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

The impact of modifiable health metrics on mortality for older adults with low cognitive function

Objectives

Cognitive impairment has emerged as a major contributing factor to mortality for older adults. Identifying the strong modifiable health metrics against mortality is of high priority, especially in this high-risk population.

Methods

This population-based study used data of US adults aged≥60 years old from the National Health and Nutrition Examination Survey 2011-2014 cycles. De-identified data for participants who completed cognitive function test were extracted. Mortality data was obtained by linking to the 2019 public-use linked mortality file.

Results

Participants with low global cognition had higher risk of all-cause mortality (HR = 1.46; 95%CI, 1.04-2.05). The highest prevalence of ideal level of health metrics was observed for sleep duration (54.36% vs. 62.37%), and the lowest was noted for blood pressure (12.06% vs. 21.25%) for participants with low and average to high global cognition, respectively. Ideal status of physical activity and diet quality were significantly associated with all-cause mortality among participants with low global cognition (HR = 0.48, 95%CI: 0.28-0.82; HR = 0.63, 95%CI: 0.43-0.95). The corresponding population-attributable fractions were 26.58 and 15.90%, respectively.

Conclusion

Low cognitive function was associated with increased risk of all-cause death for older adults. Attainment of healthy metrics, especially sufficient physical activity, consuming healthy diet and being never smoked, provided strong protection against death risk.

Screening for cognitive impairment in older adults with hypertension: the HYPER-COG study

Hypertension is a major risk factor for dementia. Yet, the most suitable cognitive screening test for hypertensive patients has yet to be identified. This study investigated cognitive impairment in hypertensive older adults and compared the discriminative ability of the most widely used cognitive screening tests. The study involved hypertensive patients aged 65+ without prior diagnosis of cognitive impairment, from the Hypertension Clinic of Careggi Hospital, Florence, Italy. Mini Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), MiniCog and Clock Drawing Test (CDT) were administered, using a comprehensive neuropsychological assessment as gold standard. The ROC curve analysis and the paired chi-square test were used to compare the discriminative ability, sensitivity and specificity for cognitive impairment of the different screening instruments. Cognitive impairment was diagnosed in 37% of 94 participants (mean age 76, 55% female), mainly involving attention and executive functions. The MoCA (AUC = 0.746), the MMSE (AUC = 0.689) and the MiniCog (AUC = 0.684) showed similar ability in detecting cognitive impairment, while the CDT had a poorer discriminative capacity (AUC = 0.535). The sensitivity of MoCA (80%) and of MMSE/MiniCog combination (74%) was higher in comparison with MiniCog alone (49%, p = 0.007 and 0.004, respectively), while MiniCog achieved the highest specificity (88%, p < 0.001 vs all). Cognitive impairment was detected in more than one-third of hypertensive older adults without prior diagnosis of dementia. MoCA, MMSE and MiniCog showed similar discriminative ability for cognitive impairment, with MoCa and MMSE showing greater sensitivity and MiniCog the highest specificity.

Body mass index and death by cognitive impairment

BACKGROUND

Epidemiological studies have reported that among participants with impaired cognitive, overweight and mild obesity are associated with substantially improved survival, this finding has been termed the "obesity paradox" and has led to uncertainty about secondary prevention.

AIMS

To explore whether the association of BMI with mortality differed in different MMSE score, and whether the obesity paradox in patient with cognitive impairment (CI) is real.

METHODS

The study used data from CLHLS, a representative prospective population-based cohort study in China, which included 8348 participants aged ≥ 60 years between 2011 and 2018. The independent association between BMI and mortality in differed MMSE score by calculating hazard ratios (HRs) in multivariate Cox regression analysis.

RESULTS

During a median (IQR) follow-up of 41.18 months, a total of 4216 participants died. In the total population, underweight increased the risk of all-cause mortality (HRs, 1.33; 95% CI 1.23-1.44), compared with normal weight, and overweight was associated with a decreased risk of all-cause mortality (HR 0.83; 95% CI 0.74-0.93). However,  compared to normal weight, only underweight was associated with increased mortality risk among participants with MMSE scores of 0-23, 24-26, 27-29, and 30, and the fully-adjusted HRs (95% CIs) for mortality were 1.30 (1.18, 1.43), 1.31 (1.07, 1.59), 1.55 (1.34, 1.80) and 1.66 (1.26, 2.20), respectively. The obesity paradox was not found in individuals with CI. Sensitivity analyses carried out had hardly any impact on this result.

CONCLUSION

We found no evidence of an obesity paradox in patients with CI, compared with patients of normal weight. But underweight individuals may have increased mortality risk whether in the population with CI or not. And overweight/obese people with CI should continue to aim for normal weight.

