairment. Our objective was to explore the association between the prevalence, medication adherence and control of hypertension and mild cognitive impairment (MCI) among elderly individuals in northern China. METHODS A two-stage clustering sampling method was used, and 9036 participants aged ≥65 years were included in the analysis. The Mini-Mental State Examination and activities of daily living were used to assess participants' cognitive function. Demographic characteristics (gender, age, marital status, education level, occupation), history and duration of hypertension, use of antihypertensive medications (AHMs) and its control effect were obtained. RESULTS The prevalence of MCI in all participants was 18.1%, and the prevalence of MCI was significantly higher in hypertensive subjects than in normotensive subjects (19.7% vs 16.2%, P < 0.01). Furthermore, in hypertensive patients, the prevalence of MCI was lower in those with good adherence (17.3%) than in those with poor adherence (23.7%, P < 0.01) and lower in those controlled (16.5%) than in those with uncontrolled adherence (20.8%, P < 0.01). In univariate analyses, being female gender, increased age, agriculture occupation, unmarried and widow, less than primary school and middle school were associated with MCI prevalence. The assessment of the hypertensive patients revealed the adjusted OR (95% CI) of having MCI in those with poor adherence to AHMs was 1.32 (1.14-1.54) compared with those having good adherence. CONCLUSION There is an association between the prevalence of hypertension, adherence to AHMs and MCI, suggesting that hypertensives should be screened for MCI to provide improved diagnoses and optimal therapeutics for cognitive decline prevention, especially in poor AHM adherence.
Collapse
Affiliation(s)
- Ling-Yun Ma
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Fangfang He
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People’s Republic of China
| | - Shuai Liu
- Tianjin Key Laboratory of Cerebrovascular and of Neurodegenerative Diseases, Department of Neurology, Tianjin Dementia Institute, Tianjin Huanhu Hospital, Tianjin, People’s Republic of China
| | - Xiao-Dan Wang
- Tianjin Key Laboratory of Cerebrovascular and of Neurodegenerative Diseases, Department of Neurology, Tianjin Dementia Institute, Tianjin Huanhu Hospital, Tianjin, People’s Republic of China
| | - Yanqin Gao
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People’s Republic of China
| | - Zhihong Shi
- Tianjin Key Laboratory of Cerebrovascular and of Neurodegenerative Diseases, Department of Neurology, Tianjin Dementia Institute, Tianjin Huanhu Hospital, Tianjin, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| | - Jianping Niu
- Department of Neurology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, People’s Republic of China
- Correspondence: Jianping Niu; Yong Ji, Tel +8618059218208; +8613612048681, Email ; ;
| | - Yong Ji
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People’s Republic of China
- Tianjin Key Laboratory of Cerebrovascular and of Neurodegenerative Diseases, Department of Neurology, Tianjin Dementia Institute, Tianjin Huanhu Hospital, Tianjin, People’s Republic of China
- China National Clinical Research Center for Neurological Diseases, Beijing, People’s Republic of China
| |
Collapse
|
29
|
Coatl-Cuaya H, Tendilla-Beltrán H, de Jesús-Vásquez LM, Garcés-Ramírez L, Gómez-Villalobos MDJ, Flores G. Losartan enhances cognitive and structural neuroplasticity impairments in spontaneously hypertensive rats. J Chem Neuroanat 2021; 120:102061. [PMID: 34952137 DOI: 10.1016/j.jchemneu.2021.102061] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 11/22/2021] [Accepted: 12/19/2021] [Indexed: 12/12/2022]
Abstract
Hypertension is a risk factor for vascular dementia, which is the second most prevalent type of dementia, just behind Alzheimer's disease. This highlights the brain vulnerability due to hypertension, which may increase with aging. Thus, studying how hypertension affects neural cells and behavior, as well as the effects of antihypertensives on these alterations, it's important to understand the hypertension consequences in the brain. The spontaneously hypertensive rat (SHR) has been useful for the study of hypertension alterations in diverse organs, including the brain. Thus, we studied the losartan effects on cognitive and structural neuroplasticity impairments in SHR of 10 months of age. In the first instance, we evaluated the losartan effects on exploratory behavior and novel object recognition test (NORT) in the SHR. Then, we assessed the density and morphology of dendritic spines of pyramidal neurons from the prefrontal cortex (PFC) layers 3 and 5, and CA1 of the dorsal Hp (dHp). Our results indicate that in SHR, losartan treatment (2 months, 15 mg/Kg/day) reduces high blood pressure to age-matched vehicle-treated Wistar-Kyoto (WKY) rat levels. Moreover, losartan improved long-term memory in SHR compared with age-matched vehicle-treated WKY rats, without affecting the locomotor and anxiety behaviors. The behavioral improvement of the SHR can be associated with the increase in the number of dendritic spines and the mushroom spine population in the PFC and the dHp. In conclusion, losartan enhances cognitive impairments by controlling the high blood pressure and improving neuroplasticity in animals with chronic hypertension.
Collapse
Affiliation(s)
- Heriberto Coatl-Cuaya
- Instituto de Fisiología, Benemérita Universidad Autónoma de Puebla (BUAP), Puebla, Mexico; Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), CDMX, Mexico
| | - Hiram Tendilla-Beltrán
- Instituto de Fisiología, Benemérita Universidad Autónoma de Puebla (BUAP), Puebla, Mexico; Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), CDMX, Mexico
| | | | - Linda Garcés-Ramírez
- Escuela Nacional de Ciencias Biológicas (ENCB), Instituto Politécnico Nacional (IPN), CDMX, Mexico
| | | | - Gonzalo Flores
- Instituto de Fisiología, Benemérita Universidad Autónoma de Puebla (BUAP), Puebla, Mexico.
| |
Collapse
|
30
|
Ungvari Z, Toth P, Tarantini S, Prodan CI, Sorond F, Merkely B, Csiszar A. Hypertension-induced cognitive impairment: from pathophysiology to public health. Nat Rev Nephrol 2021; 17:639-654. [PMID: 34127835 PMCID: PMC8202227 DOI: 10.1038/s41581-021-00430-6] [Citation(s) in RCA: 169] [Impact Index Per Article: 56.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Zoltan Ungvari
- Vascular Cognitive Impairment and Neurodegeneration Program, Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Peter Toth
- Vascular Cognitive Impairment and Neurodegeneration Program, Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment and Neurodegeneration Program, Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Calin I Prodan
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Veterans Affairs Medical Center, Oklahoma City, OK, USA
| | - Farzaneh Sorond
- Department of Neurology, Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Anna Csiszar
- Vascular Cognitive Impairment and Neurodegeneration Program, Center for Geroscience and Healthy Brain Aging, Department of Biochemistry and Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
- International Training Program in Geroscience, Doctoral School of Basic and Translational Medicine/Institute of Clinical Experimental Research, Semmelweis University, Budapest, Hungary.
