Joint effect of mid- and late-life blood pressure on the brain: the AGES-Reykjavik study

Sex-Specific Vulnerabilities to Subclinical Vascular Brain Injury in Early Late-Life: The Framingham Heart Study

OBJECTIVE

Subclinical vascular brain injury is an increasingly recognized risk factor for stroke and dementia. Despite well-established sex differences in vascular risk and disease prevalence, the impact of sex on drivers of subclinical vascular brain injury remains unclear, presenting a barrier to developing sex-specific prevention guidelines. We aimed to establish the extent to which sex moderates associations between vascular risk factors and magnetic resonance imaging (MRI) measures of subclinical brain injury in stroke-free older adults.

METHODS

We leveraged cross-sectional data from 1,579 stroke- and dementia-free Framingham Heart Study Offspring participants at exam 8 (age 65.7 ± 8.8 years, 53% women). Vascular risks were assessed using components of the Framingham Stroke Risk Profile (FSRP) and diastolic blood pressure (DBP). White matter hyperintensity volume (WMH), total cerebral brain volume (TBV), and covert brain infarcts were quantified using MRI. We examined whether vascular risk factors were associated with MRI measures across the combined cohort, and then determined whether sex modified these associations.

RESULTS

Higher FSRP and specifically systolic blood pressure (SBP) were associated with greater WMH. These associations were stronger in women and remained after adjusting for menopause age and hormone therapy use. By contrast, diabetes and lower DBP were associated with smaller TBV primarily in men. The DBP-atrophy relationship was only observed in men with declining DBP or prior hypertension.

INTERPRETATION

Our findings highlight differential vulnerability to the impact of vascular risk factors on white matter health in women and global atrophy in men, supporting the development of sex-specific guidelines to better preserve vascular brain health in aging. ANN NEUROL 2025;97:460-469.

Hypertension and Cognitive Disorders

Systemic hypertension is possibly the most important modifiable risk factor for the development of cognitive decline, both for mild cognitive impairment (MCI) and dementia. For effective blood pressure (BP) control, it requires proper assessment, using brachial, central, and ambulatory measurements, and monitoring with a focus on different BP parameters. Different BP parameters like pulse pressure, mean arterial pressure, BP variability, and circadian parameters, like nondippers and early morning surge, should be considered in the evaluation for the risk of cognitive decline due to hypertension in middle age and older adults. Chronic hypertension causes vascular remodeling in the brain and leads to brain failure or cognitive decline. Achieving specific BP goals can improve clinical outcomes and possibly slow down cognitive decline for patients with comorbid hypertension and cognitive impairment.

Influence of intraocular and blood pressure on brain volumes: Observational and Mendelian randomization analyses

Intraocular pressure (IOP) is closely correlated with blood pressure (BP), and while BP has been linked to brain volumes, the effect of IOP on brain volumes remains unclear. This study analyzed participants from the UK Biobank with MRI-measured brain volumes. Observational analyses included 8,634 participants for IOP and 36,069 for BP, followed by Mendelian randomization (MR) analyses of 37,410 participants. Observational analyses revealed that each 10-mmHg increase in diastolic BP was linked to a 0.13 mL larger white matter hyperintensity (WMH) after adjusting for covariates. Associations between IOP and brain volumes were more pronounced in younger individuals or those without hypertension. MR analyses confirmed significant relationships between diastolic BP and WMH, and each 5-mmHg increase in IOP reduced gray matter volumes by 3.24 mL. The study suggests that targeting IOP and BP could help prevent brain volume reduction.

Deprescribing of Antihypertensive Medications and Cognitive Function in Nursing Home Residents

Importance

Antihypertensive medication deprescribing is common among nursing home residents, yet its association with cognitive decline remains uncertain.

Objective

To investigate the association of deprescribing antihypertensive medication with changes in cognitive function in nursing home residents.

Design, Setting, and Participants

This cohort study using a target trial emulation approach included VA long-term care residents aged 65 years or older with stays of at least 12 weeks from 2006 to 2019. Residents who were not prescribed antihypertensive medication, with blood pressure greater than 160/90 mm Hg, or with heart failure were excluded. Eligible residents with stable medication use for 4 weeks were classified into deprescribing or stable user groups and followed for 2 years or until death or discharge for intention-to-treat (ITT) analysis. Participants switching treatment groups were censored in the per-protocol analysis. Cognitive function measurements during follow-up were analyzed using an ordinal generalized linear mixed model, adjusting for confounders with inverse probability of treatment weighting. Per-protocol analysis included inverse probability of censoring weighting. Data analyses were performed from May 1, 2023, and July 1, 2024.

Exposures

Deprescribing was defined as a reduction in the total number of antihypertensive medications or a decrease in medication dosage by 30%, sustained for a minimum of 2 weeks.

Main Outcomes and Measures

Cognitive Function Scale (CFS) was classified as cognitively intact (CFS = 1), mildly impaired (CFS = 2), moderately impaired (CFS = 3), and severely impaired (CFS = 4).

Results

Of 45 183 long-term care residents, 12 644 residents (mean [SD] age 77.7 [8.3] years; 329 [2.6%] females and 12 315 [97.4%] males) and 12 053 residents (mean [SD] age 77.7 [8.3] years; 314 [2.6%] females and 11 739 [97.4%] males) met eligibility for ITT and per-protocol analyses, respectively. At the end of the follow-up, 12.0% of residents had a worsened CFS (higher score) and 7.7% had an improved CFS (lower score) with 10.8% of the deprescribing group and 12.1% of the stable user group showing a worsened CFS score. In the per-protocol analysis, the deprescribing group had a 12% reduction in the odds of progressing to a worse CFS category per 12-week period (odds ratio, 0.88; 95% CI, 0.78-0.99) compared to the stable user group. Among residents with dementia, deprescribing was associated with 16% reduced odds of cognitive decline (odds ratio, 0.84; 95% CI, 0.72-0.98). These patterns remained consistent in the ITT analysis.

Conclusions and Relevance

This cohort study indicates that deprescribing is associated with less cognitive decline in nursing home residents, particularly those with dementia. More data are needed to understand the benefits and harms of antihypertensive deprescribing to inform patient-centered medication management in nursing homes.

Association of late-life blood pressure change with cerebral small vessel disease in the MIND-China study

OBJECTIVES

This study aimed to investigate the associations between changes in blood pressure (BP) and cerebral small vessel disease (CSVD).

METHODS

This study included 401 participants in the magnetic resonance imaging (MRI) sub-study conducted between 2018 and 2020 as a part of the Multidomain Interventions to Delay Dementia and Disability in Rural China project. MRI markers of CSVD were assessed based on international criteria. Individualized linear regression models evaluated changes in BP by estimating the trend of blood pressure changes over time and fitting a straight line from 2014 to 2018. The data were analyzed using logistic and general linear regression models.

RESULT

The mean age of the participants was 64.48 ± 2.69 years, with 237 (59.1%) being females. Increases in systolic BP in later life were significantly associated with larger volumes of periventricular white matter hyperintensity (WMH), greater perivascular spaces in the basal ganglia (BG-PVS) burden, and the presence of deep lacunes and cerebral microbleeds. Additionally, increases in diastolic BP in later life were significantly associated with the presence of infratentorial and deep lacunes.

CONCLUSIONS

CSVDs are associated with increased exposure to elevated BP later in life.

Physical exercise, cognition, and brain health in aging

Exercise training is an important strategy to counteract cognitive and brain health decline during aging. Evidence from systematic reviews and meta-analyses supports the notion of beneficial effects of exercise in cognitively unimpaired and impaired older individuals. However, the effects are often modest, and likely influenced by moderators such as exercise training parameters, sample characteristics, outcome assessments, and control conditions. Here, we discuss evidence on the impact of exercise on cognitive and brain health outcomes in healthy aging and in individuals with or at risk for cognitive impairment and neurodegeneration. We also review neuroplastic adaptations in response to exercise and their potential neurobiological mechanisms. We conclude by highlighting goals for future studies, including addressing unexplored neurobiological mechanisms and the inclusion of under-represented populations.

