Association of higher diastolic blood pressure levels with cognitive impairment

Association between untreated and treated blood pressure levels and cognitive decline in community-dwelling middle-aged and older adults in China: a longitudinal study

BACKGROUND

Optimal blood pressure (BP) levels to reduce the long-term risk of cognitive decline remains controversial. We aimed to investigate the association between BP and anti-hypertensive treatment status with cognitive decline in older adults.

METHODS

This study used data from the China Health and Retirement Longitudinal Study. Cognitive function was assessed at year 2011, 2013, 2015, and 2018. Global cognitive Z-score was calculated as the average score of episodic memory and mental intactness. BP were measured at the first and second wave. Pulse pressure (PP) was calculated as systolic BP (SBP) minus diastolic BP. Cumulative BP was calculated as the area under the curve using BP measurements from 2011 to 2013. Linear mixed models were used to assess the longitudinal association between BP-related measurements and cognitive decline.

RESULTS

We included 11,671 participants (47.3% men and mean age 58.6 years). Individual with BP > 140/90 mm Hg or taking anti-hypertensive medication were independently associated with accelerated cognitive decline (β=-0.014, 95% CI: -0.020 to -0.007). Individuals with anti-hypertensive medication use, but with controlled SBP to less than 120 mm Hg did not have a significantly increased risk of cognitive decline compared with normotension (β=-0.003, 95% CI: -0.021 to 0.014). Individuals on anti-hypertensive treatment with PP of more than 70 mm Hg had a significantly higher risk of cognitive decline (β=-0.033, 95% CI: -0.045 to -0.020). Regardless of anti-hypertensive treatment status, both elevated baseline and cumulative SBP and PP were found to be independently associated with accelerated cognitive decline.

CONCLUSIONS

Cumulatively elevated SBP, PP and uncontrolled BP were associated with subsequent cognitive decline. Effectively controlling BP with anti-hypertensive treatment may be able to preserve cognitive decline in older adults.

A Virtual Photovoice Study of Older African Americans Perceptions of Neurovascular Clinical Trials

BACKGROUND

Alzheimer disease (AD) poses a major public health crisis, especially among African Americans (AAs) who are up to 3 times more likely to develop AD compared with non-Hispanic Whites. Moreover, cardiovascular risk factors represent a precursor to cognitive decline, which contributes to racial/ethnic disparities seen within AD. Despite these disparities, AAs are underrepresented in neurovascular research. The purpose of this qualitative virtual photovoice project is to explore how older Midwestern AAs perceive neurovascular clinical trials.

METHODS

Five photovoice sessions were held virtually over a 3-month period. Participants took photos each week that captured the salient features of their environment that described their perceptions and experiences related to neurovascular clinical trials. Structured discussion using the SHOWED method was used to generate new understandings about the perspectives and experiences in neurovascular clinical trials. Data was analyzed using strategies in participatory visual research.

RESULTS

A total of 10 AAs aged 55 years and older participated and a total of 6 themes emerged from the photovoice group discussions.

CONCLUSION

Findings from this study inform the development of culturally appropriate research protocols and effective recruitment strategies to enhance participation among older AAs in neurovascular clinical trials.

White matter changes underlie hypertension-related cognitive decline in older adults

Hypertension has been well recognized as a risk factor for cognitive impairment and dementia. Although the underlying mechanisms of hypertension-affected cognitive deterioration are not fully understood, white matter changes (WMCs) seem to play an important role. WMCs include low microstructural integrity and subsequent white matter macrostructural lesions, which are common on brain imaging in hypertensive patients and are critical for multiple cognitive domains. This article provides an overview of the impact of hypertension on white matter microstructural and macrostructural changes and its link to cognitive dysfunction. Hypertension may induce microstructural changes in white matter, especially for the long-range fibers such as anterior thalamic radiation (ATR) and inferior fronto-occipital fasciculus (IFOF), and then macrostructural abnormalities affecting different lobes, especially the periventricular area. Different regions' WMCs would further exert different effects to specific cognitive domains and accelerate brain aging. As a modifiable risk factor, hypertension might provide a new perspective for alleviating and delaying cognitive impairment.

Influence of Baseline Diastolic Blood Pressure on the Effects of Systolic Blood Pressure Lowering on Cognitive Function in Type 2 Diabetes Mellitus

BACKGROUND

Lowering of systolic blood pressure (SBP) in patients with low diastolic blood pressure (DBP), can further lower DBP. This can potentially decrease cerebral perfusion and cognition. We examined the influence of baseline DBP on the effect of lowering SBP on cognition.

METHODS

This is a post hoc analysis of the Memory in Diabetes (MIND) substudy (N = 1,430) of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study (NCT00000620). Standard neuropsychological tests (Digit Symbol Substitution Test [DSST], Mini-Mental State Examination [MMSE], Rey Auditory Verbal Learning Test [RAVLT], and Stroop test) were performed at baseline and months 20 and 40. We compared the effects of intensive (goal SBP <120 mm Hg) vs. standard (goal SBP <140 mm Hg) SBP control on the changes in the 4 test scores from baseline to the averages of months 20 and 40 across the range of baseline DBP using cubic spline terms.

RESULTS

Mean age was 63 ± 6 years, 55% were women and 66% White. Participates with lower baseline DBP were older, had more cardiovascular events and a longer duration of diabetes. There was no difference in the change in DSST (-0.22; 95% CI -0.97, 0.52), MMSE (-0.14; 95% CI -0.34, 0.06), RAVLT (-0.12; 95% CI -0.29, 0.06), and Stroop interference (-0.47; 95% CI -1.76, 0.82) in the intensive vs. standard SBP intervention. There was no interaction between baseline DBP and change in scores with the SBP intervention.

CONCLUSIONS

Intensive SBP reduction does not adversely affect cognition, even in those with low baseline DBP.

Neuroimaging findings related to glymphatic system alterations in older adults with metabolic syndrome

OBJECTIVE

The glymphatic system is a glial-based perivascular network that promotes brain metabolic waste clearance. Reduced glymphatic flow has been observed in rat models of type 2 diabetes and hypertension, indicating the role of vascular risk factors in the glymphatic system. However, little is known about how vascular risk factors affect the human glymphatic system. The present study aims to assess the relationships between metabolic syndrome (MetS), a cluster of vascular risk factors, and the glymphatic system function using diffusion magnetic resonance imaging (MRI)-based measures of water diffusivity in the glymphatic compartments, including the brain interstitial space and perivascular spaces around the deep medullary vein. We hypothesized that vascular risk factors are associated with glymphatic dysfunction, leading to cognitive impairment in older adults.

METHODS

This cross-sectional study assessed 61 older adults (age range, 65-82 years) who had participated in the Bunkyo Health Study, including 15 healthy controls (mean age, 70.87 ± 4.90 years) and 46 individuals with MetS (mean age, 71.76 ± 4.61 years). Fractional volume of extracellular-free water (FW) and an index of diffusion tensor imaging along the perivascular space (DTI-ALPS) were used as indirect indicators of water diffusivity in the interstitial extracellular and perivenous spaces of white matter, respectively.