| |
Collapse
|
31
|
Qin J, He Z, Wu L, Wang W, Lin Q, Lin Y, Zheng L. Prevalence of mild cognitive impairment in patients with hypertension: a systematic review and meta-analysis. Hypertens Res 2021; 44:1251-1260. [PMID: 34285378 DOI: 10.1038/s41440-021-00704-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 02/07/2023]
Abstract
Mild cognitive impairment (MCI) is common in patients with hypertension. Prevalence estimates of MCI in hypertensive patients are needed to guide both public health and clinical decision making. A literature search was conducted in four databases, including PubMed, Embase, Cochrane Library, and Web of Science, from their inception to February 2021. The methodological quality assessment used the risk of bias tool. The pooled prevalence of MCI in hypertensive patients was determined by a random-effects model. Heterogeneity was explored using sensitivity analysis, subgroup analysis, and random effects meta-regression. Of 2314 references, 11 studies (47,179 participants) were included in the meta-analysis. The overall pooled prevalence of MCI in patients with hypertension was 30% (95% CI, 25-35), with significant heterogeneity present (I2 = 99.3%, p < 0.001). In subgroup analyses, Asian and European samples had a prevalence of 26% (95% CI, 20-31) and 40% (95% CI, 14-66), respectively; cross-sectional and cohort studies had a prevalence of 28% (95% CI, 24-32) and 38% (95% CI, -5-81); age older than 60 years had a prevalence of 28% (95% CI, 23-33); community-based and clinic-based samples had a prevalence of 17% (95% CI, 15-19) and 42% (95% CI, 23-62); and MCI diagnosis using the MoCA, NIA-AA, MMSE, and Peterson criteria had a prevalence of 64% (95% CI, 59-68), 18% (95% CI, 16-19), 19% (95% CI, 15-23), and 13% (95% CI, 9-17). Meta-regression analysis showed that different MCI diagnostic criteria could be the source of heterogeneity in the pooled results. MCI is common in patients with hypertension, with an overall prevalence of 30%. Earlier cognitive screening and management in hypertensive patients should be advocated.
Collapse
Affiliation(s)
- Jiawei Qin
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China.
| | - Zexiang He
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Lijian Wu
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Wanting Wang
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Qiuxiang Lin
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Yiheng Lin
- Department of Rehabilitation Medicine, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China
| | - Liling Zheng
- Department of Cardiovascular Surgery, First Hospital of Quanzhou Affiliated to Fujian Medical University, Quanzhou, Fujian, China.
| |
Collapse
|
32
|
Ishida N, Saito M, Sato S, Tezuka Y, Sanbe A, Taira E, Hirose M. Mizagliflozin, a selective SGLT1 inhibitor, improves vascular cognitive impairment in a mouse model of small vessel disease. Pharmacol Res Perspect 2021; 9:e00869. [PMID: 34586752 PMCID: PMC8480397 DOI: 10.1002/prp2.869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 12/25/2022] Open
Abstract
Previously, we showed that sodium/glucose cotransporter 1 (SGLT1) participates in vascular cognitive impairment in small vessel disease. We hypothesized that SGLT1 inhibitors can improve the small vessel disease induced-vascular cognitive impairment. We examined the effects of mizagliflozin, a selective SGLT1 inhibitor, and phlorizin, a non-selective SGLT inhibitor, on vascular cognitive impairment in a mouse model of small vessel disease. Small vessel disease was created using a mouse model of asymmetric common carotid artery surgery (ACAS). Two and/or 4 weeks after ACAS, all experiments were performed. Cerebral blood flow (CBF) was decreased in ACAS compared with sham-operated mice. Phlorizin but not mizagliflozin reversed the decreased CBF of ACAS mice. Both mizagliflozin and phlorizin reversed the ACAS-induced decrease in the latency to fall in a wire hang test of ACAS mice. Moreover, they reversed the ACAS-induced longer escape latencies in the Morris water maze test of ACAS mice. ACAS increased SGLT1 and proinflammatory cytokine gene expressions in mouse brains and phlorizin but not mizagliflozin normalized all gene expressions in ACAS mice. Hematoxylin/eosin staining demonstrated that they inhibited pyknotic cell death in the ACAS mouse hippocampus. In PC12HS cells, IL-1β increased SGLT1 expression and decreased survival rates of cells. Both mizagliflozin and phlorizin increased the survival rates of IL-1β-treated PC12HS cells. These results suggest that mizagliflozin and phlorizin can improve vascular cognitive impairment through the inhibition of neural SGLT1 and phlorizin also does so through the improvement of CBF in a mouse model of small vessel disease.
Collapse
Affiliation(s)
- Nanae Ishida
- Division of Molecular and Cellular PharmacologyDepartment of Pathophysiology and PharmacologyIwate Medical UniversitySchool of Pharmaceutical SciencesIwateJapan
| | - Maki Saito
- Department of PharmacyIryo Sosei UniversityFukushimaJapan
| | - Sachiko Sato
- Department of PharmacologyIwate Medical UniversitySchool of MedicineIwateJapan
| | - Yu Tezuka
- Division of PharmacotherapeuticsDepartment of Pathophysiology and PharmacologyIwate Medical University School of Pharmaceutical SciencesIwateJapan
| | - Atsushi Sanbe
- Division of PharmacotherapeuticsDepartment of Pathophysiology and PharmacologyIwate Medical University School of Pharmaceutical SciencesIwateJapan
| | - Eiichi Taira
- Department of PharmacologyIwate Medical UniversitySchool of MedicineIwateJapan
| | - Masamichi Hirose
- Division of Molecular and Cellular PharmacologyDepartment of Pathophysiology and PharmacologyIwate Medical UniversitySchool of Pharmaceutical SciencesIwateJapan
| |
Collapse
|
33
|
Yoo S, Stremlau M, Pinto A, Woo H, Curtis O, van Praag H. Effects of Combined Anti-Hypertensive and Statin Treatment on Memory, Fear Extinction, Adult Neurogenesis, and Angiogenesis in Adult and Middle-Aged Mice. Cells 2021; 10:1778. [PMID: 34359946 PMCID: PMC8304131 DOI: 10.3390/cells10071778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 01/02/2023] Open
Abstract
Hyperlipidemia and hypertension are modifiable risk factors for cognitive decline. About 25% of adults over age 65 use both antihypertensives (AHTs) and statins to treat these conditions. Recent research in humans suggests that their combined use may delay or prevent dementia onset. However, it is not clear whether and how combination treatment may benefit brain function. To begin to address this question, we examined effects of atorvastatin, a 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor, and Captopril, an angiotensin-converting enzyme inhibitor (ACEI), administration on memory function, anxiety-like behavior, adult hippocampal neurogenesis and angiogenesis in adult and middle-aged male C57Bl/6J mice. In adult mice (3-months-old) combination (combo) treatment, as well as administration of each compound individually, for six weeks, accelerated memory extinction in contextual fear conditioning. However, pattern separation in the touchscreen-based location discrimination test, a behavior linked to adult hippocampal neurogenesis, was unchanged. In addition, dentate gyrus (DG) neurogenesis and vascularization were unaffected. In middle-aged mice (10-months-old) combo treatment had no effect on spatial memory in the Morris water maze, but did reduce anxiety in the open field test. A potential underlying mechanism may be the modest increase in new hippocampal neurons (~20%) in the combo as compared to the control group. DG vascularization was not altered. Overall, our findings suggest that statin and anti-hypertensive treatment may serve as a potential pharmacotherapeutic approach for anxiety, in particular for post-traumatic stress disorder (PTSD) patients who have impairments in extinction of aversive memories.