Therapeutic potential of mesenchymal stem cells for cerebral small vessel disease

Cerebral small vessel disease (CSVD), as the most common, chronic and progressive vascular disease on the brain, is a serious neurological disease, whose pathogenesis remains unclear. The disease is a leading cause of stroke and vascular cognitive impairment and dementia, and contributes to about 20% of strokes, including 25% of ischemic strokes and 45% of dementias. Undoubtedly, the high incidence and poor prognosis of CSVD have brought a heavy economic and medical burden to society. The present treatment of CSVD focuses on the management of vascular risk factors. Although vascular risk factors may be important causes or accelerators of CSVD and should always be treated in accordance with best clinical practice, controlling risk factors alone could not curb the progression of CSVD brain injury. Therefore, developing safer and more effective treatment strategies for CSVD is urgently needed. Recently, mesenchymal stem cells (MSCs) therapy has become an emerging therapeutic modality for the treatment of central nervous system disease, given their paracrine properties and immunoregulatory. Herein, we discussed the therapeutic potential of MSCs for CSVD, aiming to enable clinicians and researchers to understand of recent progress and future directions in the field.

Visit-to-visit blood pressure variability and the risk of cardiovascular disease: a prospective cohort analysis

Large blood pressure (BP) variability contributed to subclinical brain disease thus may be implicated in the development of cardiovascular disease (CVD). This study included 64,810 CVD-free participants who attended the first two examinations from the Kailuan study to investigate the association of BP variation, considering its magnitude, direction, and time interval prior to CVD diagnosis, with the risk of CVD in Chinese population. Magnitude and directional BP variability was calculated as absolute BP difference or BP difference value divided by mean BP over 2 sequential visits, respectively. During a median follow-up of 10.91 years, a total of 4129 cases of CVD. A large SBP variability (the highest vs the lowest tertile) was associated with a higher risk of CVD (adjusted HR, 1.31; 95% CI, 1.22-1.41). The associations were stronger with longer time intervals, the hazard ratio (HR) with 95% confidence interval (CI) for CVD was 1.30 (95% CI, 1.20-1.39) at 1 years, 1.32 (1.18-1.40) at 3 years, and 1.34 (1.20-1.45) at 5 years. For directional SBP variability, rise in SBP was associated with an increased risk of CVD (HR, 6.17; 95% CI, 5.65-6.75), while fall in SBP was associated with a decreased risk of CVD (HR, 0.52; 95% CI, 0.46-0.59). Subgroup analysis showed the significant associations were only observed in men (Pint = 0.0010). Similar patterns were observed for DBP variability and CVD subtypes. The results indicated that a large SBP variation in rise direction was associated with an increased risk of incident CVD, especially in men.

Elevated blood pressure accelerates white matter brain aging among late middle-aged women: a Mendelian Randomization study in the UK Biobank

BACKGROUND

Elevated blood pressure (BP) is a modifiable risk factor associated with cognitive impairment and cerebrovascular diseases. However, the causal effect of BP on white matter brain aging remains unclear.

METHODS

In this study, we focused on N  = 228 473 individuals of European ancestry who had genotype data and clinical BP measurements available (103 929 men and 124 544 women, mean age = 56.49, including 16 901 participants with neuroimaging data available) collected from UK Biobank (UKB). We first established a machine learning model to compute the outcome variable brain age gap (BAG) based on white matter microstructure integrity measured by fractional anisotropy derived from diffusion tensor imaging data. We then performed a two-sample Mendelian randomization analysis to estimate the causal effect of BP on white matter BAG in the whole population and subgroups stratified by sex and age brackets using two nonoverlapping data sets.

RESULTS

The hypertension group is on average 0.31 years (95% CI = 0.13-0.49; P  < 0.0001) older in white matter brain age than the nonhypertension group. Women are on average 0.81 years (95% CI = 0.68-0.95; P  < 0.0001) younger in white matter brain age than men. The Mendelian randomization analyses showed an overall significant positive causal effect of DBP on white matter BAG (0.37 years/10 mmHg, 95% CI 0.034-0.71, P  = 0.0311). In stratified analysis, the causal effect was found most prominent among women aged 50-59 and aged 60-69.

CONCLUSION

High BP can accelerate white matter brain aging among late middle-aged women, providing insights on planning effective control of BP for women in this age group.

Dementia occurring over a 32-year follow-up attributable to hypertension observed at different ages: Implications for dementia prevention

INTRODUCTION

The fraction of dementia attributable to hypertension might vary depending on the age of the population considered and the age through which dementia occurs.

METHODS

In the Atherosclerosis Risk in Communities study, we quantified population attributable fractions (PAF) of dementia by age 80 and 90 from hypertension assessed at ages of 45-54 (n = 7572), 55-64 (n = 12,033), 65-74 (n = 6561), and 75-84 (n = 2086).

RESULTS

The PAF for dementia by age 80 from all non-normal blood pressure at ages 45-54 was 15.3% (95% confidence interval [CI] = 6.9%-22.3%), 19.1% (95% CI = 9.9%-26.9%) at ages 55-64, and 19.9% (95% CI = -4.4%-38.5%) at ages 65-74. The strongest PAFs were from stage 2 hypertension (11.9%-21.3%). For dementia by age 90, PAFs from non-normal blood pressure up through age 75 were smaller (10.9%-13.8%), and non-significant by age 75-84.

DISCUSSION

Interventions targeting hypertension even in early late life might reduce a sizeable proportion of dementia.

HIGHLIGHTS

We estimated prospective population attributable risks of dementia for hypertension. 15%-20% of dementia cases by age 80 are from non-normal blood pressure (BP). Associations between hypertension and dementia persisted through age 75. Midlife to early late-life BP control might reduce a large proportion of dementia.

Monitoring risk and preventing ischemic stroke in the very old

INTRODUCTION

Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old.

AREAS COVERED

The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population.

EXPERT OPINION

Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.

Identification of a Link between Suspected Metabolic Syndrome and Cognitive Impairment within Pharmaceutical Care in Adults over 75 Years of Age

The prevalence of metabolic syndrome (MetS) and cognitive impairment (CI) is increasing with age. MetS reduces overall cognition, and CI predicts an increased risk of drug-related problems. We investigated the impact of suspected MetS (sMetS) on cognition in an aging population receiving pharmaceutical care in a different state of old age (60-74 vs. 75+ years). Presence or absence of sMetS (sMetS+ or sMetS-) was assessed according to criteria modified for the European population. The Montreal Cognitive Assessment (MoCA) score, being ≤24 points, was used to identify CI. We found a lower MoCA score (18.4 ± 6.0) and a higher rate of CI (85%) in the 75+ group when compared to younger old subjects (23.6 ± 4.3; 51%; p < 0.001). In the age group of 75+, a higher occurrence, of MoCA ≤ 24 points, was in sMetS+ (97%) as compared to sMetS- (80% p < 0.05). In the age group of 60-74 years, a MoCA score of ≤24 points was identified in 63% of sMetS+ when compared to 49% of sMetS- (NS). Conclusively, we found a higher prevalence of sMetS, the number of sMetS components and lower cognitive performance in subjects aged 75+. This age, the occurrence of sMetS and lower education can predict CI.

Diastolic Blood Pressure and Cognitive Functioning: Differences by Systolic Blood Pressure Among US Adults

BACKGROUND

The role of diastolic blood pressure (DBP) with cognitive functioning is under-explored in relation to levels of systolic blood pressure (SBP).

METHODS

We studied 5466 participants from the National Health and Nutrition Examination Survey. Blood pressure was measured 3 times manually with a standardized sphygmomanometer and averaged. Cognitive functioning was measured using the digit symbol substitution test (DSST).

RESULTS

Participants were 60 years or older, 55% female, and 81% non-Hispanic White. Most participants had a DBP between 70 to <80 mmHg (33.7%), between 60 to <70 mmHg (29.3%), or <60 mmHg (18.8%). From multivariable linear regression analyses, each 5 mmHg increment of DBP was associated with significantly higher DSST scores among individuals with SBP <120 only (ß: 0.56, 95% CI: 0.09, 1.03).

CONCLUSIONS

Among older US adults, at non-elevated levels of SBP, higher DBP is associated with better cognitive performance.