RESULTS

After adjusting for age, sex, years of education, total Fazekas scale, Pittsburgh sleep quality index (PSQI) score, and intracranial volume (ICV), a significantly (P = 0.030; Cohen's d = 1.01) higher FW was observed in individuals with MetS than in the healthy controls. Furthermore, individuals with MetS had a significantly (P = 0.031; Cohen's d = 0.86) lower ALPS index than the healthy controls, with age, sex, years of education, total Fazekas scale, PSQI score, ICV, fractional anisotropy, and mean diffusivity included as confounding factors. Higher FW was significantly associated with lower ALPS index (r = -0.37; P = 0.004). Multiple linear regression (MLR) with backward elimination analyses showed that higher diastolic blood pressure (BP; standardized β = 0.33, P = 0.005) was independently associated with higher FW, whereas higher fasting plasma glucose levels (standardized β = -0.63, P = 0.002) or higher Brinkman index of cigarette consumption cumulative amount (standardized β = -0.27, P = 0.022) were associated with lower ALPS index. The lower ALPS index (standardized β, 0.28; P = 0.040) was associated with poorer global cognitive performance, which was determined using the Japanese version of the Montreal Cognitive Assessment (MOCA-J) scores. Finally, partial correlation analyses showed a significant correlation between higher FW and lower MOCA-J scores (r = -0.35; P = 0.025) and between higher FW and higher diastolic BP (r = 0.32, P = 0.044).

CONCLUSION

The present study shows the changes in diffusion MRI-based measures reflected by the higher FW and lower ALPS index in older adults with MetS, possibly due to the adverse effect of vascular risk factors on the glymphatic system. Our findings also indicate the associations between the diffusion MRI-based measures and elevated diastolic BP, hyperglycemia, smoking habit, and poorer cognitive performance. However, owing to the limitations of this study, the results should be cautiously interpreted.

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.

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.

The Spectrum of Alzheimer-Type Pathology in Cognitively Normal Individuals

BACKGROUND

The strongest risk factor for the development of Alzheimer's disease (AD) is age. The progression of Braak stage and Thal phase with age has been demonstrated. However, prior studies did not include cognitive status.

OBJECTIVE

We set out to define normative values for Alzheimer-type pathologic changes in individuals without cognitive decline, and then define levels that would qualify them to be resistant to or resilient against these changes.

METHODS

Utilizing neuropathology data obtained from the National Alzheimer's Coordinating Center (NACC), we demonstrate the age-related progression of Alzheimer-type pathologic changes in cognitively normal individuals (CDR = 0, n = 542). With plots generated from these data, we establish standard lines that may be utilized to measure the extent to which an individual's Alzheimer-type pathology varies from the estimated normal range of pathology.

RESULTS

Although Braak stage and Thal phase progressively increase with age in cognitively normal individuals, the Consortium to Establish a Registry for Alzheimer's Disease neuritic plaque score and Alzheimer's disease neuropathologic change remain at low levels.

CONCLUSION

These findings suggest that an increasing burden of neuritic plaques is a strong predictor of cognitive decline, whereas, neurofibrillary degeneration and amyloid-β (diffuse) plaque deposition, both to some degree, are normal pathologic changes of aging that occur in almost all individuals regardless of cognitive status. Furthermore, we have defined the amount of neuropathologic change in cognitively normal individuals that would qualify them to be "resilient" against the pathology (significantly above the normative values for age, but still cognitively normal) or "resistant" to the development of pathology (significantly below the normative values for age).

Interactions Between Brain 18F-FDG PET Metabolism and Hemodynamic Parameters at Different Ages of Life: Results From a Prospective Cross-Sectional Study

Brain 18F-FDG PET imaging is useful to characterize accelerated brain aging at a pre-symptomatic stage. This study aims to examine the interactions between brain glycolytic metabolism and hemodynamic parameters in different age groups.

Methods: A total of 72 patients (from 23 to 88 years of age, 38 women) without any cerebral diseases but with available cardiac, arterial peripheral, and central blood pressure measurements as well as arterial stiffness parameters obtained from brachial pressure and applanation tonometry and a brain 18F-FDG PET scan were prospectively included into this study. Quantitative voxel-to-voxel analyses were carried out to test for negative associations between brain glycolytic metabolism and individual hemodynamic parameters (p-voxel of &lt;0.001 for the whole population and &lt;0.005 for age groups).

Results: The heart rate parameter of the whole population showed the most extensive associations with brain metabolism (15,857 mm3, T-score: 5.1), predominantly affecting the frontal and temporal regions (69% of the volume). Heart rate for the younger age group, systolic and pulse pressure for the 41–60-year-old group, and diastolic pressure for the older group were most extensively associated with brain metabolism and mainly involved the fronto-temporal lobes (respective involvement of 52.8%, 60.9%, and 65.5%) which are also the regions implicated in accelerated brain aging.

Conclusion: This cross-sectional prospective study identified extensive associations between cerebral metabolism and hemodynamic parameters, indicating common aging mechanisms. Heart rate throughout adult life, systolic and pulse pressure parameters around middle age, and diastolic pressure parameters in older patients, suggest the existence of potentially therapeutic targets to prevent accelerated brain aging.

Effects of Vascular Comorbidity on Cognition in Multiple Sclerosis Are Partially Mediated by Changes in Brain Structure

Objective

Vascular comorbidities are associated with reduced cognitive performance and with changes in brain structure in people with multiple sclerosis (MS). Understanding causal pathways is necessary to support the design of interventions to mitigate the impacts of comorbidities, and to monitor their effectiveness. We assessed the inter-relationships among vascular comorbidity, cognition and brain structure in people with MS.

Methods

Adults with neurologist-confirmed MS reported comorbidities, and underwent assessment of their blood pressure, HbA1c, and cognitive functioning (i.e., Symbol Digit Modalities Test, California Verbal Learning Test, Brief Visuospatial Memory Test-Revised, and verbal fluency). Test scores were converted to age-, sex-, and education-adjusted z-scores. Whole brain magnetic resonance imaging (MRI) was completed, from which measures of thalamic and hippocampal volumes, and mean diffusivity of gray matter and normal-appearing white matter were converted to age and sex-adjusted z-scores. Canonical correlation analysis was used to identify linear combinations of cognitive measures (cognitive variate) and MRI measures (MRI variate) that accounted for the most correlation between the cognitive and MRI measures. Regression analyses were used to test whether MRI measures mediated the relationships between the number of vascular comorbidities and cognition measures.

Results

Of 105 participants, most were women (84.8%) with a mean (SD) age of 51.8 (12.8) years and age of symptom onset of 29.4 (10.5) years. Vascular comorbidity was common, with 35.2% of participants reporting one, 15.2% reporting two, and 8.6% reporting three or more. Canonical correlation analysis of the cognitive and MRI variables identified one pair of variates (Pillai's trace = 0.45, p = 0.0035). The biggest contributors to the cognitive variate were the SDMT and CVLT-II, and to the MRI variate were gray matter MD and thalamic volume. The correlation between cognitive and MRI variates was 0.50; these variates were used in regression analyses. On regression analysis, vascular comorbidity was associated with the MRI variate, and with the cognitive variate. After adjusting for the MRI variate, vascular comorbidity was not associated with the cognitive variate.

Conclusion

Vascular comorbidity is associated with lower cognitive function in people with MS and this association is partially mediated via changes in brain macrostructure and microstructure.