Collapse
Affiliation(s)
- Seungwoo Yoo
- Stiles-Nicholson Brain Institute and Charles E. Schmidt College of Medicine, Florida Atlantic University, Jupiter, FL 33458, USA; (S.Y.); (A.P.); (H.W.); (O.C.)
| | | | - Alejandro Pinto
- Stiles-Nicholson Brain Institute and Charles E. Schmidt College of Medicine, Florida Atlantic University, Jupiter, FL 33458, USA; (S.Y.); (A.P.); (H.W.); (O.C.)
| | - Hyewon Woo
- Stiles-Nicholson Brain Institute and Charles E. Schmidt College of Medicine, Florida Atlantic University, Jupiter, FL 33458, USA; (S.Y.); (A.P.); (H.W.); (O.C.)
| | - Olivia Curtis
- Stiles-Nicholson Brain Institute and Charles E. Schmidt College of Medicine, Florida Atlantic University, Jupiter, FL 33458, USA; (S.Y.); (A.P.); (H.W.); (O.C.)
| | - Henriette van Praag
- Stiles-Nicholson Brain Institute and Charles E. Schmidt College of Medicine, Florida Atlantic University, Jupiter, FL 33458, USA; (S.Y.); (A.P.); (H.W.); (O.C.)
- National Institute on Aging (NIA), Baltimore, MD 21224, USA;
| |
Collapse
|
34
|
van Dalen JW, Mutsaerts HJ, Petr J, Caan MW, van Charante EPM, MacIntosh BJ, van Gool WA, Nederveen AJ, Richard E. Longitudinal relation between blood pressure, antihypertensive use and cerebral blood flow, using arterial spin labelling MRI. J Cereb Blood Flow Metab 2021; 41:1756-1766. [PMID: 33325767 PMCID: PMC8217888 DOI: 10.1177/0271678x20966975] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Consistent cerebral blood flow (CBF) is fundamental to brain function. Cerebral autoregulation ensures CBF stability. Chronic hypertension can lead to disrupted cerebral autoregulation in older people, potentially leading to blood pressure levels interfering with CBF. This study tested whether low BP and AHD use are associated with contemporaneous low CBF, and whether longitudinal change in BP is associated with change in CBF, using arterial spin labelling (ASL) MRI, in a prospective longitudinal cohort of 186 community-dwelling older individuals with hypertension (77 ± 3 years, 53% female), 125 (67%) of whom with 3-year follow-up. Diastolic blood pressure, systolic blood pressure, mean arterial pressure, and pulse pressure were assessed as blood pressure parameters. As additional cerebrovascular marker, we evaluated the ASL signal spatial coefficient of variation (ASL SCoV), a measure of ASL signal heterogeneity that may reflect cerebrovascular health. We found no associations between any of the blood pressure measures and concurrent CBF nor between changes in blood pressure measures and CBF over three-year follow-up. Antihypertensive use was associated with lower grey matter CBF (-5.49 ml/100 g/min, 95%CI = -10.7|-0.27, p = 0.04) and higher ASL SCoV (0.32 SD, 95%CI = 0.12|0.52, p = 0.002). These results warrant future research on the potential relations between antihypertensive use and cerebral perfusion.
Collapse
Affiliation(s)
- Jan Willem van Dalen
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Henri Jmm Mutsaerts
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jan Petr
- Institute of Radiopharmaceutical Cancer Research, Helmholtz-Zentrum Dresden-Rossendorf, Dresden, Germany
| | - Matthan Wa Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Eric P Moll van Charante
- Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bradley J MacIntosh
- Department of Medical Biophysics, University of Toronto, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Willem A van Gool
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Aart J Nederveen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Edo Richard
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.,Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
35
|
Rojas M, Chávez-Castillo M, Pirela D, Parra H, Nava M, Chacín M, Angarita L, Añez R, Salazar J, Ortiz R, Durán Agüero S, Gravini-Donado M, Bermúdez V, Díaz-Camargo E. Metabolic Syndrome: Is It Time to Add the Central Nervous System? Nutrients 2021; 13:nu13072254. [PMID: 34208833 PMCID: PMC8308252 DOI: 10.3390/nu13072254] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/05/2021] [Accepted: 06/09/2021] [Indexed: 12/28/2022] Open
Abstract
Metabolic syndrome (MS) is a set of cardio-metabolic risk factors that includes central obesity, hyperglycemia, hypertension, and dyslipidemias. The syndrome affects 25% of adults worldwide. The definition of MS has evolved over the last 80 years, with various classification systems and criteria, whose limitations and benefits are currently the subject of some controversy. Likewise, hypotheses regarding the etiology of MS add more confusion from clinical and epidemiological points of view. The leading suggestion for the pathophysiology of MS is insulin resistance (IR). IR can affect multiple tissues and organs, from the classic “triumvirate” (myocyte, adipocyte, and hepatocyte) to possible effects on organs considered more recently, such as the central nervous system (CNS). Mild cognitive impairment (MCI) and Alzheimer’s disease (AD) may be clinical expressions of CNS involvement. However, the association between MCI and MS is not understood. The bidirectional relationship that seems to exist between these factors raises the questions of which phenomenon occurs first and whether MCI can be a precursor of MS. This review explores shared pathophysiological mechanisms between MCI and MS and establishes a hypothesis of a possible MCI role in the development of IR and the appearance of MS.
Collapse
Affiliation(s)
- Milagros Rojas
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela; (M.R.); (D.P.); (H.P.); (M.N.); (J.S.)
| | | | - Daniela Pirela
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela; (M.R.); (D.P.); (H.P.); (M.N.); (J.S.)
| | - Heliana Parra
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela; (M.R.); (D.P.); (H.P.); (M.N.); (J.S.)
| | - Manuel Nava
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela; (M.R.); (D.P.); (H.P.); (M.N.); (J.S.)
| | - Maricarmen Chacín
- Facultad de Ciencias de la Salud, Universidad Simón Bolívar, Barranquilla 08002, Colombia;
| | - Lissé Angarita
- Escuela de Nutrición y Dietética, Facultad de Medicina, Universidad Andrés Bello, Sede Concepción 4260000, Chile;
| | - Roberto Añez
- Departamento de Endocrinología y Nutrición, Hospital General Universitario Gregorio Marañón, 28007 Madrid, Spain;
| | - Juan Salazar
- Endocrine and Metabolic Diseases Research Center, School of Medicine, University of Zulia, Maracaibo 4004, Venezuela; (M.R.); (D.P.); (H.P.); (M.N.); (J.S.)