The Association Between 24-Hour Blood Pressure Profiles and Dementia

Midlife hypertension increases risk for dementia. Around one third of adults have diagnosed hypertension; however, many adults are undiagnosed, or remain hypertensive despite diagnosis or treatment. Since blood pressure (BP) follows a circadian rhythm, ambulatory BP monitoring allows for the assessment of BP over a 24-hour period and provides an important tool for improving the diagnosis and management of hypertension. The measurement of 24-hour BP profiles, especially nocturnal BP, demonstrate better predictive ability for cardiovascular disease and mortality than office measurement. However, few studies have examined 24-hour BP profiles with respect to dementia risk. This is an important topic since improvements in BP management could facilitate the primary prevention of vascular cognitive impairment and dementia. Therefore, this review discusses the evidence linking BP to dementia, with a focus on whether the implementation of 24-hour BP measurements can improve risk prediction and prevention strategies. Pathways linking nocturnal BP to dementia are also discussed as are risk reduction strategies. Overall, limited research suggests an association between 24-hour BP elevation and poorer cognition, cerebral small vessel disease, and dementia. However, most studies were cross-sectional. Further evidence is needed to substantiate 24-hour BP profiles, over and above office BP, as predictors of vascular cognitive impairment and incident dementia.

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

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

Synergistic interaction of high blood pressure and cerebral beta-amyloid on tau pathology

BACKGROUND

Hypertension has been associated with Alzheimer's disease (AD) dementia as well as vascular dementia. However, the underlying neuropathological changes that link hypertension to AD remain poorly understood. In our study, we examined the relationships of a history of hypertension and high current blood pressure (BP) with in vivo AD pathologies including β-amyloid (Aβ) and tau and also investigated whether a history of hypertension and current BP respectively affect the association between Aβ and tau deposition.

METHODS

This cross-sectional study was conducted as part of the Korean Brain Aging Study for Early Diagnosis and Prediction of Alzheimer's Disease, a prospective cohort study. Cognitively normal older adults who underwent both Aβ and tau positron emission tomography (PET) (i.e., [¹¹C]-Pittsburgh compound B and [¹⁸F] AV-1451 PET) were selected. History of hypertension and current BP were evaluated and cerebral Aβ and tau deposition measured by PET were used as main outcomes. Generalized linear regression models were used to estimate associations.

RESULTS

A total of 68 cognitively normal older adults (mean [SD] age, 71.5 [7.4] years; 40 women [59%]) were included in the study. Neither a history of hypertension nor the current BP exhibited a direct association with Aβ or tau deposition. However, the synergistic interaction effects of high current systolic (β, 0.359; SE, 0.141; p = 0.014) and diastolic (β, 0.696; SE, 0.158; p < 0.001) BP state with Aβ deposition on tau deposition were significant, whereas there was no such effect for a history of hypertension (β, 0.186; SE, 0.152; p = 0.224).

CONCLUSIONS

The findings suggest that high current BP, but not a history of hypertension, synergistically modulate the relationship between cerebral Aβ and tau deposition in late-life. In terms of AD prevention, the results support the importance of strict BP control in cognitively normal older adults with hypertension.

Sedentary behaviour and brain health in middle-aged and older adults: a systematic review

Sedentary behaviour may increase the risk of dementia. Studying physiological effects of sedentary behaviour on cerebral health may provide new insights into the nature of this association. Accordingly, we reviewed if and how acute and habitual sedentary behaviour relate to brain health factors in middle-aged and older adults (≥45 years). Four databases were searched. Twenty-nine studies were included, with mainly cross-sectional designs. Nine studies examined neurotrophic factors and six studied functional brain measures, with the majority of these studies finding no associations with sedentary behaviour. The results from studies on sedentary behaviour and cerebrovascular measures were inconclusive. There was a tentative association between habitual sedentary behaviour and structural white matter health. An explanatory pathway for this effect might relate to the immediate vascular effects of sitting, such as elevation of blood pressure. Nevertheless, due to the foremost cross-sectional nature of the available evidence, reverse causality could also be a possible explanation. More prospective studies are needed to understand the potential of sedentary behaviour as a target for brain health.

COVID-19, "A Gift and a Curse" in Unsettling Times: A Qualitative Study

The objectives of this study were to rapidly explore the perceptions of female-headed African American families on "stressors," "stress reactions," and "opportunities" amid the COVID-19 pandemic lockdown mandates. Semistructured telephone interviews were conducted with 9 African American women in a rural Midwestern (US) community, who were single parents/grandparents and cared for at least one child/grandchild aged 5 to 17 years. A thematic analytical approach was used to review, code, and analyze phone interview transcripts. Coding schemes were developed through an interactive iterative process. Three main themes emerged-pandemic as a curse, de-stressors and coping mechanisms, and the pandemic as a gift. Most participants reported increased stress for themselves and their children and adopted several coping strategies. However, for most mothers, COVID-19 was paradoxical because it also provided opportunities for families to bond despite these stressors. Public health actions such as social and physical distancing infringe on personal freedoms and can have negative effects on the health of those affected. There is a need to proactively address important areas such as health education and economic and social support to mitigate common sociopsychological effects of a pandemic.

Effects of Higher Normal Blood Pressure on Brain Are Detectable before Middle-Age and Differ by Sex

Background: To quantify the association between blood pressure (BP) across its full range, brain volumes and white matter lesions (WMLs) while investigating the effects of age, sex, body mass index (BMI), and antihypertensive medication. Methods: UK Biobank participants (n = 36,260) aged (40−70) years were included and stratified by sex and four age groups (age ≤ 45, 46−55, 56−65 and > 65 years). Multi-level regression analyses were used to assess the association between mean arterial pressure (MAP), systolic BP (SBP), diastolic BP (DBP), and brain volumes segmented using the FreeSufer software (gray matter volume [GMV], white matter volume [WMV], left [LHCV] and right hippocampal volume [RHCV]) and WMLs. Interaction effects between body mass index (BMI), antihypertensive medication and BP in predicting brain volumes and WMLs were also investigated. Results: Every 10 mmHg higher DBP was associated with lower brain volumes (GMV: −0.19%−−0.40%) [SE = 47.7−62.4]; WMV: −0.20−−0.23% [SE = 34.66−53.03]; LHCV: −0.40−−0.59% [SE = 0.44−0.57]; RHCV: −0.17−−0.57% [SE = 0.32−0.95]) across all age groups. A similar pattern was detected in both sexes, although it was weaker in men. Every 10 mmHg higher MAP was associated with larger WMLs across all age groups but peaked >65 years (1.19−1.23% [SE = 0.002]). Both lower BMI and anti-hypertensive medication appeared to afford a protective effect. Conclusion: Higher BP is associated with worse cerebral health across the full BP range from middle adulthood and into old age.

Association of cerebral small vessel disease burden with brain structure and cognitive and vascular risk trajectories in mid-to-late life

We characterize the associations of total cerebral small vessel disease (SVD) burden with brain structure, trajectories of vascular risk factors, and cognitive functions in mid-to-late life. Participants were 623 community-dwelling adults from the Whitehall II Imaging Sub-study with multi-modal MRI (mean age 69.96, SD = 5.18, 79% men). We used linear mixed-effects models to investigate associations of SVD burden with up to 25-year retrospective trajectories of vascular risk and cognitive performance. General linear modelling was used to investigate concurrent associations with grey matter (GM) density and white matter (WM) microstructure, and whether these associations were modified by cognitive status (Montreal Cognitive Asessment [MoCA] scores of < 26 vs. ≥ 26). Severe SVD burden in older age was associated with higher mean arterial pressure throughout midlife (β = 3.36, 95% CI [0.42-6.30]), and faster cognitive decline in letter fluency (β = -0.07, 95% CI [-0.13--0.01]), and verbal reasoning (β = -0.05, 95% CI [-0.11--0.001]). Moreover, SVD burden was related to lower GM volumes in 9.7% of total GM, and widespread WM microstructural decline (FWE-corrected p < 0.05). The latter association was most pronounced in individuals who demonstrated cognitive impairments on MoCA (MoCA < 26; F_3,608 = 2.14, p = 0.007). These findings highlight the importance of managing midlife vascular health to preserve brain structure and cognitive function in old age.

Association of Early Adulthood 25-Year Blood Pressure Trajectories With Cerebral Lesions and Brain Structure in Midlife

IMPORTANCE

Midlife elevated blood pressure (BP) is an important risk factor associated with brain structure and function. Little is known about trajectories of BP that modulate this risk.

OBJECTIVE

To identify BP trajectory patterns from young adulthood to midlife that are associated with brain structure in midlife.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data of US adults from Coronary Artery Risk Development in Young Adults (CARDIA), a prospective longitudinal study of Black and White men and women (baseline age 18 to 30 years) examined up to 8 times over 30 years (1985-1986 to 2015-2016). There were 885 participants who underwent brain magnetic resonance imaging (MRI) in the 25th or 30th year examinations. Analyses were conducted November 2019 to December 2020.