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

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

Cognitive impairment and depression after acute myocardial infarction: associations with ejection fraction and demographic characteristics

Cognitive impairment and depression are often associated with acute myocardial infarction, however, the risk factors for their occurrence after myocardial infarction are still unclear. To determine the effect of reduced ejection fraction and demographic characteristics on the occurrence of cognitive impairment and depression after myocardial infarction. In the prospective study, the final sample consisted of 82 patients. Based on the value of the ejection fraction, the patients were divided into those with a value of < 40% and those having a value of ≥ 40%. Demographic data (age, gender, education), and data on comorbidities, were collected from the patients' medical history. The instruments of studies were: Mini-mental test and Beck depression inventory. The occurrence of cognitive impairment and depression was not, to a significant degree, associated with the level of ejection fraction. In contrast, demographics have shown positive predictive effects. Among demographic characteristics, the age of the patient proved to be a significant predictor for the occurrence of cognitive impairment (p = 0.004). The probability of cognitive impairment increases 1.16 times for each year of life. Significant depression predictor was female gender (p = 0.014). The probability of depression was 3.5 times greater for female gender. Cognitive impairment after acute myocardial infarction is more common in older patients, and depression in more common in women.

[Cognitive impairment in patients with cardiovascular risk: DECOG study]

OBJECTIVE

To evaluate the correlation between cardiovascular risk factors (CRF) and mild cognitive impairment (MCI) in the primary care setting.

MATERIALS AND METHODS

Observational, cross-sectional and multicenter study conducted in the setting of primary care. Information regarding demographic variables, CRF, comorbidities, and cognitive impairment determined by Mini-Mental State Examination (MMSE) score was collected. These data were correlated by multivariate analysis.

RESULTS

Data from a total of 458 patients were collected. CRFs significantly negative correlated with MCI were patient age, presence of cardiovascular disease, family history of dyslipemia, diastolic blood pressure and cholesterol levels; while factors such as education level and folic acid levels were significant and positive related to higher MMSE scores.

CONCLUSIONS

This study confirms that the presence of CRF impacts on MCI development, already detectable in the primary care setting. High cholesterol levels and high blood pressure are key elements in MCI, and therefore, measures to control these two conditions from primary care should be reinforced in order to stop the development of dementias.

Vascular risk factors are associated with a decline in resting-state functional connectivity in cognitively unimpaired individuals at risk for Alzheimer's disease: Vascular risk factors and functional connectivity changes

Resting-state functional connectivity is suggested to be cross-sectionally associated with both vascular burden and Alzheimer's disease (AD) pathology. However, evidence is lacking regarding longitudinal changes in functional connectivity. This study includes 247 cognitively unimpaired individuals with a family history of sporadic AD (185 women/ 62 men; mean [SD] age of 63 [5.3] years). Plasma total-, HDL-, and LDL-cholesterol and systolic and diastolic blood pressure were measured at baseline. Global (whole-brain) brain functional connectivity and connectivity from canonical functional networks were computed from resting-state functional MRI obtained at baseline and ~3.5 years of annual follow-ups, using a predefined functional parcellation. A subsample underwent Aβ- and tau-PET (n=91). Linear mixed-effects models demonstrated that global functional connectivity increased over time across the entire sample. In contrast, higher total-cholesterol and LDL-cholesterol levels were associated with greater reduction of functional connectivity in the default-mode network over time. In addition, higher diastolic blood pressure was associated with global functional connectivity reduction. The associations were similar when the analyses were repeated using two other functional brain parcellations. Aβ and tau deposition in the brain were not associated with changes in functional connectivity over time in the subsample. These findings provide evidence that vascular burden is associated with a decrease in functional connectivity over time in older adults with elevated risk for AD. Future studies are needed to determine if the impact of vascular risk factors on functional brain changes precede the impact of AD pathology on functional brain changes.

Carotid Atherosclerosis and Cognitive Function in a General Population Aged 63-65 Years: Data from the Akershus Cardiac Examination (ACE) 1950 Study

BACKGROUND

Studies on the relationship between carotid atherosclerosis and cognitive function in subjects from the general population are few and results have been inconsistent.

OBJECTIVE

We aimed to investigate the association between carotid atherosclerotic burden and cognitive function in a cross-sectional analysis of a population-based cohort aged 63-65 years.

METHODS

All habitants born in 1950 from Akershus County, Norway were invited to participate. A linear regression model was used to assess the association between carotid atherosclerosis and cognitive function. We used carotid plaque score as a measure of carotid atherosclerotic burden and the Montreal Cognitive Assessment (MoCA) for global cognitive function.

RESULTS

We analyzed 3,413 individuals aged 63-65 with mean MoCA score 25.3±2.9 and 87% visible carotid plaques. We found a negative correlation between carotid plaque score and MoCA score (r = -0.14, p < 0.001), but this association was lost in multivariable analysis. In contrast, diameter or area of the thickest plaque was independently associated with MoCA score. Lower educational level, male sex, current smoking, and diabetes were also associated with lower MoCA score in multivariable analysis.

CONCLUSION

Carotid atherosclerotic burden was, unlike other measures of advanced carotid atherosclerosis, not independently associated with global cognitive function.

Visit-to-Visit Blood Pressure Variability Is Associated With Cognitive Decline and Incident Dementia: The S.AGES Cohort

To investigate the impact of visit-to-visit systolic blood pressure variability (BPV), diastolic BPV, mean arterial pressure variability, and pulse pressure variability on cognitive decline and incident dementia in noninstitutionalized patients aged ≥65 years. A total of 3319 subjects from the S.AGES (Sujets AGÉS-Aged Subjects) cohort underwent clinical examinations every 6 months during 3 years. Variability was evaluated using standard deviation (SD), coefficient of variation, average real variability, successive variation, variation independent of mean, and residual SD. Cognition was assessed using the Mini-Mental State Examination and dementia with the Diagnostic Statistical Manual of Mental Disorders. Linear mixed models and Cox proportional hazards models were used. Higher systolic BPV was associated with poorer cognition independently of baseline SBP: adjusted 1-SD increase of coefficient of variation: β (SE)=-0.12 (0.06), P=0.04. Similar results were observed for diastolic BPV and mean arterial pressure variability: β (SE)=-0.20 (0.06), P<0.001 for both. Higher pulse pressure variability was no longer associated with cognitive function after adjustment for age, except with residual SD (P=0.02). Among the 3319 subjects, 93 (2.8%) developed dementia. Higher systolic BPV was associated with greater dementia risk (adjusted 1-SD increase of coefficient of variation: hazard ratios=1.23 [95% CI, 1.01-1.50], P=0.04). Similar results were found for diastolic BPV and mean arterial pressure variability (P<0.01). Pulse pressure variability was not associated with dementia risk. Beyond hypertension, higher BPV is a major clinical predictor of cognitive impairment and dementia. Further studies are needed to assess whether controlling BP instability could be a promising interventional target in preserving cognition among older adults.

Vascular-brain Injury Progression after Stroke (VIPS) study: concept for understanding racial and geographic determinants of cognitive decline after stroke

Cognitive impairment and dementia (CID) are major public health problems with substantial personal, social, and financial burdens. African Americans are at a heightened risk for Vascular Cognitive Impairment (VCI) compared to European Americans. Recent lines of evidence also suggest a high burden of Post-stroke VCI among indigenous Africans. A better understanding of the cause(s) of the racial disparity in CID, specifically VCI, is needed in order to develop strategies to reduce it. We propose and discuss the conceptual framework for a unique tri-population, trans-continental study titled The Vascular brain Injury Progression after Stroke (VIPS) study. The overarching objective of the VIPS Study will be to explore the interplay of multiple factors (racial, geographical, vascular, lifestyle, nutritional, psychosocial and inflammatory) influencing the level and trajectory of post-stroke cognitive outcomes and examine whether differences between indigenous Africans, African Americans and European Americans exist. We hypothesize that differences which might be due to racial factors will be observed in African Americans versus European Americans as well as Indigenous Africans versus European Americans but not in African Americans versus Indigenous Americans; differences due to geographical factors will be observed in Indigenous Americans versus African Americans and Indigenous Africans versus European Americans but not in African Americans versus European Americans. This overarching objective could be accomplished by building upon existing National Institutes of Health investments in the REasons for Geographical And Racial Differences in Stroke (REGARDS) study (based in the United States of America) and the Stroke Investigative Research and educational Network (SIREN) study (based in Sub-Saharan Africa).