| | - Rina Ortiz
- Posgrado, Carrera de Medicina, Universidad Católica de Cuenca, Cantón de Cuenca 010101, Ecuador;
| | - Samuel Durán Agüero
- Facultad de Ciencias Para el Cuidado de la Salud, Universidad San Sebastián, Los Leones 8420524, Chile;
| | - Marbel Gravini-Donado
- Facultad de Ciencias Jurídicas y Sociales, Universidad Simón Bolívar, Barranquilla 080002, Colombia;
| | - Valmore Bermúdez
- Facultad de Ciencias Jurídicas y Sociales, Universidad Simón Bolívar, Cúcuta 540006, Colombia;
| | - Edgar Díaz-Camargo
- Facultad de Ciencias Jurídicas y Sociales, Universidad Simón Bolívar, Cúcuta 540006, Colombia;
- Correspondence:
| |
Collapse
|
36
|
Cuddy LK, Prokopenko D, Cunningham EP, Brimberry R, Song P, Kirchner R, Chapman BA, Hofmann O, Hide W, Procissi D, Hanania T, Leiser SC, Tanzi RE, Vassar R. Aβ-accelerated neurodegeneration caused by Alzheimer's-associated ACE variant R1279Q is rescued by angiotensin system inhibition in mice. Sci Transl Med 2021; 12:12/563/eaaz2541. [PMID: 32998969 DOI: 10.1126/scitranslmed.aaz2541] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 05/06/2020] [Indexed: 12/18/2022]
Abstract
Recent genome-wide association studies identified the angiotensin-converting enzyme gene (ACE) as an Alzheimer's disease (AD) risk locus. However, the pathogenic mechanism by which ACE causes AD is unknown. Using whole-genome sequencing, we identified rare ACE coding variants in AD families and investigated one, ACE1 R1279Q, in knockin (KI) mice. Similar to AD, ACE1 was increased in neurons, but not microglia or astrocytes, of KI brains, which became elevated further with age. Angiotensin II (angII) and angII receptor AT1R signaling were also increased in KI brains. Autosomal dominant neurodegeneration and neuroinflammation occurred with aging in KI hippocampus, which were absent in the cortex and cerebellum. Female KI mice exhibited greater hippocampal electroencephalograph disruption and memory impairment compared to males. ACE variant effects were more pronounced in female KI mice, suggesting a mechanism for higher AD risk in women. Hippocampal neurodegeneration was completely rescued by treatment with brain-penetrant drugs that inhibit ACE1 and AT1R. Although ACE variant-induced neurodegeneration did not depend on β-amyloid (Aβ) pathology, amyloidosis in 5XFAD mice crossed to KI mice accelerated neurodegeneration and neuroinflammation, whereas Aβ deposition was unchanged. KI mice had normal blood pressure and cerebrovascular functions. Our findings strongly suggest that increased ACE1/angII signaling causes aging-dependent, Aβ-accelerated selective hippocampal neuron vulnerability and female susceptibility, hallmarks of AD that have hitherto been enigmatic. We conclude that repurposed brain-penetrant ACE inhibitors and AT1R blockers may protect against AD.
Collapse
Affiliation(s)
- Leah K Cuddy
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Dmitry Prokopenko
- Genetics and Aging Unit and McCance Center for Brain Health, Department of Neurology, Massachusetts General Hospital, Boston, MA 02129, USA
| | - Eric P Cunningham
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Ross Brimberry
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Peter Song
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Rory Kirchner
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Brad A Chapman
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA
| | - Oliver Hofmann
- Department of Clinical Pathology, University of Melbourne, Victoria 3000, Melbourne, Australia
| | - Winston Hide
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Daniele Procissi
- Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | | | | | - Rudolph E Tanzi
- Genetics and Aging Unit and McCance Center for Brain Health, Department of Neurology, Massachusetts General Hospital, Boston, MA 02129, USA.
| | - Robert Vassar
- Ken and Ruth Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA. .,Mesulam Center for Cognitive Neurology and Alzheimer's Disease, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| |
Collapse
|
37
|
Jung H, Yang PS, Kim D, Jang E, Yu HT, Kim TH, Sung JH, Pak HN, Lee MH, Lip GYH, Joung B. Associations of hypertension burden on subsequent dementia: a population-based cohort study. Sci Rep 2021; 11:12291. [PMID: 34112942 PMCID: PMC8192762 DOI: 10.1038/s41598-021-91923-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/17/2021] [Indexed: 12/19/2022] Open
Abstract
In this nationwide cohort study, we assessed the effects of hypertension burden and blood pressure (BP) control on dementia in different age subgroups. From the Korean National Health Insurance Service-Health Screening cohort from January 1, 2005 to December 31, 2013, we enrolled 428,976 subjects aged 40-79 years without previous diagnosis of dementia or stroke. During a mean follow-up of 7.3 ± 1.5 years, 9435 (2.2%) were diagnosed with dementia. Per 10 mmHg increase in systolic BP (SBP), risk of dementia was increased by 22% (95% confidence interval [CI] 1.15-1.30) in subjects aged 40-59 years and 8% (95% CI 1.04-1.11) in subjects aged 60-69 years. No significant associations were observed in subjects aged ≥ 70 years. Among subjects aged 40-59 years, both vascular and Alzheimer's dementia risks were increased with increasing SBP. Increasing hypertension burden (proportion of days with increased BP) was associated with higher dementia risk (hazard ratio [HR] 1.09 per 10% increase, 95% CI 1.08-1.10). Among patients with baseline SBP ≥ 140 mmHg, optimal follow-up SBP (120-139 mmHg) was associated with decreased dementia risk (HR 0.69, 95% CI 0.50-0.95). Hypertension burden was associated with higher risks of dementia. Adequate BP control was associated with lower risk of dementia in individuals aged < 70 years.
Collapse
Affiliation(s)
- Hyunjean Jung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Pil-Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Eunsun Jang
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Hee Tae Yu
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Tae-Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Jung-Hoon Sung
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, England, UK.
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.
| |
Collapse
|
38
|
Colbourne L, Luciano S, Harrison PJ. Onset and recurrence of psychiatric disorders associated with anti-hypertensive drug classes. Transl Psychiatry 2021; 11:319. [PMID: 34039956 PMCID: PMC8155006 DOI: 10.1038/s41398-021-01444-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/01/2021] [Accepted: 05/11/2021] [Indexed: 11/12/2022] Open
Abstract
The major anti-hypertensive (AHT) drug classes have been associated with differential risks of psychiatric disorders. However, existing data are limited largely to depression, and confounding variables have not always been controlled for. We sought to fill the evidence gap, using TriNetX Analytics, an electronic health records network. Amongst 58.6 million patients aged 18-90 years, patients prescribed a calcium channel blocker (CCB) were compared with those taking a diuretic, angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or β-blocker. Cohorts were propensity score-matched for age, sex, race, and blood pressure. Over a 2-year exposure period, we measured the incidence and risk ratio of a first diagnosis (ICD-10 codes), or a recurrence, of psychotic, affective, and anxiety disorders, as well as substance use disorders and sleep disorders. Cohort sizes ranged from 33,734 to 322,814. CCBs were associated with a lower incidence of psychotic, affective, and anxiety disorders than β-blockers (risk ratios 0.69-0.99) and a higher incidence than ARBs (risk ratios 1.04-2.23) for both first and recurrent diagnoses. Comparisons of CCBs with ACEIs or diuretics showed smaller risk ratios that varied between disorders, and between first episode and recurrence. AHT classes were also associated with the incidence of substance use and sleep disorders. Results remained largely unchanged after more extensive cohort matching for additional potential confounders. In a secondary analysis, a comparison between ARBs and ACEIs showed lower rates of psychotic, affective, and substance use disorders with ARBs, but higher risks of anxiety and sleep disorders. In conclusion, AHT classes are differentially associated with the incidence of psychiatric disorders. ARBs show the most advantageous profile and β-blockers the least. The apparent beneficial effects of ARBs merit further study.
Collapse
Affiliation(s)
- Lucy Colbourne
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
| | | | - Paul J Harrison
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, OX3 7JX, UK.