EXPOSURES

Using group-based trajectory modeling, 5 25-year BP trajectories for 3 BP traits were identified in the total CARDIA cohort of participants with 3 or more BP measures, which were then applied to analyses of the subset of 853 participants in the Brain MRI substudy. Mean arterial pressure (MAP) was examined as an integrative measure of systolic and diastolic BP. With linear regression, the associations of the BP trajectories with brain structures were examined, adjusting sequentially for demographics, cardiovascular risk factors, and antihypertensive medication use.

MAIN OUTCOMES AND MEASURES

Brain MRI outcomes include total brain, total gray matter, normal-looking and abnormal white matter volumes, gray matter cerebral blood flow, and white matter fractional anisotropy.

RESULTS

Brain MRI analyses were conducted on 853 participants (mean [SD] age, 50.3 [3.6] years; 399 [46.8%] men; 354 [41.5%] Black and 499 [58.5%] White individuals). The MAP trajectory distribution was 187 individuals (21.1%) with low-stable, 385 (43.5%) with moderate-gradual, 71 (8.0%) with moderate-increasing, 204 (23.1%) with elevated-stable, and 38 (4.3%) with elevated-increasing. Compared with the MAP low-stable trajectory group, individuals in the moderate-increasing and elevated-increasing groups were more likely to have higher abnormal white matter volume (moderate: β, 0.52; 95% CI, 0.23 to 0.82; elevated: β, 0.57; 95% CI, 0.19 to 0.95). Those in the MAP elevated-increasing group had lower gray matter cerebral blood flow (β, -0.42; 95% CI, -0.79 to -0.05) after adjusting for sociodemographics and cardiovascular risk factors. After adjustment for antihypertensive medication use, the difference was consistent for abnormal white matter volume, but results were no longer significant for gray matter cerebral blood flow.

CONCLUSIONS AND RELEVANCE

Among young adults with moderate to high levels of BP, a gradual increase in BP to middle-age may increase the risk in diffuse small vessel disease and lower brain perfusion.

Association of blood pressure with brain structure in youth with and without bipolar disorder

BACKGROUND

We previously found that blood pressure (BP) is elevated, and associated with poorer neurocognition, in youth with bipolar disorder (BD). While higher BP is associated with smaller brain structure in adults, studies have not examined this topic in BD or youth.

METHODS

Participants were 154 youth, ages 13-20 (n = 81 BD, n = 73 HC). Structural magnetic resonance imaging and diastolic (DBP), and systolic (SBP) pressure were obtained. Region of interest (ROI; anterior cingulate cortex [ACC], insular cortex, hippocampus) and vertex-wise analyses controlling for age, sex, body-mass-index, and intracranial volume investigated BP-neurostructural associations; a group-by-BP interaction was also assessed.

RESULTS

In ROI analyses, higher DBP in the overall sample was associated with smaller insular cortex area (β=-0.18 p = 0.007) and was associated with smaller ACC area to a significantly greater extent in HC vs. BD (β=-0.14 p = 0.015). In vertex-wise analyses, higher DBP and SBP were associated with smaller area and volume in the insular cortex, frontal, parietal, and temporal regions in the overall sample. Additionally, higher SBP was associated with greater thickness in temporal and parietal regions. Finally, higher SBP was associated with smaller area and volume in frontal, parietal, and temporal regions to a significantly greater extent in BD vs. HC.

LIMITATIONS

Cross-sectional design, single assessment of BP.

CONCLUSION

BP is associated with brain structure in youth, with variability related to structural phenotype (volume vs. thickness) and psychiatric diagnosis (BD vs. HC). Future studies evaluating temporality of these findings, and the association of BP changes on brain structure in youth, are warranted.

Risk Factors, Lifestyle Behaviors, and Vascular Brain Health

Although a relationship between traditional cardiovascular risk factors and stroke has long been recognized, these risk factors likely play a role in other aspects of brain health. Clinical stroke is only the tip of the iceberg of vascular brain injury that includes covert infarcts, white matter hyperintensities, and microbleeds. Furthermore, an individual's risk for not only stroke but poor brain health includes not only these traditional vascular risk factors but also lifestyle and genetic factors. The purpose of this narrative review is to summarize the state of the evidence on traditional and nontraditional vascular risk factors and their contributions to brain health. Additionally, we will review important modifiers that interact with these risk factors to increase, or, in some cases, reduce risk of adverse brain health outcomes, with an emphasis on genes and biomarkers associated with Alzheimer disease. Finally, we will consider the importance of social determinants of health in brain health outcomes.

Short cognitive screening in elderlies as a part of advanced pharmaceutical care in Slovak community pharmacies - The pilot study KOGNIMET-SK

The aim of this study is to evaluate the implementation of a simple, easy-to-use cognitive screening test in the pharmaceutical care of elderly patients (aged 60 years and over) in community pharmacies and to test whether cognitive decline is associated with metabolic syndrome (MetS).

Current research has reported the increasing prevalence of MetS with age and indicated a link between cardiovascular risk factors and impairment of cognitive functions. We hypothesized that the short cognitive test realised in pharmaceutical care in community pharmacies could help identify risk groups of patients with potential cognitive decline. Because of the increasing pressure on primary care, collaboration between community pharmacists and general practitioners is essential, especially in preventive programmes and regarding chronically ill patients.

The study included 222 elderly patients aged 60 years and over reached between February 2018 and February 2019 in 16 community pharmacies in Slovakia. Criteria for the classification of MetS were used, following the International Diabetes Federation Worldwide Definition of MetS (2005) for European populations. Cognitive performance was evaluated using the Slovak version of the Montreal Cognitive Assessment. The scale range of the MoCA test is 0–30 points, and the cut-off for cognitive impairment is ≤ 24 points.

Our outcomes show that the presence of metabolic syndrome only slightly contributes to the impairment of cognitive functions of patients receiving routine pharmaceutical care in community pharmacies. Cognitive assessment might be an important tool for identifying risk groups of patients that would benefit from a specific approach within the framework of pharmaceutical care.

Different cardiovascular risk factors are related to distinct white matter hyperintensity MRI phenotypes in older adults

•

White matter hyperintensity (WMH) shape: a novel, advanced MRI marker.

•

Hypertension correlates with a more irregular shape of periventricular/confluent WMH.

•

Different cardiovascular/pathological mechanisms lead to distinct WMH MRI phenotypes.

The underlying mechanisms of the association between cardiovascular risk factors and a higher white matter hyperintensity (WMH) burden are unknown. We investigated the association between cardiovascular risk factors and advanced WMH markers in 155 non-demented older adults (mean age: 71 ± 5 years). The association between cardiovascular risk factors and quantitative MRI-based WMH shape and volume markers were examined using linear regression analysis. Presence of hypertension was associated with a more irregular shape of periventricular/confluent WMH (convexity (B (95 % CI)): −0.12 (−0.22–−0.03); concavity index: 0.06 (0.02–0.11)), but not with total WMH volume (0.22 (−0.15–0.59)). Presence of diabetes was associated with deep WMH volume (0.89 (0.15–1.63)). Body mass index or hyperlipidemia showed no association with WMH markers. In conclusion, different cardiovascular risk factors seem to be related to a distinct pattern of WMH shape markers in non-demented older adults. These findings may suggest that different underlying cardiovascular pathological mechanisms lead to different WMH MRI phenotypes, which may be valuable for early detection of individuals at risk for stroke and dementia.

Vascular Cognitive Impairment (VCI)

Vascular cognitive impairment (VCI) is predominately caused by vascular risk factors and cerebrovascular disease. VCI includes a broad spectrum of cognitive disorders, from mild cognitive impairment to vascular dementia caused by ischemic or hemorrhagic stroke, and vascular factors alone or in a combination with neurodegeneration including Alzheimer's disease (AD) and AD-related dementia. VCI accounts for at least 20-40% of all dementia diagnosis. Growing evidence indicates that cerebrovascular pathology is the most important contributor to dementia, with additive or synergistic interactions with neurodegenerative pathology. The most common underlying mechanism of VCI is chronic age-related dysregulation of CBF, although other factors such as inflammation and cardiovascular dysfunction play a role. Vascular risk factors are prevalent in VCI and if measured in midlife they predict cognitive impairment and dementia in later life. Particularly, hypertension, high cholesterol, diabetes, and smoking at midlife are each associated with a 20 to 40% increased risk of dementia. Control of these risk factors including multimodality strategies with an inclusion of lifestyle modification is the most promising strategy for treatment and prevention of VCI. In this review, we present recent developments in age-related VCI, its mechanisms, diagnostic criteria, neuroimaging correlates, vascular risk determinants, and current intervention strategies for prevention and treatment of VCI. We have also summarized the most recent and relevant literature in the field of VCI.