Hypertension and the Risk of Dementia

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

Metabolic Syndrome and Cardiovascular Disease Impacts on the Pathophysiology and Phenotype of HIV-Associated Neurocognitive Disorders

Evidence from epidemiological studies on the general population suggests that midlife cardiovascular disease (CVD) and/or metabolic syndrome (MetS) are associated with an increased risk of cognitive impairment and dementia later in life. In the modern combined antiretroviral therapy (cART) era, as in the general population, CVD and MetS were strongly and independently associated with poorer cognitive performances of sustained immunovirologically controlled persons living with human immunodeficiency viruses (PLHIVs). Those findings suggest that CV/metabolic comorbidities could be implicated in the pathogenesis of HIV-associated neurocognitive disorders (HAND) and might be more important than factors related to HIV infection or its treatment, markers of immunocompetence, or virus replication. The association between CVD/MetS and cognition decline is driven by still not well-understood mechanisms, but risk might well be the consequence of increased brain inflammation and vascular changes, notably cerebral small-vessel disease. In this review, we highlight the correspondences observed between the findings concerning CVD and MetS in the general population and virus-suppressed cART-treated PLHIVs to evaluate the real brain-aging processes. Indeed, incomplete HIV control mainly reflects HIV-induced brain damage described during the first decades of the pandemic. Given the growing support that CVD and MetS are associated with HAND, it is crucial to improve early detection and assure appropriate management of these conditions.

Predictors for Blood Pressure Reduction in American Latinos: Secondary Analysis of the Adelgaza Program Data

Little is known about factors that predict blood pressure (BP) reduction in overweight American Latinos. The aim of this secondary analysis was to explore predictors of changes in mean systolic and diastolic BPs over an 8-week weight loss intervention period in a sample of 54 overweight American Latinos using data collected during the Adelgaza trial. Baseline BP, exercise energy use (in units of metabolic equivalent of task), weight change, average daily intake of calories from beverages, average daily intake of calories from fat, age, and gender were considered as potential predictors of reductions in BP, as measured at baseline, 3, and 8 weeks. Baseline characteristics were as follows: mean age 45.3 (SD = 10.8) years, 31.5% male, 61.1% born in the United States. Mean baseline systolic and diastolic BPs were 122.1 (SD = 14.4) mmHg and 76.6 (SD = 9.8) mmHg, respectively. Both baseline systolic and diastolic BPs predicted reductions in systolic BP after adjusting for other factors (p < .001). None of the nine variables predicted reductions in diastolic BP (p > .05). This finding suggests that overweight American Latinos with higher baseline systolic or diastolic BP should be identified and provided with early intervention education to achieve better hypertension management or prevention.

Cognitive Function and Vascular Risk Factors Among Older African American Adults

To evaluate the association between vascular risk factors and cognitive impairment among older African American (AA) adults in a primary care clinic. Participants included 96 AA adults aged 60 years or older who were evaluated for global and domain-specific cognition. Participants were interviewed using the Computerized Assessment of Memory and Cognitive Impairment (CAMCI). The relationship between CAMCI cognitive domain scores and vascular risk factors were examined using hierarchical regression models. Patients who smoked, those with higher SBP/DBP values had lower accuracy rates on CAMCI cognitive domains (attention, executive, memory).Those with higher BMI had better attention scores. Patients with higher HbA1C values had worse verbal memory. Patients with higher blood pressure were significantly faster in responding to tasks in the executive domain. Primary care providers working with older AA adults with these VRFs could implement cognitive screening earlier into their practice to reduce barriers of seeking treatment.

Gradual hypertension induction in middle-aged Cyp1a1-Ren2 transgenic rats produces significant impairments in spatial learning

Hypertension is a major health concern in the developed world, and its prevalence increases with advancing age. The impact of hypertension on the function of the renal and cardiovascular systems is well studied; however, its influence on the brain regions important for cognition has garnered less attention. We utilized the Cyp1a1-Ren2 xenobiotic-inducible transgenic rat model to mimic both the age of onset and rate of induction of hypertension observed in humans. Male, 15-month-old transgenic rats were fed 0.15% indole-3-carbinol (I3C) chow to slowly induce renin-dependent hypertension over a 6-week period. Systolic blood pressure significantly increased, eventually reaching 200 mmHg by the end of the study period. In contrast, transgenic rats fed a control diet without I3C did not show significant changes in blood pressure (145 mmHg at the end of study). Hypertension was associated with cardiac, aortic, and renal hypertrophy as well as increased collagen deposition in the left ventricle and kidney of the I3C-treated rats. Additionally, rats with hypertension showed reduced savings from prior spatial memory training when tested on the hippocampus-dependent Morris swim task. Motor and sensory functions were found to be unaffected by induction of hypertension. Taken together, these data indicate a profound effect of hypertension not only on the cardiovascular-renal axis but also on brain systems critically important for learning and memory. Future use of this model and approach may empower a more accurate investigation of the influence of aging on the systems responsible for cardiovascular, renal, and neurological health.

Predictors of Source Memory Success and Failure in Older Adults

Source memory decline has been identified as one of the types of memory most seriously affected during older age. It refers to our capacity to recollect the contextual information in which our experiences take place. Although most elderly adults will be affected by progressive source memory decline, a subset of individuals will not follow this average pattern; instead, their source memory capabilities will remain functional. Likewise, a minority of individuals will manifest an extreme decay of their source memory abilities. The objective of the present study was to identify among 120 potential predictors that significantly contributed to these two extreme source memory outcomes. Spatial source memory was measured in a sample of 519 healthy individuals between 61 and 80 years old. Individuals who performed below the 20th and above the 80th percentiles in the source memory task were defined as individuals whose episodic memory failed and succeeded, respectively. Logistic models identified five and six significant predictors of source memory success and failure in older age, respectively. High source memory performance was mainly predicted by healthy cardiovascular markers and psychological traits, whereas low source memory performance was primarily predicted by consumption habits and by less engagement in mental activities. The models identified relevant biological and life experiences that underlie these unusual source memory outcomes in older age.

Exercise Improves Vascular Function, but does this Translate to the Brain?

The number of adults with Alzheimer’s disease (AD) or related dementia is expected to increase exponentially. Interventions aimed to reduce the risk and progression of AD and dementia are critical to the prevention and treatment of this devastating disease. Aging and cardiovascular disease risk factors are associated with reduced vascular function, which can have important clinical implications, including brain health. The age-associated increase in blood pressure and impairment in vascular function may be attenuated or even reversed through lifestyle behaviors. Greater volumes of habitual exercise and higher cardiorespiratory fitness are associated with beneficial effects on vascular health and cognition. Exercise and cardiorespiratory fitness may be most important during midlife, as physical activity and cardiorespiratory fitness during the middle-aged years are associated with future cognitive function. The extent to which exercise, and more specifically aerobic exercise, influences the cerebral circulation is not well established. In this review, we present our working hypothesis showing how cerebrovascular function may be a mediating factor underlying the association between exercise and cognition, as well as discuss recent studies evaluating the effect of exercise interventions on the cerebral circulation.