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK.
| |
Collapse
|
39
|
Cunningham EL, Todd SA, Passmore P, Bullock R, McGuinness B. Pharmacological treatment of hypertension in people without prior cerebrovascular disease for the prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2021; 5:CD004034. [PMID: 34028812 PMCID: PMC8142793 DOI: 10.1002/14651858.cd004034.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2006 (McGuinness 2006), and previously updated in 2009 (McGuinness 2009). Hypertension is a risk factor for dementia. Observational studies suggest antihypertensive treatment is associated with lower incidences of cognitive impairment and dementia. There is already clear evidence to support the treatment of hypertension after stroke. OBJECTIVES To assess whether pharmacological treatment of hypertension can prevent cognitive impairment or dementia in people who have no history of cerebrovascular disease. SEARCH METHODS We searched the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, CENTRAL, MEDLINE, Embase, three other databases, as well as many trials registries and grey literature sources, most recently on 7 July 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which pharmacological interventions to treat hypertension were given for at least 12 months. We excluded trials of pharmacological interventions to lower blood pressure in non-hypertensive participants. We also excluded trials conducted solely in people with stroke. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected information regarding incidence of dementia, cognitive decline, change in blood pressure, adverse effects and quality of life. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, totaling 30,412 participants, in this review. Eight studies compared active treatment with placebo. Of the four non-placebo-controlled studies, two compared intensive versus standard blood pressure reduction. The two final included studies compared different classes of antihypertensive drug. Study durations varied from one to five years. The combined result of four placebo-controlled trials that reported incident dementia indicated no evidence of a difference in the risk of dementia between the antihypertensive treatment group and the placebo group (236/7767 versus 259/7660, odds ratio (OR) 0.89, 95% confidence interval (CI) 0.72 to 1.09; very low certainty evidence, downgraded due to study limitations and indirectness). The combined results from five placebo-controlled trials that reported change in Mini-Mental State Examination (MMSE) may indicate a modest benefit from antihypertensive treatment (mean difference (MD) 0.20, 95% CI 0.10 to 0.29; very low certainty evidence, downgraded due to study limitations, indirectness and imprecision). The certainty of evidence for both cognitive outcomes was downgraded on the basis of study limitations and indirectness. Study durations were too short, overall, to expect a significant difference in dementia rates between groups. Dementia and cognitive decline were secondary outcomes for most studies. Additional sources of bias include: the use of antihypertensive medication by the placebo group in the placebo-controlled trials; failure to reach recruitment targets; and early termination of studies on safety grounds. Meta-analysis of the placebo-controlled trials reporting results found a mean change in systolic blood pressure of -9.25 mmHg (95% CI -9.73, -8.78) between treatment (n = 8973) and placebo (n = 8820) groups, and a mean change in diastolic blood pressure of -2.47 mmHg (95% CI -2.70, -2.24) between treatment (n = 7700) and placebo (n = 7509) groups (both low certainty evidence downgraded on the basis of study limitations and inconsistency). Three trials - SHEP 1991, LOMIR MCT IL 1996 and MRC 1996 - reported more withdrawals due to adverse events in active treatment groups than placebo groups. Participants on active treatment in Syst Eur 1998 were less likely to discontinue treatment due to side effects, and participants on active treatment in HYVET 2008 reported fewer 'serious adverse events' than in the placebo group. There was no evidence of a difference in withdrawals rates between groups in SCOPE 2003, and results were unclear for Perez Stable 2000 and Zhang 2018. Heterogeneity precluded meta-analysis. Five of the placebo-controlled trials provided quality of life (QOL) data. Heterogeneity again precluded meta-analysis. SHEP 1991, Syst Eur 1998 and HYVET 2008 reported no evidence of a difference in QOL measures between active treatment and placebo groups over time. The SCOPE 2003 sub-study (Degl'Innocenti 2004) showed a smaller drop in QOL measures in the active treatment compared to the placebo group. LOMIR MCT IL 1996 reported an improvement in a QOL measure at twelve months in one active treatment group and deterioration in another. AUTHORS' CONCLUSIONS High certainty randomised controlled trial evidence regarding the effect of hypertension treatment on dementia and cognitive decline does not yet exist. The studies included in this review provide low certainty evidence (downgraded primarily due to study limitations and indirectness) that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, leads to less cognitive decline compared to controls. This difference is below the level considered clinically significant. The studies included in this review also provide very low certainty evidence that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, prevents dementia.
Collapse
Affiliation(s)
| | - Stephen A Todd
- Care of the Elderly Medicine, Western Health and Social Care Trust, Londonderry, UK
| | - Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Roger Bullock
- Kingshill Research Centre, Victoria Hospital, Swindon, UK
| | | |
Collapse
|
40
|
Palmer JC, Tayler HM, Dyer L, Kehoe PG, Paton JFR, Love S. Zibotentan, an Endothelin A Receptor Antagonist, Prevents Amyloid-β-Induced Hypertension and Maintains Cerebral Perfusion. J Alzheimers Dis 2021; 73:1185-1199. [PMID: 31903990 PMCID: PMC7081103 DOI: 10.3233/jad-190630] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cerebral blood flow is reduced in Alzheimer’s disease (AD), which is associated with mid-life hypertension. In people with increased cerebral vascular resistance due to vertebral artery or posterior communicating artery hypoplasia, there is evidence that hypertension develops as a protective mechanism to maintain cerebral perfusion. In AD, amyloid-β (Aβ) accumulation may similarly raise cerebral vascular resistance by upregulation of the cerebral endothelin system. The level of endothelin-1 in brain tissue correlates positively with Aβ load and negatively with markers of cerebral hypoperfusion such as increased vascular endothelial growth factor. We previously showed that cerebroventricular infusion of Aβ40 exacerbated pre-existing hypertension in Dahl rats. We have investigated the effects of 28-day cerebral infusion of Aβ40 on blood pressure and heart rate and their variability; carotid flow; endothelin-1; and markers of cerebral oxygenation, in the (normotensive) Wistar rat, and the modulatory influence of the endothelin A receptor antagonist Zibotentan (ZD4054). Cerebral infusion of Aβ caused progressive rise in blood pressure (p < 0.0001) (paired t-test: increase of 3 (0.1–5.6) mmHg (p = 0.040)), with evidence of reduced baroreflex responsiveness, and accumulation of Aβ and elevated endothelin-1 in the vicinity of the infusion. Oral Zibotentan (3 mg/kg/d, administered for 31 d) abrogated the effects of Aβ40 infusion on baroreflex responsiveness and blood pressure, which declined, although without reduction in carotid blood flow, and Zibotentan caused uncoupling of the positive linear relationship between endothelin-1 and vascular endothelial growth factor, which as a sensor of tissue oxygenation would be expected to increase if there were hypoperfusion.
Collapse
Affiliation(s)
- Jennifer C Palmer
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Hannah M Tayler
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Laurence Dyer
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Patrick G Kehoe
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julian F R Paton
- Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, New Zealand
| | - Seth Love
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
41
|
Rosenberg A, Mangialasche F, Ngandu T, Solomon A, Kivipelto M. Multidomain Interventions to Prevent Cognitive Impairment, Alzheimer's Disease, and Dementia: From FINGER to World-Wide FINGERS. JPAD-JOURNAL OF PREVENTION OF ALZHEIMERS DISEASE 2021; 7:29-36. [PMID: 32010923 PMCID: PMC7222931 DOI: 10.14283/jpad.2019.41] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Alzheimer’s disease (AD) and dementia are a global public health priority, and prevention has been highlighted as a pivotal component in managing the dementia epidemic. Modifiable risk factors of dementia and AD include lifestyle-related factors, vascular and metabolic disorders, and psychosocial factors. Randomized controlled clinical trials (RCTs) are needed to clarify whether modifying such factors can prevent or postpone cognitive impairment and dementia in older adults. Given the complex, multifactorial, and heterogeneous nature of late-onset AD and dementia, interventions targeting several risk factors and mechanisms simultaneously may be required for optimal preventive effects. The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) is the first large, long-term RCT to demonstrate that a multidomain lifestyle-based intervention ameliorating vascular and lifestyle-related risk factors can preserve cognitive functioning and reduce the risk of cognitive decline among older adults at increased risk of dementia. To investigate the multidomain intervention in other populations and diverse cultural and geographical settings, the World-Wide FINGERS (WW-FINGERS) network was recently launched (https://alz.org/wwfingers). Within this network, new FINGER-type trials with shared core methodology, but local culture and context-specific adaptations, will be conducted in several countries. The WW-FINGERS initiative facilitates international collaborations, provides a platform for testing multidomain strategies to prevent cognitive impairment and dementia, and aims at generating high-quality scientific evidence to support public health and clinical decision-making. Furthermore, the WW-FINGERS network can support the implementation of preventive strategies and translation of research findings into practice.