Heart health meets cognitive health: evidence on the role of blood pressure

The enormous societal and financial burden of Alzheimer's disease and related dementias requires the identification of risk factors and pathways to reduce dementia risk. Blood pressure (BP) management and control is one promising area, in which data have been inconclusive. Accumulating evidence over the past 5 years shows the effectiveness of BP management interventions among older individuals at risk, most notably from the SPRINT-MIND trial. These findings have been coupled with longitudinal observational data. However, to date, the results do not concur on the optimal timing and target of BP lowering, and further study in diverse populations is needed. Given the long preclinical phase of dementia and data supporting the importance of BP control earlier in the lifecourse, long-term interventional and observational studies in ethnically and racially diverse populations, with novel imaging and blood-based biomarkers of neurodegeneration and vascular cognitive impairment to understand the pathophysiology, are needed to advance the field.

Higher Handgrip Strength Is Linked to Better Cognitive Performance in Chinese Adults with Hypertension

OBJECTIVE

There is growing evidence that in adults, higher levels of handgrip strength (HGS) are linked to better cognitive performance. However, the relationship between HGS and cognitive performance has not been sufficiently investigated in special cohorts, such as individuals with hypertension who have an intrinsically higher risk of cognitive decline. Thus, the purpose of this study was to examine the relationship between HGS and cognitive performance in adults with hypertension using data from the Global Ageing and Adult Health Survey (SAGE).

METHODS

A total of 4486 Chinese adults with hypertension from the SAGE were included in this study. Absolute handgrip strength (aHGS in kilograms) was measured using a handheld electronic dynamometer, and cognitive performance was assessed in the domains of short-term memory, delayed memory, and language ability. Multiple linear regression models were fitted to examine the association between relative handgrip strength (rHGS; aHGS divided by body mass index) and measures of cognitive performance.

RESULTS

Overall, higher levels of rHGS were associated with higher scores in short-term memory (β = 0.20) and language (β = 0.63) compared with the lowest tertiles of rHGS. In male participants, higher HGS was associated with higher scores in short-term memory (β = 0.31), language (β = 0.64), and delayed memory (β = 0.22). There were no associations between rHGS and cognitive performance measures in females.

CONCLUSION

We observed that a higher level of rHGS was associated with better cognitive performance among hypertensive male individuals. Further studies are needed to investigate the neurobiological mechanisms, including sex-specific differences driving the relationship between measures of HGS and cognitive performance in individuals with hypertension.

Contributions of Cerebral Blood Flow to Associations Between Blood Pressure Levels and Cognition: The Age, Gene/Environment Susceptibility-Reykjavik Study

[Figure: see text].

Protective effect of controlled blood pressure on risk of dementia in low-risk, grade 1 hypertension

OBJECTIVE

High blood pressure (BP) increases the risk of dementia; however, few studies have reported on the risk of dementia in patients with low-risk, early-grade hypertension. We investigated the protective effect of controlled BP on risk of dementia in treated, low-risk, grade 1 hypertensive patients from the entire National Health Insurance Service National Health Examinee cohort.

METHODS

We selected grade 1 hypertension (140-159/90-99 mmHg) patients with low risk, diagnosed in 2005-2006. All patients (N = 128 665) were classified into controlled (average BP < 140/90 mmHg during the follow-up) and uncontrolled (average BP ≥ 140/90 mmHg) BP groups and followed up until 2015. The risk of dementia was estimated using Cox proportional hazard model after adjustments for propensity score.

RESULTS

Average BP was 131/81 mmHg in the controlled group (N = 49 408) and 144/87 mmHg in the uncontrolled group (N = 99 257). Overall dementia incidence rates in controlled and uncontrolled groups were 4.9 and 8.1 per 1000 person-year, respectively. The controlled group showed lower risk of overall dementia, Alzheimer's disease, and vascular dementia than the uncontrolled group. The controlled group had a low risk of vascular dementia at all ages, especially in the younger group (age <60). The optimal BP level associated with the lowest risk of dementia was 130 to less than 140 mmHg for SBP and 70 to less than 80 mmHg for DBP.

CONCLUSION

We concluded that among even low-risk and grade 1 hypertension patients, controlled BP significantly reduced the risk of dementia, including Alzheimer's disease and vascular dementia.

Higher Blood Pressure is Associated with Greater White Matter Lesions and Brain Atrophy: A Systematic Review with Meta-Analysis

BACKGROUND

To summarise and quantify the evidence on the association between Blood pressure (BP), white matter lesions (WMLs), and brain volumes.

METHOD

Electronic databases PubMed, Scopus, and Clarivate were searched in February 2020 using an established methodology and pre-determined search terms. Studies were eligible for inclusion if they reported on the association between BP and WMLs or brain volume in cognitively healthy individuals, while adjusting for age and intra-cranial volume.

RESULTS

Searches yielded 7509 articles, of which 52 (26 longitudinal and 33 cross-sectional), were eligible and had a combined sample size of 343,794 individuals. Analyses found that 93.7% of studies reported that higher BP was associated with poorer cerebral health (higher WMLs and lower brain volumes). Meta-analysis of compatible results indicated a dose-dependent relationship with every one standard deviation increase in systolic BP (SBP) above 120 mmHg being associated with a 11.2% (95% CI 2.3, 19.9, p = 0.0128) increase in WMLs and -0.13% (95% CI -0.25, -0.023, p = 0.0183) smaller hippocampal volume.

CONCLUSION

The association between BP and brain volumes appears across the full range of BP measurements and is not limited to hypertensive individuals. Higher BP in community-residing individuals is associated with poorer cerebral health.

Hypertension and Hypercholesterolemia Modify Dementia Risk in Relation to APOEɛ4 Status

BACKGROUND

There is significant interest in understanding the role of modifiable vascular risk factors contributing to dementia risk across age groups.

OBJECTIVE

Risk of dementia onset was assessed in relation to vascular risk factors of hypertension and hypercholesterolemia among cognitively normal APOEɛ4 carriers and non-carriers.

METHODS

In a sample of prospectively characterized longitudinal cohort from the National Alzheimer's Coordinating Center database, 9,349 participants met criteria for normal cognition at baseline, had a CDR-Global (CDR-G) score of zero, and had concomitant data on APOEɛ4 status and medical co-morbidities including histories of hypertension and hypercholesterolemia. Multivariable Cox proportional hazards models adjusted for well-known potential confounders were used to compare dementia onset among APOEɛ4 carriers and non-carriers by young (≤65 years) and old (> 65 year) age groups.

RESULTS

519 participants converted to dementia within an average follow up of 5.97 years. Among older APOEɛ4 carriers, hypercholesterolemia was related to lower risk of dementia (HR (95% CI), 0.68 (0.49-0.94), p = 0.02). Among older APOEɛ4 non-carriers, hypertension was related to higher risk of dementia (HR (95% CI), 1.44 (1.13-1.82), p = 0.003). These results were corroborated among a subset with autopsy data characterizing underlying neuropathology. Among younger participants, vascular risk factors did not impact dementia risk, likely from a lower frequency of vascular and Alzheimer's as etiologies of dementia among this cohort.

CONCLUSION

A history of hypercholesterolemia related to a lower risk of dementia among older APOEɛ4 carriers, while hypertension related to a higher risk of dementia among older APOEɛ4 non-carriers.

Blood Pressure Variation and Subclinical Brain Disease

BACKGROUND

Large blood pressure (BP) variability may contribute to stroke and dementia, but the mechanisms are largely unknown.

OBJECTIVES

This study investigated the association of BP variation, considering its magnitude and direction, with the presence and progression of subclinical brain disease in the general population.