Differential Associations of Diastolic and Systolic Pressures With Cerebral Measures in Older Individuals With Mild Cognitive Impairment

BACKGROUND

Reports on the relative importance of the diastolic and systolic blood pressures (DBP and SBP) in age-related cognitive decline are mixed. Investigating the relation between DBP/SBP and functional and structural brain changes could elucidate which of the 2 measures is more critically important for brain function and, consequently, cognitive impairment.

METHODS

We investigated the association of SBP and DBP with cortical volume, cerebral blood flow (CBF), and white matter lesions (WML), in nondemented older adults with and without mild cognitive impairment (MCI; N = 265, 185 MCI, mean age = 64 years). Brachial blood pressure was measured twice while seated, and the average of the 2 measures was used. Cortical volume, gray matter (GM) CBF, and WML were estimated using T1-weighted imaging, arterial spin labeling, and fluid attenuation inversion recovery, respectively.

RESULTS

Reduced cortical volume was associated with elevated DBP (β= -0.18, P = 0.034) but not with SBP (β = -0.10, P = 0.206). GM CBF was associated with DBP (β = -0.13, P = 0.048) but not with SBP (β = -0.07, P = 0.275). Likewise, CBF within brain regions where MCI patients showed hypoperfusion were only associated with DBP (DBP: β = -0.17, P = 0.005; SBP: β = -0.09, P = 0.120). WML volume was associated with both DBP (β = 0.20, P = 0.005) and SBP (β = 0.30, P < 0.001). For all measures, there was no interaction between DBP/SBP and cognitive status, indicating that these associations were independent of the cognitive status.

CONCLUSIONS

Independently of the cognitive status, DBP is more critically important for GM volume and perfusion, whereas WML is associated with both blood pressures, likely reflecting long-term effect of hypertension and autoregulation dysfunction.

Hypertension and High Blood Pressure Are Associated With Dementia Among Chinese Dwelling Elderly: The Shanghai Aging Study

Background: To explore the association between blood pressure and cognition in older participants in the Shanghai Aging Study.

Methods: Data were drawn from 3,327 participants at the baseline of Shanghai Aging Study. History of hypertension was inquired and confirmed from participants' medical records. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured by research nurses in the early morning. Participants were diagnosed with “cognitive normal,” “mild cognitive impairment (MCI),” or “dementia” by neurologists using DSM-IV and Petersen criteria. Multivariate logistic regression was used to evaluate the association between history of hypertension, duration of hypertension, SBP, DBP, or classification of blood pressure and cognitive function. Generalized linear model was used to assess the relation between duration of hypertension, SBP, or DBP and Mini Mental State Examination (MMSE).

Results: A significantly higher proportion of hypertension [78 (76.5%)] was found in participants with dementia than in those with MCI [347 (59.3%)] and cognitive normal [1,350 (51.1%)] (P < 0.0001). Participants with dementia had significantly higher SBP [157.6 (26.1) mmHg] than those with MCI [149.0 (23.7) mmHg] and cognitive normal [143.7 (22.6) mmHg] (P < 0.0001). After adjusting for sex, age, education, living alone, body mass index, anxiety, depression, heart disease, diabetes, and stroke, the likelihood of having dementia was positively associated with history of hypertension (OR = 2.10; 95% CI: 1.22, 3.61), duration of hypertension (OR = 1.02 per increment year; 95% CI: 1.01, 1.04), higher SBP (OR = 1.14 per increment of 10 mmHg; 95% CI: 1.04, 1.25), higher DBP (OR = 1.22 per increment of 10 mmHg; 95% CI: 1.02, 1.45), moderate hypertension (OR = 2.09; 95% CI: 1.10, 3.99), or severe hypertension (OR = 2.45; 95% CI: 1.20, 4.99). The MMSE score was inversely correlated to duration of hypertension (β = −0.0088 per increment year; 95% CI: −0.0158, −0.0018, P = 0.0132), SBP (β = −0.0655 per increment of 10 mmHg; 95% CI: −0.1022, −0.0288, P = 0.0005), and DBP (β = −0.1230 per increment of 10 mmHg; 95% CI: −0.1915, −0.0545, P = 0.0004).

Conclusion: Our results suggest that hypertension and high blood pressure may be potential risk factors for dementia. Blood pressure management for the elderly may be important for maintaining cognitive vitality.

Blood Pressure and Hispanic/Latino Cognitive Function: Hispanic Community Health Study/Study of Latinos Results

BACKGROUND

Hispanics/Latinos are at increased risk for cardiovascular disease and cognitive decline and dementias. High blood pressure (BP) has been implicated in both stroke and dementias. Associations between BP and cognition among diverse Latinos are still unpublished.

OBJECTIVE

We examined associations between cognition and four BP based measures among diverse Hispanics/Latinos. We hypothesized that higher BP, particularly systolic pressure, and increased arterial stiffness (i.e., pulse pressure), would be associated with lower cognitive function.

METHODS

We used baseline (2008-2011) Hispanic Community Health Study/Study of Latinos (HCHS/SOL; n = 9,019; ages 45-74 years) data to examine cognition in relation to BP measures.

RESULTS

In age, sex, and education adjusted models, systolic, pulse, and mean arterial pressure were consistently negatively associated with executive function, psychomotor speed and sustained attention, verbal episodic learning and memory, speech fluency, and mental status measures. These associations were attenuated but remained statistically significant in fully adjusted models.

CONCLUSION

Among middle-aged and older diverse Hispanics/Latinos, we found modest but consistent associations between indicators of arterial stiffness, and compromised blood flow and lower cognitive function. Clinical management and public health interventions to raise awareness and enhance BP management beginning in midlife could reduce disparities and improve population health by reducing cognitive decline burdens.

In Vivo Brain Plaque and Tangle Burden Mediates the Association Between Diastolic Blood Pressure and Cognitive Functioning in Nondemented Adults

OBJECTIVE

Growing evidence supports an association between increased blood pressure and: (a) poor cognitive performance in older adults, and (b) various biomarkers of increased Alzheimer's disease (AD) neuropathology. The objective of this study was to determine whether systolic blood pressure (SBP) and diastolic blood pressure (DBP) were significantly associated with cognitive functioning in non-demented adults, and to examine in vivo AD pathology as a possible mediator of this association.

METHODS

Positron emission tomography (PET) scans with 2-(1-{6-[(2-[F-18]fluoroethyl)(methyl)amino]-2-naphthyl}ethylidene)malononitrile (FDDNP) provide in vivo measurements of plaque and tangle burden. A total of 101 non-demented older subjects with blood pressure data and FDDNP-PET scans were drawn from a larger study of predictors of cognitive decline. A neuropsychological test battery was used to compute "global cognitive scores" (averaged across five key domains), which served as an index of general cognitive functioning.

RESULTS

Higher DBP (but not SBP) was significantly associated with lower cognitive scores, controlling for age, sex, antihypertensive medication use, and ApoE genotype (η2 = 0.06). However, this relationship was no longer significant after introducing FDDNP-PET binding as an additional covariate in the statistical models. In vivo plaque and tangle burden accounted for over 30% of the observed association between higher DBP and poorer cognitive performance.