Collapse
Affiliation(s)
- A Rosenberg
- Miia Kivipelto, Division of Clinical Geriatrics, Center for Alzheimer Research, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska Universitetssjukhuset, Karolinska Vägen 37 A, QA32, 171 64 Solna, Sweden, Phone: +46 (0)73 99 40 922,
| | | | | | | | | |
Collapse
|
42
|
Harrison PJ, Colbourne L, Luciano S. Incidence of neurodegenerative and cerebrovascular diseases associated with antihypertensive drug classes. Br J Psychiatry 2021; 218:283-285. [PMID: 33407979 PMCID: PMC7611720 DOI: 10.1192/bjp.2020.249] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Antihypertensive drugs (AHTs) are associated with lowered risks of neurodegenerative diseases and stroke. However, the relative risks associated with different AHT classes are unclear. Using an electronic health record network with 34 million eligible patients, we compared rates of these disorders over a 2-year period, in propensity score-matched cohorts of people taking calcium channel blockers (CCBs) compared with those taking other AHT classes. CCBs were associated with a higher incidence of all disorders compared with renin-angiotensin system agents, and a higher incidence of dementia and cerebrovascular disease compared with diuretics. CCBs were associated with a lower incidence of movement disorders and cerebrovascular disease compared with beta-blockers. The data show that AHT classes confer differential risks of neurodegenerative and cerebrovascular diagnoses.
Collapse
Affiliation(s)
- Paul J Harrison
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX,Oxford Health NHS Foundation Trust, Oxford OX3 7JX,Correspondence to Prof PJ Harrison, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, U.K.
| | - Lucy Colbourne
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX,Oxford Health NHS Foundation Trust, Oxford OX3 7JX
| | | |
Collapse
|
43
|
Zhao Q, Wang X, Wang T, Dmytriw AA, Zhang X, Yang K, Luo J, Bai X, Jiang N, Yang B, Ma Y, Jiao L, Xie Y. Cognitive rehabilitation interventions after stroke: protocol for a systematic review and meta-analysis of randomized controlled trials. Syst Rev 2021; 10:66. [PMID: 33663590 PMCID: PMC7931553 DOI: 10.1186/s13643-021-01607-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stroke is the second leading cause of death worldwide, and 53.4% of stroke survivors suffer from post-stroke cognitive impairment. Post-stroke cognitive impairment can increase hospitalization rate and cost of care and decrease the quality of life of stroke patients. To date, multiple cognitive rehabilitation interventions have been tested in stroke populations with post-stroke cognitive impairment. However, the most efficacious intervention has not been established. This systematic review aims to compare the efficacy of cognitive rehabilitation interventions for patients with post-stroke cognitive impairment. METHODS We will search MEDLINE, EMBASE, CENTRAL, PsycINFO, CINAHL, PubMed, and clinical trial registries to identify eligible randomized clinical trials with no restrictions in the date of publication and language. Studies conducted with patients aged 18 or over, with the presence of cognitive impairment after being diagnosed with stroke will be included. Studies will be restricted to randomized controlled trials comparing a cognitive rehabilitation intervention with another intervention. The primary outcome is any clinical changes in the general or specific cognitive domain (e.g., executive function, attention, memory, or perception). The secondary outcomes that will be collected include adverse effects (e.g., stroke, disability, or mortality) and quality of life. Two independent reviewers will assess articles to identify trials eligible for inclusion. Data extraction and risk of bias assessment of the included studies will also be done independently. Any discrepancies will be solved by discussion, or a third reviewer will be consulted if necessary. A meta-analysis will be carried out if appropriate. DISCUSSION This systematic review for patients with post-stroke cognitive impairment will assess the efficacy of cognitive rehabilitation interventions. And our results will help clinical decision-making and support the development of clinical practice guidelines. TRIAL REGISTRATION Systematic review registration: PROSPERO CRD42020173988.
Collapse
Affiliation(s)
- Qing Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China.,Department of Clinical Medicine, Peking Union Medical College, No. 5 Dongdan Three Street, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Adam A Dmytriw
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, USA
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Jichang Luo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Nan Jiang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Yan Ma
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China.,China International Neuroscience Institute (China-INI), No. 45 Changchun Street, Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Yunyan Xie
- Department of Neurology, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, 100053, China.
| |
Collapse
|
44
|
Nakaoku Y, Takahashi Y, Tominari S, Nakayama T. Predictors of New Dementia Diagnoses in Elderly Individuals: A Retrospective Cohort Study Based on Prefecture-Wide Claims Data in Japan. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18020629. [PMID: 33451034 PMCID: PMC7828475 DOI: 10.3390/ijerph18020629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/16/2022]
Abstract
Preventing dementia in elderly individuals is an important public health challenge. While early identification and modification of predictors are crucial, predictors of dementia based on routinely collected healthcare data are not fully understood. We aimed to examine potential predictors of dementia diagnosis using routinely collected claims data. In this retrospective cohort study, claims data from fiscal years 2012 (baseline) and 2016 (follow-up), recorded in an administrative claims database of the medical care system for the elderly (75 years or older) in Niigata prefecture, Japan, were used. Data on baseline characteristics including age, sex, diagnosis, and prescriptions were collected, and the relationship between subsequent new diagnoses of dementia and potential predictors was examined using multivariable logistic regression models. A total of 226,738 people without a diagnosis of dementia at baseline were followed. Of these, 26,092 incident dementia cases were detected during the study period. After adjusting for confounding factors, cerebrovascular disease (odds ratio, 1.15; 95% confidence interval, 1.11-1.18), depression (1.38; 1.31-1.44), antipsychotic use (1.40; 1.31-1.49), and hypnotic use (1.17; 1.11-1.24) were significantly associated with subsequent diagnosis of dementia. Analyses of routinely collected claims data revealed neuropsychiatric symptoms including depression, antipsychotic use, hypnotic use, and cerebrovascular disease to be predictors of new dementia diagnoses.
Collapse
Affiliation(s)
- Yuriko Nakaoku
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto 606-8501, Japan; (Y.T.); (S.T.); (T.N.)
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita 564-8565, Japan
- Correspondence: ; Tel.: +81-6-6170-1070
| | - Yoshimitsu Takahashi
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto 606-8501, Japan; (Y.T.); (S.T.); (T.N.)
| | - Shinjiro Tominari
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto 606-8501, Japan; (Y.T.); (S.T.); (T.N.)