METHODS

This study included 2,348 participants age ≥55 years from a prospective cohort study. BP was measured at each visit every 3 to 4 years from 1990 onward. Brain magnetic resonance imaging (MRI) was performed at all visits from 2005 onward. The authors primarily assessed variation as the absolute difference in BP divided by the mean over 2 sequential visits for both systolic BP (SBP) and diastolic BP (DBP), and further assessed the direction of the variation. The authors investigated the multivariate-adjusted associations of BP variation with subsequent measurements of MRI markers of cerebral small vessel disease, brain tissue volumes, and white matter microstructural integrity. Longitudinal changes in these markers also were assessed.

RESULTS

A large SBP variation (top vs. bottom tertiles), measured on average 7 years preceding brain MRI, was associated with higher odds of having severe white matter hyperintensities (WMH) (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.21 to 1.43), lacunes (OR: 1.25; 95% CI: 1.04 to 1.48), and microbleeds (OR: 1.16; 95% CI: 1.03 to 1.31). Similarly, this variation was associated with smaller total brain volume and worse white matter microstructural integrity (all p < 0.001). A large SBP variation was also associated with the progression of WMH (rate ratio [RR]: 1.14; 95% CI: 1.02 to 1.27). Higher burdens of these brain imaging markers were observed with both large rises and falls in SBP. Similar findings were observed for DBP variation.

CONCLUSIONS

Elevated BP variation was associated with a wide range of subclinical brain structural changes, including MRI markers of cerebral small vessel disease, smaller brain tissue volumes, and worse white matter microstructural integrity. These subclinical brain changes could be the underlying mechanisms linking BP variation to dementia and stroke.

Uncontrolled hypertension associates with subclinical cerebrovascular health globally: a multimodal imaging study

OBJECTIVES

The study aimed to analyze the association between hypertension control and subclinical cerebrovascular health using a comprehensive multimodal imaging approach.

METHODS

The study included 200 hypertensive older males without previous cardiovascular diseases. Clinic blood pressure (BP) was measured using a standard approach. Cerebrovascular health was evaluated using magnetic resonance imaging in the following four aspects: Intracranial atherosclerosis as determined by vessel wall imaging; Vascular rarefaction (defined as less discernible vessels on angiography) was evaluated using a custom-developed technique. Cerebral blood flow (CBF) and white matter hyperintensity (WMH) were assessed using arterial spin-labeling imaging and fluid-attenuated inversion recovery imaging, respectively.

RESULTS

A total of 189 subjects had MRI scans. The mean age was 64.9 (± 7.2) years. For intracranial atherosclerosis, there was a significant association between uncontrolled hypertension and presence of intracranial plaque. When systolic and diastolic BP were analyzed separately, the association remained significant for both. For vascular rarefaction, uncontrolled hypertension was associated with less discernible vessel branches or shorter vessel length on angiography. Further analysis revealed that this is due to uncontrolled diastolic BP, but not uncontrolled systolic BP. There was an association between uncontrolled hypertension and reduced CBF, which was also mainly driven by uncontrolled diastolic BP. We also found that uncontrolled diastolic BP, but not uncontrolled systolic BP, was associated with increased WMH volume.

CONCLUSIONS

Uncontrolled hypertension was associated with subclinical cerebrovascular injury globally, with both small and medium-to-large arteries being affected.

KEY POINTS

• In this study, we leveraged the advantage of a series of cutting-edge MR imaging and analysis techniques and found uncontrolled hypertension is associated with subclinical globally compromised cerebrovascular health. • The detrimental consequences of uncontrolled BP affect not only the small vessels but also the medium-to-large arteries, and uncontrolled systolic and diastolic BP are both independently associated with certain types of cerebrovascular injury. • Our data suggest that cerebrovascular health is impaired globally in uncontrolled hypertension before the onset of stroke.

High blood pressure predicts hippocampal atrophy rate in cognitively impaired elders

INTRODUCTION

Understanding relationships among blood pressure (BP), cognition, and brain volume could inform Alzheimer's disease (AD) management.

METHODS

We investigated Alzheimer's Disease Neuroimaging Initiative (ADNI) participants: 200 controls, 346 mild cognitive impairment (MCI), and 154 AD. National Alzheimer's Co-ordinating Center (NACC) participants were separately analyzed: 1098 controls, 2297 MCI, and 4845 AD. Relationships between cognition and BP were assessed in both cohorts and BP and atrophy rates in ADNI. Multivariate mixed linear-regression models were fitted with joint outcomes of BP (systolic, diastolic, and pulse pressure), cognition (Mini-Mental State Examination, Logical Memory, and Digit Symbol) and atrophy rate (whole-brain, hippocampus).

RESULTS

ADNI MCI and AD patients with greater baseline systolic BP had higher hippocampal atrophy rates ([r, P value]; 0.2, 0.005 and 0.2, 0.04, respectively). NACC AD patients with lower systolic BP had lower cognitive scores (0.1, 0.0003).

DISCUSSION

Higher late-life BP may be associated with faster decline in cognitively impaired elders.

Lower Blood Pressure, Small-Vessel Disease, and Apathy in Older Persons With Mild Cognitive Deficits

BACKGROUND

In older persons, both high and low blood pressure (BP) levels are associated with symptoms of apathy. Population characteristics, such as burden of cerebral small-vessel disease (CSVD), may underlie these apparently contradictory findings. We aimed to explore, in older persons, whether the burden of CSVD affects the association between BP and apathy.

DESIGN

Cross-sectional study.

SETTING

Primary care setting, the Netherlands.

PARTICIPANTS

Community-dwelling older persons (mean age = 80.7 years; SD = 4.1 years) with mild cognitive deficits and using antihypertensive treatment, participating in the baseline measurement of the magnetic resonance imaging substudy (n = 210) of the Discontinuation of Antihypertensive Treatment in the Elderly Study Leiden.

MEASUREMENTS

During home visits, BP was measured in a standardized way and apathy was assessed with the Apathy Scale (range = 0-42). Stratified linear regression analyses were performed according to the burden of CSVD. A higher burden of CSVD was defined as 2 or more points on a compound CSVD score (range = 0-3 points), defined as presence of white matter hyperintensities (greater than median), any lacunar infarct, and/or two or more microbleeds.

RESULTS

In the entire population, those with a lower systolic and those with a lower diastolic BP had more symptoms of apathy (β = -.35 [P = .01] and β = -.66 [P = .02], respectively). In older persons with a higher burden of CSVD (n = 50 [24%]), both lower systolic BP (β = -.64, P = .02) and lower diastolic BP (β = -1.6, P = .01) were associated with more symptoms of apathy, whereas no significant association was found between BP and symptoms of apathy in older persons with a lower burden of CSVD (n = 160).

CONCLUSIONS

Particularly in older persons with a higher burden of CSVD, lower BP was associated with more symptoms of apathy. Adequate BP levels for optimal psychological functioning may vary across older populations with a different burden of CSVD. J Am Geriatr Soc 68:1811-1817, 2020.

Decrease in Serum HDL-C Level Is Associated with Elevation of Blood Pressure: Correlation Analysis from the Korean National Health and Nutrition Examination Survey 2017

A low-serum, high-density lipoproteins-cholesterol (HDL-C) level and high blood pressure (BP) are independent risk factors for cardiovascular disease and dementia. In the present study, in order to find putative correlation between low HDL-C and hypertension, 4552 subjects (20-80 years old) were selected from the Korean National Health And Nutrition Examination Survey 2017 (KNHANES VII-2, n = 2017 men, n = 2535 women). They were classified into four levels of blood pressure, ranging from BP1 (normal, below 120/80 mmHg for systolic BP (SBP)/diastolic BP (DBP), BP2 (prehypertension, 120/80 to 139/89 mmHg), BP3 (hypertension stage 1, 140/90-159/99 mmHg), and BP4 (hypertension stage 2, higher than 160/100 mmHg). Generally, in the total population, a higher SBP level and age were associated with a lower HDL-C in both genders. However, DBP was not associated with age in men. In the total population, Pearson's correlation analysis revealed that SBP (r = -0.188, p < 0.001) and DBP (r = -0.198, p < 0.001) showed negative correlations with percentage of HDL-C in total cholesterol (TC), HDL-C/TC (%). In both genders, HDL-C gradually decreased with age and HDL-C/TC (%) was more accurate in expressing a correlation with BP. Women showed a more distinct decrease in HDL-C with an elevation of BP and age than men. Both elevation of DBP and SBP were associated with a decrease in HDL-C, around 2.3-2.4 mg/dL, between normal range and hypertension 2 stage. Additionally, DBP was significantly associated with HDL-C/TC (%) (men: r = -0.136, p < 0.001; women: r = -0.152, p < 0.001), while HDL-C did not show a significant association with a change in DBP. In conclusion, SBP was positively correlated with age, but DBP did not change significantly with age. The correlation of BP and HDL-C depending on age showed that SBP gradually increased and HDL-C decreased with an increase in age. The percentage of HDL-C in TC was more significantly associated with a change in SBP and DBP in both genders.