CONCLUSIONS

By suggesting a mediation of the relationship between DBP and cognitive functioning by FDDNP-PET binding, this study advances our understanding of some potential predictors of cognitive decline in non-demented adults, and underscores the importance of devising early multimodal interventions to more effectively combat degenerative brain disorders.

Vulnerability of the frontal and parietal regions in hypertensive patients during working memory task

BACKGROUND

Hypertension is related with cognitive decline in the elderly. The frontal-parietal executive system plays an important role in cognitive aging and is also vulnerable to damage in elderly patients with hypertension. Examination of the brain's functional characteristics in frontal-parietal regions of hypertension is likely to be important for understanding the neural mechanisms of hypertension's effect on cognitive aging.

METHODS

We address this issue by comparing hypertension and control-performers in a functional MRI study. Twenty-eight hypertensive patients and 32 elderly controls were tested with n-back task with two load levels.

RESULTS

The hypertensive patients exhibited worse executive and memory abilities than control subjects. The patterns of brain activation changed under different working memory loads in the hypertensive patients, who exhibited reduced activation only in the precentral gyrus under low loads and reduced activation in the middle frontal gyrus, left medial superior frontal gyrus and right precuneus under high loads. Thus, more regions of diminished activation were observed in the frontal and parietal regions with increasing task difficulty. More importantly, we found that lower activation in changed frontal and parietal regions was associated with worse cognitive function in high loads.

CONCLUSION

The results demonstrate the relationship between cognitive function and frontoparietal functional activation in hypertension and their relevance to cognitive aging risk. Our findings provide a better understanding of the mechanism of cognitive decline in hypertension and highlight the importance of brain protection in hypertension.

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

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

Hyperinsulinemia and elevated systolic blood pressure independently predict white matter hyperintensities with associated cognitive decrement in the middle-aged offspring of dementia patients

Cerebrovascular disease is an independent risk factor for dementia that may also be synergistic with Alzheimer's disease. In recent years attention has switched from cerebral infarcts to microvascular disease as the primary cause of cerebrovascular cognitive decline, with damage to the white matter the primary mechanism. Uncertainties remain regarding the risks posed by different types vascular threat, the extent to which cerebrovascular damage occurs in middle age, and whether relatively "normal" amounts of white matter damage are accompanied by meaningful degrees of cognitive decline. We explored these issues via laboratory, cardiovascular, cognitive, and magnetic resonance imaging (MRI) data in 67 middle-aged cognitively normal offspring of dementia patients. The sample was enriched for vascular risk. Plasma insulin, 24-h systolic blood pressure, body mass index, age, and % small dense LDL cholesterol were the strongest correlates of MRI white matter hyperintensity (WMH) volume. With shared variance controlled for, 24 h systolic BP, plasma insulin, and age remained as significant predictors of WMH volume. An interaction variable (24 h BP * insulin) did not improve the prediction of WMH. WMH volume correlated negatively with cognition. No evidence for an ApoE ε4 effect emerged for either WMH or cognition. Hypertension and hyperinsulinemia appear to pose independent, consequential threats to the cerebral small vessel vasculature in middle age, reflected in the presence of areas of WMH on MRI scans. Our data show that even modest WMH volumes in middle age are associated with cognitive decrement, underscoring the importance of aggressive treatment and lifestyle modifications to address vascular risk throughout adulthood.

Paleolithic and Mediterranean Diet Pattern Scores Are Inversely Associated with All-Cause and Cause-Specific Mortality in Adults

Background: Poor diet quality is associated with a higher risk of many chronic diseases that are among the leading causes of death in the United States. It has been hypothesized that evolutionary discordance may account for some of the higher incidence and mortality from these diseases.Objective: We investigated associations of 2 diet pattern scores, the Paleolithic and the Mediterranean, with all-cause and cause-specific mortality in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study, a longitudinal cohort of black and white men and women ≥45 y of age.Methods: Participants completed questionnaires, including a Block food-frequency questionnaire (FFQ), at baseline and were contacted every 6 mo to determine their health status. Of the analytic cohort (n = 21,423), a total of 2513 participants died during a median follow-up of 6.25 y. We created diet scores from FFQ responses and assessed their associations with mortality using multivariable Cox proportional hazards regression models adjusting for major risk factors.Results: For those in the highest relative to the lowest quintiles of the Paleolithic and Mediterranean diet scores, the multivariable adjusted HRs for all-cause mortality were, respectively, 0.77 (95% CI: 0.67, 0.89; P-trend < 0.01) and 0.63 (95% CI: 0.54, 0.73; P-trend < 0.01). The corresponding HRs for all-cancer mortality were 0.72 (95% CI: 0.55, 0.95; P-trend = 0.03) and 0.64 (95% CI: 0.48, 0.84; P-trend = 0.01), and for all-cardiovascular disease mortality they were 0.78 (95% CI: 0.61, 1.00; P-trend = 0.06) and HR: 0.68 (95% CI: 0.53, 0.88; P-trend = 0.01).Conclusions: Findings from this biracial prospective study suggest that diets closer to Paleolithic or Mediterranean diet patterns may be inversely associated with all-cause and cause-specific mortality.

Effects of combined epidural and general anesthesia on intraoperative hemodynamic responses, postoperative cellular immunity, and prognosis in patients with gallbladder cancer: A randomized controlled trial

BACKGROUND

This study is supposed to investigate the effects of combined epidural and general anesthesia on intraoperative hemodynamic responses, postoperative cellular immunity, and prognosis in patients with gallbladder cancer (GBC).

METHODS

One hundred forty-four GBC patients were selected and randomly divided into the general anesthesia (GA) group and the combined epidural-general anesthesia (CEGA) group. Before anesthesia induction (t0), at intubation (t1), at the beginning of surgery (t2), 5 minutes after pneumoperitoneum (t3), at the end of surgery (t4), after recovery of spontaneous breathing (t5), after regaining consciousness (t6), and after extubation (t7), the heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and the depth of anesthesia (bispectral index [BIS]) were detected. Blood samples were separately collected 30 minutes before anesthesia induction (T1), 2 hours after the beginning of surgery (T2), at the end of surgery (T3), 1 day after surgery (T4), 3 days after surgery (T5). The survival rates of T cell subsets (CD3+, CD4+, CD8+, CD4+/CD8+) and natural killer (NK) cells were determined by flow cytometry. Postoperative nausea and vomiting (PONV), visual analog scale (VAS), and sedation-agitation scale (SAS) were performed to assess postoperative adverse reactions. A 3-year follow-up was conducted.

RESULTS

Compared with the GA group, the CEGA group had significant lower SBP values at t5 and t6, lower DBP values at t1, t3, t4, and t5, lower HR values at t1 and t5, and higher BIS values at t4, t5, t6, and t7. No PONV was observed in the CEGA group. In comparison to the GA group, the VAS was markedly increased and survival rates of CD3+, CD4+, and CD4+/CD8+ cells were increased at T2, T3, T4, and T5 in the CEGA group. The 1-year, 2-year, and 3-year survival rates were not evidently different between the CEGA group and the GA group.

CONCLUSION

Our study provides evidence that the combined epidural-general anesthesia might attenuate intraoperative hemodynamic responses and improve postoperative cellular immunity, so that it might be a more available anesthesia method for GBC patients.