Mortality rate of high cardiovascular risk patients with mild cognitive impairment

People with mild cognitive impairment (MCI) may be at higher risk of death than normal aging ones. On the other hand, patients with cardiovascular risk factors are also with higher risk of death. It may be logical to question then if the combination of MCI and cardio-vascular risk factors (in most cases arterial hypertension) can lead to higher mortality rate than expected both for high cardio-vascular risk patients and for the general population. This hypothesis is important in the light of effective early screening and prophylaxis. The general death rate of patients with very high-cardio-vascular-risk was compared in the subgroups of normal cognition and MCI. We used MMSE and MoCA (reassessment 6 months apart), Geriatric Depression scale and 4-point version of the scale for evaluating the performance in instrumental activities of daily living (4-IADL) in 249 patients. The patients also had laboratory testing, ambulatory blood pressure monitoring, ECG and echocardiography. The general mortality rate of this very high cardio-vascular risk group was assessed 8–10 years afterwards and also compared to the general national death rate published for the corresponding period from the National Social Security Institute of Bulgaria. We registered significantly higher general death rate in patients with MCI and very high cardio-vascular risk as compared to the group without MCI. The logistic regression analysis attributed approximately 14.6% of the mortality rate in this high-risk group to MCI. The major cardio-vascular risk factor was arterial hypertension—with 63.85% of the patients with home blood pressure values not in the target range at the initial cognitive screening. During the neuropsychological reevaluation 56.43% were with poor control despite the multidrug antihypertensive regimen. It is known that MCI is correlated with cardiovascular risk factors with the leading role of arterial hypertension. We found that the combination of MCI and arterial hypertension can lead to higher mortality rate than in the general aging population. This has important clinical implications for the everyday practice.

Combined association of cognitive impairment and poor oral health on mortality risk in older adults: Results from the NHANES with 15 years of follow-up

Background

Cognitive impairment and poor oral health are frequently seen among older adults. Both conditions have been identified as risk factors for mortality. However, the combined associations of cognitive impairment and poor oral health with mortality have not been well studied and are therefore the aim of this cohort study.

Methods

We analyzed data from the National Health and Nutrition Examination Survey (1999–2002) linked with mortality data obtained from the 2015 public‐use linked mortality file. Cognitive impairment was defined as a digit symbol substitution test score lower than the lowest quartile. Oral health status was assessed based on presence of untreated caries, moderate to severe periodontitis, and edentulism. The combined effects of caries/periodontitis or edentulism and cognitive impairment on all‐cause and cardiometabolic mortality were examined using the Cox proportional hazard models after adjusting for potential confounders including demographic characteristics, lifestyle, biomarkers, and comorbidities.

Results

In total, 1973 participants were enrolled in the prospective study. At a median follow‐up of 13.4 years, 978 participants had died (264 deaths because of cardiometabolic disease). Cognitive impairment, periodontitis, and edentulism were each found to be significant predictors of all‐cause mortality. Caries, however, was not significantly related to mortality. When analyzing these predictors in combination, a diagnosis of cognitive impairment and periodontitis was associated with an 83.1% increase in all‐cause mortality risk and an 87.7% increase in cardiometabolic mortality risk compared with healthy controls. Similarly, the risk for all‐cause mortality was highest in cases where impaired cognition and edentulism co‐occurred (adjusted hazard ratio = 1.701, 1.338–2.161).

Conclusion

Concomitant presence of cognitive impairment and periodontitis or edentulism can be associated with a higher risk of mortality among older U.S. adults.

Blood Pressure and Risk of Cognitive Impairment: The Role of Vascular Disease in Neurodegeneration

(1) Background: Both cerebral vascular disorders and cognitive decline increase in incidence with age. The role of cerebral vascular disease and hemodynamic changes in the development of cognitive deficits is controversial. The objective of this study was to assess the cardiovascular response during cardiac stress testing in neurologically asymptomatic individuals who developed cognitive impairment several years after previous cardiac stress testing. (2) Methods: This was a retrospective cohort study of patients who underwent cardiac stress testing between January 2001 and December 2010. Patients were followed up until May 2015, and we selected those who developed cognitive dysfunction including dementia, mild cognitive impairment, and subjective cognitive decline, after the stress test. Heart rate and blood pressure both at rest and at peak exercise, and the mean R-R interval at rest were recorded. For each patient who developed cognitive impairment, we selected one matched control who did not show cognitive decline by the end of the follow-up period. (3) Results: From the cohort of 7224 patients, 371 developed cognitive impairment; of these, 186 (124 men) met the inclusion criteria, and 186 of the other patients were selected as matched controls. During follow-up, cognitive impairment appeared 6.2 ± 4.7 years after the cardiac stress test. These patients who had subsequently developed cognitive impairment had significantly lower at-rest systolic, diastolic, and mean blood pressure than controls (p < 0.05). Further, compared with controls, their maximum heart rate was significantly higher at peak exercise. (4) Conclusion: The results from this study suggest that differences in cardiovascular response to stress might be present in individuals who develop cognitive decline. These findings challenge the possibility of assessing blood pressure and heart rate variability at rest and during cardiac stress as potential risk factors associated with cognitive impairment.