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto 606-8501, Japan; (Y.T.); (S.T.); (T.N.)
| |
Collapse
|
45
|
Kim D, Yang PS, Joung B. Prevention of Dementia in Patients with Atrial Fibrillation. Korean Circ J 2021; 51:308-319. [PMID: 33821580 PMCID: PMC8022029 DOI: 10.4070/kcj.2021.0027] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 01/29/2021] [Indexed: 12/11/2022] Open
Abstract
Atrial fibrillation (AF) has been associated with an increased risk of dementia. Although there does not appear to be solid evidence that any specific treatment prevents or delays AF-associated cognitive decline, evidence is accumulating regarding the possible treatment strategies for preventing dementia. In this review, we summarize the evidence linking AF to dementia and critically appraise the proposed treatment strategies. Atrial fibrillation (AF) is the most common form of arrhythmia in the elderly population and increases stroke risk by a factor of 4- to 5-fold. There is increasing evidence to suggest that incident AF may contribute to the development of dementia, independent of overt stroke. In particular, relatively younger patients with AF are more prone to dementia development than older patients with AF. Evidence is accumulating regarding the possible treatment strategies for preventing dementia in patients with AF. Oral anticoagulation may be effective for reducing the risk of dementia, even in patients with low stroke risks. Among oral anticoagulants, the use of non-vitamin K antagonists have been associated with a considerably decreased risk of dementia than warfarin. Moreover, successful catheter ablation for AF has also been associated with decreased dementia risk compared to medical therapy, suggesting that restoration of sinus rhythm, and not the ablation procedure itself, as the important mechanism in the prevention of AF-associated dementia. Among midlife patients with AF, there appeared to be a U-shaped association of blood pressure (BP) and a linear association of hypertension with dementia risk. A BP of 120 to 129/80 to 84 mmHg has been identified as the optimal range. Finally, integrated management of AF was associated with a reduced risk of dementia in AF patients.
Collapse
Affiliation(s)
- Daehoon Kim
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Pil Sung Yang
- Department of Cardiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| |
Collapse
|
46
|
Cragg JJ, Azoulay L, Collins G, De Vera MA, Etminan M, Lalji F, Gershon AS, Guyatt G, Harrison M, Jutzeler C, Kassam R, Kendzerska T, Lynd L, Mansournia MA, Sadatsafavi M, Tong B, Warner FM, Tremlett H. The reporting of observational studies of drug effectiveness and safety: recommendations to extend existing guidelines. Expert Opin Drug Saf 2021; 20:1-8. [PMID: 33170749 DOI: 10.1080/14740338.2021.1849134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 11/06/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION The use of observational data to assess drug effectiveness and safety can provide relevant information, much of which may not be feasible to obtain through randomized clinical trials. Because observational studies provide critical drug safety and effectiveness information that influences drug policy and prescribing practices, transparent, consistent, and accurate reporting of these studies is critical. AREAS COVERED We provide recommendations to extend existing reporting guidelines, covering the main components of primary research studies (methods, results, discussion). EXPERT OPINION Our recommendations include extending drug safety and effectiveness guidelines to include explicit checklist items on: study registration, causal diagrams, rationale for measures of effect, comprehensive assessment of bias, comprehensive data cleaning steps, drug equivalents, subject-level drug data visualization, sex and gender-based analyses and results, patient-oriented outcomes, and patient involvement in research.
Collapse
Affiliation(s)
- Jacquelyn J Cragg
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, BC, Canada
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University , Montreal, QC, Canada
| | - Gary Collins
- Centre for Statistics in Medicine, University of Oxford , Oxford, United Kingdom & EQUATOR
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Mahyar Etminan
- Departments of Ophthalmology and Medicine, Faculty of Medicine, University of British Columbia , Vancouver, BC, Canada
| | - Fawziah Lalji
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Andrea S Gershon
- Department of Medicine, University of Toronto , Toronto, Ontario
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, McMaster University , Hamilton, Ontario, Canada
| | - Mark Harrison
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
- Center for Health Evaluation and Outcome Sciences (CHEOS), St. Paul's Hospital , Vancouver, BC, Canada
| | - Catherine Jutzeler
- Department of Biosystems Science & Engineering, ETH Zurich , Zurich, Switzerland
| | - Rosemin Kassam
- School of Population and Public Health, University of British Columbia , Vancouver, BC, Canada
| | | | - Larry Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences , Tehran, Iran
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Bobo Tong
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia , Vancouver, BC, Canada
| | - Freda M Warner
- Faculty of Pharmaceutical Sciences, University of British Columbia , Vancouver, BC, Canada
| | - Helen Tremlett
- Division of Neurology, Department of Medicine, University of British Columbia , Vancouver, BC, Canada
| |
Collapse
|
47
|
Ribeiro VT, de Souza LC, Simões E Silva AC. Renin-Angiotensin System and Alzheimer's Disease Pathophysiology: From the Potential Interactions to Therapeutic Perspectives. Protein Pept Lett 2020; 27:484-511. [PMID: 31886744 DOI: 10.2174/0929866527666191230103739] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 08/27/2019] [Accepted: 11/16/2019] [Indexed: 12/21/2022]
Abstract
New roles of the Renin-Angiotensin System (RAS), apart from fluid homeostasis and Blood Pressure (BP) regulation, are being progressively unveiled, since the discoveries of RAS alternative axes and local RAS in different tissues, including the brain. Brain RAS is reported to interact with pathophysiological mechanisms of many neurological and psychiatric diseases, including Alzheimer's Disease (AD). Even though AD is the most common cause of dementia worldwide, its pathophysiology is far from elucidated. Currently, no treatment can halt the disease course. Successive failures of amyloid-targeting drugs have challenged the amyloid hypothesis and increased the interest in the inflammatory and vascular aspects of AD. RAS compounds, both centrally and peripherally, potentially interact with neuroinflammation and cerebrovascular regulation. This narrative review discusses the AD pathophysiology and its possible interaction with RAS, looking forward to potential therapeutic approaches. RAS molecules affect BP, cerebral blood flow, neuroinflammation, and oxidative stress. Angiotensin (Ang) II, via angiotensin type 1 receptors may promote brain tissue damage, while Ang-(1-7) seems to elicit neuroprotection. Several studies dosed RAS molecules in AD patients' biological material, with heterogeneous results. The link between AD and clinical conditions related to classical RAS axis overactivation (hypertension, heart failure, and chronic kidney disease) supports the hypothesized role of this system in AD. Additionally, RAStargeting drugs as Angiotensin Converting Enzyme inhibitors (ACEis) and Angiotensin Receptor Blockers (ARBs) seem to exert beneficial effects on AD. Results of randomized controlled trials testing ACEi or ARBs in AD are awaited to elucidate whether AD-RAS interaction has implications on AD therapeutics.