Hypertension Severity Is Associated With Impaired Cognitive Performance

BACKGROUND

Most evidence of target-organ damage in hypertension (HTN) is related to the kidneys and heart. Cerebrovascular and cognitive impairment are less well studied. Therefore, this study analyzed changes in cognitive function in patients with different stages of hypertension compared to nonhypertensive controls.

METHODS AND RESULTS

In a cross-sectional study, 221 (71 normotensive and 150 hypertensive) patients were compared. Patients with hypertension were divided into 2 stages according to blood pressure (BP) levels or medication use (HTN-1: BP, 140-159/90-99 or use of 1 or 2 antihypertensive drugs; HTN-2: BP, ≥160/100 or use of ≥3 drugs). Three groups were comparatively analyzed: normotension, HTN stage 1, and HTN stage 2. The Mini-Mental State Examination, Montreal Cognitive Assessment, and a validated comprehensive battery of neuropsychological tests that assessed 6 main cognitive domains were used to determine cognitive function. Compared to the normotension and HTN stage-1, the severe HTN group had worse cognitive performance based on Mini-Mental State Examination (26.8±2.1 vs 27.4±2.1 vs 28.0±2.0; P=0.004) or Montreal Cognitive Assessment (23.4±3.7 vs 24.9±2.8 vs 25.5±3.2; P<0.001). On the neuropsychological tests, patients with hypertension had worse performance in language, processing speed, visuospatial abilities, and memory. Age, hypertension stage, and educational level were the best predictors of cognitive impairment in patients with hypertension in different cognitive domains.

CONCLUSIONS

Cognitive impairment was more frequent in patients with hypertension, and this was related to hypertension severity.

Post-exercise pulse pressure is a better predictor of executive function than pre-exercise pulse pressure in cognitively normal older adults

Exercise "stress tests" are widely used to assess cardiovascular function and to detect abnormalities. In line with the view of exercise as a stressor, the present study examined the relationship between cognitive function and cardiovascular activity before and after light physical exercise in a sample of 84 non-demented community-dwelling older adults. Based on known relationships between hypertension, executive function and cerebral white matter changes, we hypothesized that greater post-exercise reactivity, as indexed by higher pulse pressure, would be more related to worse performance on frontal-executive tasks than pre-exercise physiologic measures. All participants were administered a comprehensive neuropsychological battery and underwent a Six Minute Walk Test (6MWT), with blood pressure (BP) measures obtained immediately before and after the walk. Pulse pressure (PP) was derived from BP as an indicator of vascular auto-regulation and composite scores were computed for each cognitive domain assessed. As predicted, worse executive function scores exhibited a stronger relationship with post-exercise PP than pre-exercise PP. Results suggest that PP following system stress in the form of walking may be more reflective of the state of vascular integrity and associated executive dysfunction in older adults than baseline physiologic measures.

Blood pressure and neuropsychological test performance in healthy postmenopausal women

PURPOSE

To study the association between blood pressure and neuropsychological test performance in healthy postmenopausal women.

METHODS

Data from 88 healthy postmenopausal women aged 46-73 years, who were not experiencing hot flashes, and who had participated in a prior drug trial, were analyzed to find whether baseline blood pressure was associated with impaired performance on neuropsychological testing done at 3 follow-up visits separated by 4 weeks. Factor analysis was used to reduce the dimensions of neuropsychological test performance. Mixed linear modeling was used to evaluate the association between baseline blood pressure and repeatedly measured neuropsychological test performance at follow-up in a complete case analysis (n=53). In a sensitivity analysis (n=88), multiple-imputation using the Markov Chain Monte Carlo method was used to account for missing data (blood pressure results) for some visits.

RESULTS

The variables recording neuropsychological test performance were reduced to two main factors (Factor 1=selective attention; Factor 2=complex processing). In the complete case analysis, the association between a 20-mmHg increase in diastolic blood pressure and Factor 1 remained statistically significant after adjusting for potential confounders, before adjusting for systolic blood pressure (slope=0.60; 95%CI=0.04,1.16), and after adjusting for systolic blood pressure (slope=0.76; 95%CI=0.06, 1.47). The positive slopes indicated an increase in the time spent performing a given task (i.e., a decrease in neuropsychological test performance). No other significant associations were found between systolic blood pressure and either factor. The results did not materially change after applying the multiple-imputation method.

CONCLUSIONS

An increase in diastolic blood pressure was associated with a decrease in neuropsychological test performance among older healthy postmenopausal women experiencing hot flashes.

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

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

Relationship Between 24-Hour Ambulatory Blood Pressure and Cognitive Function in Community-Living Older Adults: The UCSD Ambulatory Blood Pressure Study

BACKGROUND

Twenty-four-hour ambulatory blood pressure (BP) patterns have been associated with diminished cognitive function in hypertensive and very elderly populations. The relationship between ambulatory BP patterns and cognitive function in community-living older adults is unknown.

METHODS

We conducted a cross-sectional study in which 24-hour ambulatory BP, in-clinic BP, and cognitive function measures were obtained from 319 community-living older adults.

RESULTS

The mean age was 72 years, 66% were female, and 13% were African-American. We performed linear regression with performance on the Montreal Cognitive Assessment (MoCA) as the primary outcome and 24-hour BP patterns as the independent variable, adjusting for age, sex, race/ethnicity, education, and comorbidities. Greater nighttime systolic dipping (P = 0.046) and higher 24-hour diastolic BP (DBP; P = 0.015) were both significantly associated with better cognitive function, whereas 24-hour systolic BP (SBP), average real variability, and ambulatory arterial stiffness were not.

CONCLUSIONS

Higher 24-hour DBP and greater nighttime systolic dipping were significantly associated with improved cognitive function. Future studies should examine whether low 24-hour DBP and lack of nighttime systolic dipping predict future cognitive impairment.

Correlates of Incident Cognitive Impairment in the REasons for Geographic and Racial Differences in Stroke (REGARDS) Study

OBJECTIVE

To identify approximately 500 cases of incident cognitive impairment (ICI) in a large, national sample adapting an existing cognitive test-based case definition and to examine relationships of vascular risk factors with ICI.

METHOD

Participants were from the REGARDS study, a national sample of 30,239 African-American and White Americans. Participants included in this analysis had normal cognitive screening and no history of stroke at baseline, and at least one follow-up cognitive assessment with a three-test battery (TTB). Regression-based norms were applied to TTB scores to identify cases of ICI. Logistic regression was used to model associations with baseline vascular risk factors.

RESULTS

We identified 495 participants with ICI of 17,630 eligible participants. In multivariable modeling, income (OR 1.83 CI 1.27,2.62), stroke belt residence (OR 1.45 CI 1.18,1.78), history of transient ischemic attack (OR 1.90 CI 1.29,2.81), coronary artery disease(OR 1.32 CI 1.02,1.70), diabetes (OR 1.48 CI 1.17,1.87), obesity (OR 1.40 CI 1.05,1.86), and incident stroke (OR 2.73 CI 1.52,4.90) were associated with ICI.

CONCLUSIONS

We adapted a previously validated cognitive test-based case definition to identify cases of ICI. Many previously identified risk factors were associated with ICI, supporting the criterion-related validity of our definition.

Mild cognitive impairment: vascular risk factors in community elderly in four cities of Hebei Province, China

Background

Evidence has demonstrated that vascular risk factors (VRFs) contribute to mild cognitive impairment (MCI) in the elderly population. Because of the race and different diagnosis standard, there is still no definitive conclusions.