The Longitudinal Association Between Cardiovascular Risk and Cognitive Function in Middle-Aged and Older Adults in China: A Nationally Representative Cohort Study

Objective: China has the largest population living with dementia, causing a tremendous burden on the aging society. Cardiovascular disease (CVD) may trigger a cascade of pathologies associated with cognitive aging. We aim to investigate the association between cardiovascular risk (CVR) factors and cognitive function in the nationally representative cohort in China. Methods: Participants were recruited from 150 counties in 28 provinces via a four-stage sampling method. The outcomes included several cognitive tasks. The independent variable was a composite score of cardiovascular risk calculated from sex-specific equations. We fitted the time-lagged regression to model the association between CVR and cognition. Besides, we performed cross-group analyses to test for model invariance across sex and age. We thus constrained path coefficients to be equal across each grouping variable (e.g., sex) and compared the fit of this constrained model with an unconstrained model in which the path coefficients were allowed to vary by group. Results: A total of 3,799 participants were included in the final analyses. We found that the CVR had a negative linear association with global cognition (β = -0.1, p < 0.01). Additionally, CVR had inverse linear associations with domain-specific measurements of memory and learning, calculation, orientation, and visual-spatial ability (all values of p < 0.01). Regarding sex and age moderation, males had a more pronounced association between higher CVR and worse general cognition, immediate recall, orientation, calculation, and visual-spatial ability (all values of p < 0.0001). In contrast, females exhibited a slightly larger negative association in delayed recall. Older participants (>65 years old) had a more pronounced association between higher CVR and worse calculation ability (p = 0.003). Conclusion: CVD are risk factors for lower global cognition and cognitive subdomains in middle-aged and older adults in China.

Cognitive Function Is a Prognostic Factor for Mortality of Nursing Home Residents during a 3-Year Observational Period

Introduction

Assessing cognitive function could help to provide appropriate care for nursing home residents. The aim of the study was to identify the factors affecting cognitive function in nursing home residents in Poland and assess how it influenced the mortality rate during a 3-year observational period.

Methods

This study included 202 elderly individuals from a nursing home in 2015. The investigation included examination of cognitive function using the MMSE and bioelectrical impedance analysis. Collected data included sex, age, blood pressure (BP), heart rate, number of comorbidities, years spent in the nursing home, educational level, and cigarette-smoking.

Results

The mean MMSE score was 21.36 ± 6.35, which was negatively correlated with age and diastolic BP (p = 0.001 and p = 0.024, respectively) and positively correlated with body mass, BMI, fat-free mass, fat, muscle mass, and education level (p = 0.004, p = 0.004, p = 002, p = 0.049, p = 0.005, and p ˂ 0.001, respectively). Patients who died during the observational period had lower MMSE scores than those who survived (23.34 ± 5.68 vs. 20.16 ± 6.45; p < 0.001). Smokers had better MMSE results than nonsmokers (23.34 ± 5.98 vs. 20.08 ± 4.94; p < 0.001).

Discussion

Polish nursing home residents had mild cognitive impairment depending on their age, sex, educational level, and nutritional status. Lower MMSE score was a prognostic factor for mortality in the 3-year observational period.

Association of cognitive impairment and grip strength trajectories with mortality among middle-aged and elderly adults

ABSTRACTBackground:This study investigates whether maintaining high levels of cognitive impairment and weak grip strength will predict a higher risk for mortality.

METHODS

Data from the Korean Longitudinal Study of Aging (KLoSA) from 2006 to 2014 was assessed using longitudinal data analysis and included 5,812 research subjects. Our modeling approach jointly estimated multi-period trajectories of grip strength and cognitive impairment, and the primary analysis was based on Cox proportional hazards models.

RESULTS

A four-class linear solution fit the data best in both cognitive impairment and grip strength based on the model fitness, respectively. The hazard ratio (HR) of mortality in group 1 (consistently low) of cognitive impairment and of grip strength were 2.114 times higher (p-value 0.001) and 3.405 times higher (p-value <.0001) compared with group 3 (consistently high) and group 4 (consistently high), respectively.