Rapid Systolic Blood Pressure Changes After Standing Up Associate With Impaired Physical Performance in Geriatric Outpatients

Background

Orthostatic hypotension is a prevalent condition in older adults and is associated with impaired physical performance and falls. The ability of older adults to compensate for rapid changes in systolic blood pressure (SBP; ie, SBP decline rate and SBP variability) may be important for physical performance. This study investigates the association of rapid SBP changes after standing up with physical performance.

Methods and Results

Consecutive patients who visited the Center of Geriatrics Amsterdam in 2014 and 2015 were included. The following SBP parameters were computed in 2 intervals (0–15 and 15–180 seconds) after standing up: steepness of steepest SBP decline; ratio of standing/supine SBP variability; and magnitude of largest SBP decline. Physical performance was assessed using the following measures: chair stand time, timed up and go time, walking speed, handgrip strength, and tandem stance performance. A total of 109 patients (45% men; age, mean, 81.7 years [standard deviation, 7.0 years]) were included. Steepness of steepest SBP decline (0–15 seconds) was associated with slower chair stand time (P<0.001), timed up and go time (P=0.022), and walking speed (P=0.024). Ratio of standing/supine SBP variability (0–15 seconds) was associated with slower chair stand time (P=0.005). Magnitude of largest SBP decline was not associated with physical performance.

Conclusions

SBP parameters reflecting rapid SBP changes were more strongly associated with physical performance compared with SBP decline magnitude in geriatric outpatients. These results support the hypothesis of an inadequate cerebral autoregulation during rapid SBP changes and advocate the use of continuous blood pressure measurements.

Blood Pressure and Memory: Novel Approaches to Modeling Nonlinear Effects in Longitudinal Studies

BACKGROUND

Linear models cannot capture nonlinear associations when the relationships between cognition and risk factors vary across risk levels. We demonstrate a method of modelling nonlinear associations using the example of blood pressure (BP) and memory.

METHODS

We measured memory and BP (in mm Hg) annually for 10 years in a population-based cohort (N=1982) aged 65+. We evaluated the relationship between BP and memory at the same time points using both linear mixed models and generalized additive mixed models with smoothing splines, adjusting for relevant covariates.

RESULTS

Linear mixed models found no significant associations. Generalized additive mixed models detected different associations between BP and memory across baseline BP categories (normotensive, hypertensive, hypotensive). Among normotensives, systolic blood pressure (SBP)/diastolic blood pressure (DBP) around 140/80 was associated with the highest, while SBP/DBP around 110/60 was associated with the lowest, predicted memory scores. Among hypertensives, SBP/DBP around 130/85 was associated with the highest, while SBP/DBP around 150/65 was associated with the lowest, predicted memory scores. Among hypotensives, no significant association was found. Among both normotensives and hypertensives, a DBP >75 was associated with better memory.

CONCLUSIONS

By modelling nonlinear associations, we showed that the relationship between BP and memory performance varied by baseline BP among normotensives and hypertensives.

Associations between blood pressure across adulthood and late-life brain structure and pathology in the neuroscience substudy of the 1946 British birth cohort (Insight 46): an epidemiological study

BACKGROUND

Midlife hypertension confers increased risk for cognitive impairment in late life. The sensitive period for risk exposure and extent that risk is mediated through amyloid or vascular-related mechanisms are poorly understood. We aimed to identify if, and when, blood pressure or change in blood pressure during adulthood were associated with late-life brain structure, pathology, and cognition.

METHODS

Participants were from Insight 46, a neuroscience substudy of the ongoing longitudinal Medical Research Council National Survey of Health and Development, a birth cohort that initially comprised 5362 individuals born throughout mainland Britain in one week in 1946. Participants aged 69-71 years received T1 and FLAIR volumetric MRI, florbetapir amyloid-PET imaging, and cognitive assessment at University College London (London, UK); all participants were dementia-free. Blood pressure measurements had been collected at ages 36, 43, 53, 60-64, and 69 years. We also calculated blood pressure change variables between ages. Primary outcome measures were white matter hyperintensity volume (WMHV) quantified from multimodal MRI using an automated method, amyloid-β positivity or negativity using a standardised uptake value ratio approach, whole-brain and hippocampal volumes quantified from 3D-T1 MRI, and a composite cognitive score-the Preclinical Alzheimer Cognitive Composite (PACC). We investigated associations between blood pressure and blood pressure changes at and between 36, 43, 53, 60-64, and 69 years of age with WMHV using generalised linear models with a gamma distribution and log link function, amyloid-β status using logistic regression, whole-brain volume and hippocampal volumes using linear regression, and PACC score using linear regression, with adjustment for potential confounders.

FINDINGS

Between May 28, 2015, and Jan 10, 2018, 502 individuals were assessed as part of Insight 46. 465 participants (238 [51%] men; mean age 70·7 years [SD 0·7]; 83 [18%] amyloid-β-positive) were included in imaging analyses. Higher systolic blood pressure (SBP) and diastolic blood pressure (DBP) at age 53 years and greater increases in SBP and DBP between 43 and 53 years were positively associated with WMHV at 69-71 years of age (increase in mean WMHV per 10 mm Hg greater SBP 7%, 95% CI 1-14, p=0·024; increase in mean WMHV per 10 mm Hg greater DBP 15%, 4-27, p=0·0057; increase in mean WMHV per one SD change in SBP 15%, 3-29, p=0·012; increase in mean WMHV per 1 SD change in DBP 15%, 3-30, p=0·017). Higher DBP at 43 years of age was associated with smaller whole-brain volume at 69-71 years of age (-6·9 mL per 10 mm Hg greater DBP, -11·9 to -1·9, p=0·0068), as were greater increases in DBP between 36 and 43 years of age (-6·5 mL per 1 SD change, -11·1 to -1·9, p=0·0054). Greater increases in SBP between 36 and 43 years of age were associated with smaller hippocampal volumes at 69-71 years of age (-0·03 mL per 1 SD change, -0·06 to -0·001, p=0·043). Neither absolute blood pressure nor change in blood pressure predicted amyloid-β status or PACC score at 69-71 years of age.

INTERPRETATION

High and increasing blood pressure from early adulthood into midlife seems to be associated with increased WMHV and smaller brain volumes at 69-71 years of age. We found no evidence that blood pressure affected cognition or cerebral amyloid-β load at this age. Blood pressure monitoring and interventions might need to start around 40 years of age to maximise late-life brain health.

FUNDING

Alzheimer's Research UK, Medical Research Council, Dementias Platform UK, Wellcome Trust, Brain Research UK, Wolfson Foundation, Weston Brain Institute, Avid Radiopharmaceuticals.

Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia

Importance

The association between late-life blood pressure (BP) and cognition may depend on the presence and chronicity of past hypertension. Late-life declines in blood pressure following prolonged hypertension may be associated with poor cognitive outcomes.

Objective

To examine the association of midlife to late-life BP patterns with subsequent dementia, mild cognitive impairment, and cognitive decline.

Design, Setting, and Participants

The Atherosclerosis Risk in Communities prospective population-based cohort study enrolled 4761 participants during midlife (visit 1, 1987-1989) and followed-up over 6 visits through 2016-2017 (visit 6). BP was examined over 24 years at 5 in-person visits between visits 1 and 5 (2011-2013). During visits 5 and 6, participants underwent detailed neurocognitive evaluation. The setting was 4 US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Follow-up ended on December 31, 2017.

Exposures

Five groups based on longitudinal patterns of normotension, hypertension (>140/90 mm Hg), and hypotension (<90/60 mm Hg) at visits 1 to 5.