Collapse
Affiliation(s)
- Victor Teatini Ribeiro
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Leonardo Cruz de Souza
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil.,Department of Internal Medicine, Service of Neurology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Ana Cristina Simões E Silva
- Interdisciplinary Laboratory of Medical Investigation, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| |
Collapse
|
48
|
Antonazzo B, Marano G, Romagnoli E, Ronzoni S, Frati G, Sani G, Janiri L, Mazza M. Impact of arterial hypertension and its management strategies on cognitive function and dementia: a comprehensive umbrella review. Minerva Cardiol Angiol 2020; 70:285-297. [PMID: 33258570 DOI: 10.23736/s2724-5683.20.05452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Cognitive decline and dementia recognize multiple risk factors and pathophysiological mechanisms, often involved simultaneously with complex interactions. Several studies have shown that both arterial hypertension and hypotension are associated with a greater risk of cognitive decline and dementia, but clinical evidence on this point is conflicting. Our aim was to conduct an umbrella review on cognitive function, dementia, and blood pressure, with particular attention to epidemiological, prognostic and therapeutic aspects. EVIDENCE ACQUISITION We conducted a dedicated literature search on PubMed for systematic reviews and meta-analyses that focused on arterial pressure, hypertension, hypotension and similar conditions, and cognitive function, cognitive decline and dementia. The internal validity of systematic reviews and meta-analyses was formally analyzed using the OQAQ tool. The umbrella review was planned in accordance with current international recommendations and was described as specified by the PRISMA guidelines. EVIDENCE SYNTHESIS Seventeen systematic reviews (including 13 meta-analyses) were included, for a total of 675 clinical studies and over 1 million patients. Hypertension results to be associated with a lower risk of Alzheimer's dementia, greater risk of vascular dementia and greater risk of cognitive decline. Orthostatic hypotension seems to be associated with greater risk of Alzheimer's dementia, vascular dementia and dementia of Parkinson's disease. Therapy with acetylcholinesterase inhibitors produces lower risk of cardiovascular events, greater risk of hypertension and greater risk of bradycardia, while the anti-hypertensive therapy leads to a lower risk of dementia of all types and lower risk of cognitive decline. CONCLUSIONS To date, the evidence on the relationship between blood pressure, cognitive decline and dementia provides somewhat heterogeneous data. Further studies are clearly needed, with explicit inclusion criteria as objective as possible, adequate follow-up and precise characterization of implemented cardiovascular and cognitive treatments.
Collapse
Affiliation(s)
| | - Giuseppe Marano
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Enrico Romagnoli
- Department of Cardiovascular and Thoracic Sciences, Institute of Cardiology, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Rome, Italy
| | | | - Giacomo Frati
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University, Rome, Italy.,IRCCS NEUROMED, Pozzilli, Isernia, Italy
| | - Gabriele Sani
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Luigi Janiri
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Marianna Mazza
- Department of Geriatrics, Institute of Psychiatry and Psychology, Neuroscience and Orthopedics, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy -
| |
Collapse
|
49
|
Kalaitzidis RG, Balafa O, Dounousi E, Stagikas D, Tsimihodimos V. Adherence to Treatment, Arterial Stiffness and Cognitive Function in Irbesartan- Treated Newly Diagnosed Hypertensive Patients. Curr Vasc Pharmacol 2020; 19:565-571. [PMID: 33222674 DOI: 10.2174/1570161119666201120160104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/28/2020] [Accepted: 11/01/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Non-adherence to antihypertensive agents leads to reduced blood pressure (BP) control. Data supporting the correlation of adherence with arterial stiffness (AS) are few. Furthermore, the causal relationship between AS and cognitive dysfunction (CO/DY) has not been clearly established. It is suggested that angiotensin II receptor blockers (ARBs) exhibit the lowest discontinuation rate among antihypertensive drugs. DESIGN AND METHODS We followed up with patients receiving monotherapy with irbesartan. CO/DY was assessed with the Mini-Mental State Examination (MΜSE) and other tests. RESULTS Patients [n=77; mean age: 56±11 years; 39 men (50.6%)] were followed-up for 16.1±10.9 months. At the end of follow up, significant reductions were observed in mean peripheral systolic BP (135±117 vs 153±11 mmHg; p<0.005), mean peripheral diastolic BP (85±11 vs 95±10 mmHg; p<0.005), mean central systolic BP (130±11 vs 142±12 mmHg; p<0.005) as well as in mean central diastolic BP (85±8 vs 95±97 mmHg; p<0.005). AS indices [carotid-femoral pulse wave velocity and augmentation index] also improved significantly: 7.7±1.4 vs 8.2±1.4 m/sec (p<0.005), and 29.1±8.3 vs 32.3±9.1 (p<0.005), respectively. At the end of the study, a significant improvement was observed in the MMSE test (29.7±0.7 vs. 29.2±0.9; p<0.02), as well as a significant reduction in 24h urine albumin (94±82 vs. 204±112 mg/24h, p<0.005). The level of adherence was high in 60/77 (77.9%), medium in 9/77 (11.6%) and low in 8/77 (10.38%) patients. CONCLUSION Hypertensive patients receiving mono-therapy with an ARB showed reduced AS, cognitive improvement, significant reductions in BP (peripheral and central) and decreased 24h urinary albumin excretion.
Collapse
Affiliation(s)
- Rigas G Kalaitzidis
- Hypertension Excellence Centre, Division of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Olga Balafa
- Hypertension Excellence Centre, Division of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Evangelia Dounousi
- Hypertension Excellence Centre, Division of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Dimitrios Stagikas
- Department of Internal Medicine, University Hospital of Ioannina, Ioannina, Greece
| | | |
Collapse
|
50
|
Sayed MA, Eldahshan W, Abdelbary M, Pillai B, Althomali W, Johnson MH, Arbab AS, Ergul A, Fagan SC. Stroke promotes the development of brain atrophy and delayed cell death in hypertensive rats. Sci Rep 2020; 10:20233. [PMID: 33214598 PMCID: PMC7678843 DOI: 10.1038/s41598-020-75450-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 09/29/2020] [Indexed: 12/11/2022] Open
Abstract
Post-stroke cognitive impairment (PSCI) is a major source of disability, affecting up to two thirds of stroke survivors with no available therapeutic options. The condition remains understudied in preclinical models due to its delayed presentation. Although hypertension is a leading risk factor for dementia, how ischemic stroke contributes to this neurodegenerative condition is unknown. In this study, we used a model of hypertension to study the development of PSCI and its mechanisms. Spontaneously hypertensive rats (SHR) were compared to normotensive rats and were subjected to 1-h middle cerebral artery occlusion or sham surgery. Novel object recognition, passive avoidance test and Morris water maze were used to assess cognition. In addition, brain magnetic resonance images were obtained 12-weeks post-stroke and tissue was collected for immunohistochemistry and protein quantification. Stroked animals developed impairment in long-term memory at 4-weeks post-stroke despite recovery from motor deficits, with hypertensive animals showing some symptoms of anhedonia. Stroked SHRs displayed grey matter atrophy and had a two-fold increase in apoptosis in the ischemic borderzone and increased markers of inflammatory cell death and DNA damage at 12 weeks post-stroke. This indicates that preexisting hypertension exacerbates the development of secondary neurodegeneration after stroke beyond its acute effects on neurovascular injury.
Collapse
Affiliation(s)
- Mohammed A Sayed
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, 914 New Baillie Street, HM Building Room 116, Augusta, GA, 30901, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Wael Eldahshan
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, 914 New Baillie Street, HM Building Room 116, Augusta, GA, 30901, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Mahmoud Abdelbary
- Department of Physiology, Medical College of Georgia, Augusta, GA, USA
| | - Bindu Pillai
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, 914 New Baillie Street, HM Building Room 116, Augusta, GA, 30901, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | - Waleed Althomali
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, 914 New Baillie Street, HM Building Room 116, Augusta, GA, 30901, USA
- Charlie Norwood VA Medical Center, Augusta, GA, USA
| | | | | | - Adviye Ergul
- Department of Pathology and Laboratory Medicine, Medical University of South Carolina, Charleston, SC, USA
- Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Susan C Fagan
- Clinical and Experimental Therapeutics, College of Pharmacy, University of Georgia, 914 New Baillie Street, HM Building Room 116, Augusta, GA, 30901, USA.
- Charlie Norwood VA Medical Center, Augusta, GA, USA.
| |
Collapse
|