CONCLUSION

This study provides insightful scientific evidence into the specificity of longitudinal changes in grip strength and cognitive impairment on mortality. Our findings suggest that declined cognitive ability and weak grip strength are predictors of mortality in older Korean people.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

The prevalence of depressive symptoms among older patients with hypertension in rural China

OBJECTIVE

The comorbidity of depression and hypertension (HTN) is common and complicates the management of both conditions. This study investigated the prevalence of depressive symptoms among older patients with HTN in rural China and explored the relationship between the two conditions.

METHODS

The baseline data of older patients diagnosed with HTN included in the depression/HTN in Chinese Older Adults-Collaborations for Health Study were used for the analysis. The Chinese Older Adults-Collaborations for Health Study was conducted in rural villages of Tonglu County, Zhejiang Province, China. In all, 10 389 older village residents had HTN (57.2% female, mean age 71.5 ± 8.1 years). Blood pressure was measured by using a calibrated manual sphygmomanometer and stethoscope. Depressive symptom was measured by using the Chinese version of the nine-item Patient Health Questionnaire.

RESULTS

Among 10 389 patients with HTN, 12.8% had significant depressive symptoms (nine-item Patient Health Questionnaire ≥ 10). Rates of significant depressive symptoms were 5.3% and 32.8% among patients with controlled and uncontrolled HTN (systolic blood pressure ≥ 140 and/or diastolic blood pressure ≥ 90), respectively (χ2  = 8.701, p < 0.001). Logistic regression analysis indicated that those in older age group (≥70 years) and with uncontrolled HTN have higher rates of significant depressive symptoms than those who are younger (age 60 to <70) and with controlled HTN.

CONCLUSION

Our findings show high rates of depressive symptoms among patients with HTN in rural China and higher rates of depressive symptoms among patients with uncontrolled HTN. These support the development and dissemination of integrative care approaches for older adults with HTN and depression in rural China. Copyright © 2016 John Wiley & Sons, Ltd.

Blood Pressure and All-Cause Mortality by Level of Cognitive Function in the Elderly: Results From a Population-Based Study in Rural Greece

This study aimed to investigate whether the effect of blood pressure (BP) on mortality differs by levels of cognitive function. The associations of brachial systolic BP, diastolic BP, mean arterial pressure (MAP), and pulse pressure with all-cause mortality were prospectively explored (follow-up 7.0±2.2 years) in 660 community-dwelling individuals (≥60 years) using adjusted Cox models, stratified by cognitive impairment (Mini-Mental State Examination [MMSE] <24). No association between brachial BP variables and mortality was shown for the total sample in quartiles analysis; however, MAP in the highest quartile, compared with the second, was associated with mortality (hazard ratio, 1.85; 95% confidence intervals, 1.09-3.12) among cognitively impaired individuals. The fractional-polynomials approach for BP confirmed this finding and further showed, solely in the MMSE <24 subcohort, U-shaped trends of MAP and systolic BP, with increased mortality risk in extremely low or high values; no such pattern was evident for patients with MMSE ≥24. Elderly individuals with cognitive impairment might be more susceptible to the detrimental effects of low and elevated MAP and systolic BP.

Hypertension and cognitive dysfunction in elderly: blood pressure management for this global burden

Arterial hypertension and stroke are strong independent risk factors for the development of cognitive impairment and dementia. Persistently elevated blood pressure (BP) is known to impair cognitive function, however onset of new cognitive decline is common following a large and multiple mini strokes. Among various forms of dementia the most prevalent include Alzheimer’s disease (AD) and vascular dementia (VaD) which often present with similar clinical symptoms and challenging diagnosis. While hypertension is the most important modifiable vascular risk factor with antihypertensive therapy reducing the risk of stroke and potentially slowing cognitive decline, optimal BP levels for maintaining an ideal age-related mental performance are yet to be established. Cognition has improved following the use of at least one representative agent of the major drug classes with further neuroprotection with renin angiotensin inhibitors and calcium channel blockers in the hypertensive elderly. However, a reduction in BP may worsen cerebral perfusion causing an increased risk of CV complications due to the J-curve phenomenon. Given the uncertainties and conflicting results from randomized trials regarding the hypertension management in the elderly, particularly octogenarians, antihypertensive approaches are primarily based on expert opinion. Herein, we summarize available data linking arterial hypertension to cognitive decline and antihypertensive approach with potential benefits in improving cognitive function in elderly hypertensive patients.