Main Outcomes and Measures

Primary outcome was dementia onset after visit 5, based on Ascertain Dementia-8 informant questionnaires, Six-Item Screener telephone assessments, hospital discharge and death certificate codes, and the visit 6 neurocognitive evaluation. Secondary outcome was mild cognitive impairment at visit 6, based on the neurocognitive evaluation.

Results

Among 4761 participants (2821 [59%] women; 979 [21%] black race; visit 5 mean [SD] age, 75 [5] years; visit 1 mean age range, 44-66 years; visit 5 mean age range, 66-90 years), there were 516 (11%) incident dementia cases between visits 5 and 6. The dementia incidence rate for participants with normotension in midlife (n = 833) and late life was 1.31 (95% CI, 1.00-1.72 per 100 person-years); for midlife normotension and late-life hypertension (n = 1559), 1.99 (95% CI, 1.69-2.32 per 100 person-years); for midlife and late-life hypertension (n = 1030), 2.83 (95% CI, 2.40-3.35 per 100 person-years); for midlife normotension and late-life hypotension (n = 927), 2.07 (95% CI, 1.68-2.54 per 100 person-years); and for midlife hypertension and late-life hypotension (n = 389), 4.26 (95% CI, 3.40-5.32 per 100 person-years). Participants in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) and in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly increased risk of subsequent dementia compared with those who remained normotensive. Irrespective of late-life BP, sustained hypertension in midlife was associated with dementia risk (HR, 1.41 [95% CI, 1.17-1.71]). Compared with those who were normotensive in midlife and late life, only participants with midlife hypertension and late-life hypotension had higher risk of mild cognitive impairment (37 affected individuals (odds ratio, 1.65 [95% CI, 1.01-2.69]). There was no significant association of BP patterns with late-life cognitive change.

Conclusions and Relevance

In this community-based cohort with long-term follow-up, sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal BP, were associated with increased risk for subsequent dementia.

Association of peripheral blood pressure with gray matter volume in 19- to 40-year-old adults

OBJECTIVE

To test whether elevated blood pressure (BP) relates to gray matter (GM) volume (GMV) changes in young adults who had not previously been diagnosed with hypertension (systolic BP [SBP]/diastolic BP [DBP] ≥140/90 mm Hg).

METHODS

We associated BP with GMV from structural 3T T1-weighted MRI of 423 healthy adults between 19 and 40 years of age (mean age 27.7 ± 5.3 years, 177 women, SBP/DBP 123.2/73.4 ± 12.2/8.5 mm Hg). Data originated from 4 previously unpublished cross-sectional studies conducted in Leipzig, Germany. We performed voxel-based morphometry on each study separately and combined results in image-based meta-analyses (IBMA) to assess cumulative effects across studies. Resting BP was assigned to 1 of 4 categories: (1) SBP <120 and DBP <80 mm Hg, (2) SBP 120-129 or DBP 80-84 mm Hg, (3) SBP 130-139 or DBP 85-89 mm Hg, (4) SBP ≥140 or DBP ≥90 mm Hg.

RESULTS

IBMA yielded the following results: (1) lower regional GMV was correlated with higher peripheral BP; (2) lower GMV was found with higher BP when comparing individuals in subhypertensive categories 3 and 2, respectively, to those in category 1; (3) lower BP-related GMV was found in regions including hippocampus, amygdala, thalamus, frontal, and parietal structures (e.g., precuneus).

CONCLUSION

BP ≥120/80 mm Hg was associated with lower GMV in regions that have previously been related to GM decline in older individuals with manifest hypertension. Our study shows that BP-associated GM alterations emerge continuously across the range of BP and earlier in adulthood than previously assumed. This suggests that treating hypertension or maintaining lower BP in early adulthood might be essential for preventing the pathophysiologic cascade of asymptomatic cerebrovascular disease to symptomatic end-organ damage, such as stroke or dementia.

Autonomic Cardiovascular Dysregulation at Rest and During Stress in Chronically Low Blood Pressure

Abstract. Chronic low blood pressure (hypotension) is accompanied by symptoms such as fatigue, reduced drive, faintness, dizziness, cold limbs, and concentration difficulties. The study explored the involvement of aberrances in autonomic cardiovascular control in the origin of this condition. In 40 hypotensive and 40 normotensive subjects, impedance cardiography, electrocardiography, and continuous blood pressure recordings were performed at rest and during stress induced by mental calculation. Parameters of cardiac sympathetic control (i.e., stroke volume, cardiac output, pre-ejection period, total peripheral resistance), parasympathetic control (i.e., heart rate variability), and baroreflex function (i.e., baroreflex sensitivity) were obtained. The hypotensive group exhibited markedly lower stroke volume, heart rate, and cardiac output, as well as higher pre-ejection period and baroreflex sensitivity than the control group. Hypotension was furthermore associated with a smaller blood pressure response during stress. No group differences arose in total peripheral resistance and heart rate variability. While reduced beta-adrenergic myocardial drive seems to constitute the principal feature of the autonomic impairment that characterizes chronic hypotension, baroreflex-related mechanisms may also contribute to this state. Insufficient organ perfusion due to reduced cardiac output and deficient cardiovascular adjustment to situational requirements may be involved in the manifestation of bodily and mental symptoms.

Association between systolic blood pressure and dementia in the Whitehall II cohort study: role of age, duration, and threshold used to define hypertension

Aims

To examine associations of diastolic and systolic blood pressure (SBP) at age 50, 60, and 70 years with incidence of dementia, and whether cardiovascular disease (CVD) over the follow-up mediates this association.

Methods and results

Systolic and diastolic blood pressure were measured on 8639 persons (32.5% women) from the Whitehall II cohort study in 1985, 1991, 1997, and 2003. Incidence of dementia (n dementia/n total = 385/8639) was ascertained from electronic health records followed-up until 2017. Cubic splines using continuous blood pressure measures suggested SBP ≥130 mmHg at age 50 but not at age 60 or 70 was associated with increased risk of dementia, confirmed in Cox regression analyses adjusted for sociodemographic factors, health behaviours, and time varying chronic conditions [hazard ratio (HR) 1.38; 95% confidence interval (95% CI) 1.11, 1.70]. Diastolic blood pressure was not associated with dementia. Participants with longer exposure to hypertension (SBP ≥ 130 mmHg) between mean ages of 45 and 61 years had an increased risk of dementia compared to those with no or low exposure to hypertension (HR 1.29, 95% CI 1.00, 1.66). In multi-state models, SBP ≥ 130 mmHg at 50 years of age was associated with greater risk of dementia in those free of CVD over the follow-up (HR 1.47, 95% CI 1.15, 1.87).

Conclusion

Systolic blood pressure ≥130 mmHg at age 50, below the conventional ≥140 mmHg threshold used to define hypertension, is associated with increased risk of dementia; in these persons this excess risk is independent of CVD.

HIV disease and diabetes interact to affect brain white matter hyperintensities and cognition

BACKGROUND

Since the onset of combination antiretroviral therapy use, the incidence of HIV-associated dementia and of HIV encephalitis has fallen dramatically. The present study investigates the extent of white matter hyperintensities (WMHs) among individuals with HIV disease, and factors that predict their presence and their impact on psychomotor speed.

METHODS

A total of 322 men participating in the Multicenter AIDS Cohort Study (185 HIV-infected, age: 57.5 ± 6.0) underwent MRI scans of the brain. T1-weighted magnetization-prepared rapid gradient-echo (MP-RAGE) and T2-weighted Fluid Attenuated Inversion Recovery (FLAIR) images were obtained and processed using an automated method for identifying and measuring WMHs. WMH burden was expressed as the log10 transformed percentage of total white matter.

RESULTS

There were no significant associations between WMHs and HIV disease. However, the extent of WMHs was predicted by age more than 60 (β = 0.17), non-white race (β = 0.14), glomerular filtration rate (β = -0.11), and the presence of diabetes (β = 0.12). There were no interactions between HIV status and age (β = -0.03) or between age and diabetes (β = 0.07). However, the interaction between HIV infection and diabetes was significant (β = 0.26). The extent of WMHs was significantly associated with performance on measures of psychomotor speed (β = 0.15).

CONCLUSION

In today's therapeutic environment, in HIV-infected and HIV seronegative individuals, those factors which affect the cerebrovasculature are the best predictors of WMHs. Diabetes has a specific impact among HIV-infected, but not uninfected, men, suggesting the need for more aggressive treatment even in the prediabetes state, especially as WMHs affect cognitive functions.