Objective

To estimate the VRFs and potential protective factors for MCI in elderly population living in the community in North China.

Methods

A total of 3136 participants entered the study. They were screened for hypertension, coronary heart disease (CHD), and cerebrovascular disease (CVD). Cognitive function was assessed with Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). The diagnosis of MCI was made according to Petersen’s criteria. We investigated the relationship between vascular risk factors, potential protective factors and MCI.

Results

A total of 2511 (80%) participant belonged to normal group and 625 (20%) participants showed MCI. Multiple logistic regression analysis demonstrated that stroke and diabetes, but not hypertension or CHD was associated with MCI. Besides, exercise habit could lower the risk of MCI.

Conclusions

Vascular Risk Factors, including stroke and diabetes, rather than hypertension and CHD are independent risk factors of MCI. Involvement in physical activities seems to reduce the risk of MCI.

Association between arterial stiffness, cerebral small vessel disease and cognitive impairment: A systematic review and meta-analysis

Arterial stiffness may be a cause of cerebral small vessel disease and cognitive impairment. We therefore performed a systematic review and meta-analysis of studies on the association between stiffness, cerebral small vessel disease and cognitive impairment. For the associations between stiffness (i.e. carotid-femoral pulse wave velocity (cfPWV), brachial-ankle PWV (baPWV), carotid stiffness and pulse pressure) on the one hand and cerebral small vessel disease and cognitive impairment on the other, we identified 23 (n=15,666/20 cross-sectional; 1 longitudinal; 2 combined cross-sectional/longitudinal) and 41 studies (n=57,671/26 cross-sectional; 11 longitudinal; 4 combined cross-sectional/longitudinal), respectively. Pooled analyses of cross-sectional studies showed that greater stiffness was associated with markers of cerebral small vessel disease with odds ratios, per +1 SD, of 1.29-1.32 (P<.001). Studies on cognitive impairment could not be pooled due to large heterogeneity. Some (but not all) studies showed an association between greater stiffness and cognitive impairment, and the strength of this association was relatively weak. The present study supports the hypothesis that greater arterial stiffness is a contributor to microvascular brain disease.

Adherence to a Mediterranean diet and prediction of incident stroke

BACKGROUND AND PURPOSE

There are limited data on the potential association of adherence to Mediterranean diet (MeD) with incident stroke. We sought to assess the longitudinal association between greater adherence to MeD and risk of incident stroke.

METHODS

We prospectively evaluated a population-based cohort of 30 239 individuals enrolled in REasons for Geographic and Racial Differences in Stroke (REGARDS) study, after excluding participants with stroke history, missing demographic data or food frequency questionnaires, and unavailable follow-up information. Adherence to MeD was categorized using MeD score. Incident stroke was adjudicated by expert panel review of medical records during a mean follow-up period of 6.5 years.

RESULTS

Incident stroke was identified in 565 participants (2.8%; 497 and 68 cases of ischemic stroke [IS] and hemorrhagic stroke, respectively) of 20 197 individuals fulfilling the inclusion criteria. High adherence to MeD (MeD score, 5-9) was associated with lower risk of incident IS in unadjusted analyses (hazard ratio, 0.83; 95% confidence interval, 0.70-1.00; P=0.046). The former association retained its significance (hazard ratio, 0.79; 95% confidence interval, 0.65-0.96; P=0.016) after adjustment for demographics, vascular risk factors, blood pressure levels, and antihypertensive medications. When MeD was evaluated as a continuous variable, a 1-point increase in MeD score was independently associated with a 5% reduction in the risk of incident IS (95% confidence interval, 0-11%). We documented no association of adherence to MeD with incident hemorrhagic stroke. There was no interaction of race (P=0.37) on the association of adherence to MeD with incident IS.

CONCLUSIONS

High adherence to MeD seems to be associated with a lower risk of incident IS independent of potential confounders. Adherence to MeD is not related to the risk of incident hemorrhagic stroke.

Is there a multiplicative adverse effect of cardiovascular and kidney disease on neuropsychological measures?

Increasing age is accompanied by increased incidence and comorbidity of various chronic diseases. Many of these conditions, such as cardiovascular and kidney disease, can lead to declines in cognitive functioning. A simple additive effect may be commonly assumed. We here evaluate the hypothesis that such effects may be multiplicative/interactive rather than simply additive, resulting in disproportionate decrements in performance on tests of different cognitive functions. Participants were the 1,782 Canadians aged 65 years and older who completed the clinical assessment of the national Canadian Study of Health and Aging and who were without dementia. Participants were categorized as having either kidney disease, cardiovascular disease, neither, or both. Scores on a measure of verbal fluency showed the predicted interaction effects, but not in the predicted pattern of worst performance in the group with both disorders. Reasons for the relative lack of observed main effects of disease and multiplicative interactions, such as the exclusion of people with dementia and nature of the sample from the community, are discussed.

Performance of the NINDS-CSN 5-minute protocol in a national population-based sample

In 2006, the National Institute of Neurological Disorders and Stroke-Canadian Stroke Network (NINDS-CSN) Vascular Cognitive Impairment Harmonization Standards recommended a 5-Minute Protocol as a brief screening instrument for vascular cognitive impairment (VCI). We report demographically adjusted norms for the 5-Minute Protocol and its relation to other measures of cognitive function and cerebrovascular risk factors. We performed a cross-sectional analysis of 7199 stroke-free adults in the REasons for Geographic And Racial Differences in Stroke (REGARDS) study on the NINDS-CSN 5-Minute Protocol score. Total scores on the 5-Minute Protocol were inversely correlated with age and positively correlated with years of education, and performance on the Six-Item Screener, Word List Learning, and Animal Fluency (all p-values <.001). Higher cerebrovascular risk on the Framingham Stroke Risk Profile (FSRP) was associated with lower total 5-Minute Protocol scores (p <.001). The 5-Minute Protocol also differentiated between participants with and without confirmed stroke and with and without stroke symptom histories (p <.001). The NINDS-CSN 5-Minute Protocol is a brief, easily administered screening measure that is sensitive to cerebrovascular risk and offers a valid method of screening for cognitive impairment in populations at risk for VCI.

Measurement-to-measurement blood pressure variability is related to cognitive performance: the Maine Syracuse study

The objective was to investigate the association between variability in blood pressure (BP) and cognitive function for sitting, standing, and reclining BP values and variability derived from all 15 measures. In previous studies, only sitting BP values have been examined, and only a few cognitive measures have been used. A secondary objective was to examine associations between BP variability and cognitive performance in hypertensive individuals stratified by treatment success. Cross-sectional analyses were performed on 972 participants of the Maine Syracuse Study for whom 15 serial BP clinic measures (5 sitting, 5 recumbent, and 5 standing) were obtained before testing of cognitive performance. Using all 15 measures, higher variability in systolic and diastolic BP was associated with poorer performance on multiple measures of cognitive performance, independent of demographic factors, cardiovascular risk factors, and pulse pressure. When sitting, reclining, and standing systolic BP values were compared, only variability in standing BP was related to measures of cognitive performance. However, for diastolic BP, variability in all 3 positions was related to cognitive performance. Mean BP values were weaker predictors of cognition. Furthermore, higher overall variability in both systolic and diastolic BP was associated with poorer cognitive performance in unsuccessfully treated hypertensive individuals (with BP ≥140/90 mm Hg), but these associations were not evident in those with controlled hypertension.