{"id":683,"date":"2015-04-23T11:00:03","date_gmt":"2015-04-23T11:00:03","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=683"},"modified":"2017-08-21T11:50:51","modified_gmt":"2017-08-21T11:50:51","slug":"primary-care-corner-with-geoffrey-modest-md-too-low-blood-pressure-and-cognitive-decline-in-elderly","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/04\/23\/primary-care-corner-with-geoffrey-modest-md-too-low-blood-pressure-and-cognitive-decline-in-elderly\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Too low blood pressure and cognitive decline in elderly"},"content":{"rendered":"

By: Dr. Geoffrey Modest\u00a0<\/strong><\/p>\n

An Italian prospective cohort study of elderly\u00a0patients (>65 yo)\u00a0with baseline cognitive impairment\u00a0assessed the association between achieved blood pressure in those who were hypertensive\u00a0and the rate of cognitive decline (see\u00a0JAMA Intern Med. 2015;175(4):578-585<\/strong>\u200b).<\/p>\n

\"elderly\"<\/p>\n

Details:<\/p>\n

–172 patients followed in 2 outpatient memory clinics, mean age 79, 63.4% female,\u00a0mean mini-mental status exam (MMSE) baseline\u00a0score of 22.1 (normal range 0-30, with scores of 21-24 indicating mild cognitive impairment, MCI,\u00a0and 10-21 indicating moderate impairment). MMSE was assessed\u00a0again after 9 months.<\/p>\n

–baseline:\u00a068.0% had dementia, 32.0% had MCI, and 73.3% had hypertension with\u00a069.8% were on\u00a0antihypertensive drugs. They also assessed an array of common morbidities (including\u00a0diabetes, CHF, CAD, CKD) as well as\u00a0ADLs\/IADLs (activities of daily living, instrumental ADLs)<\/p>\n

–primary outcome: assess the role of office\u00a0BP, ambulatory blood pressure monitoring (ABPM),\u00a0and BP meds in changes in\u00a0cognitive function and progression of disabilities. Secondary outcome: effect of office and ABPM on adverse events.<\/p>\n

–patients in the lowest tertile of daytime\u00a0systolic blood pressure by ABPM, SBP <=128 mmHg, had greater decrease in MMSE (-2.8) vs those in the intermediate tertile (SBP 129-144, with MMSE -0.7, p=0.002) vs highest tertile\u00a0(SBP\u00a0>=145, with MMSE -0.7, p=0.003)<\/p>\n

–the association between SBP and MMSE decline was significant only in those on antihypertensive drugs, for both subgroups of those with MCI and dementia.<\/p>\n

–in multivariate model (controlling for age, baseline MMSE, vascular comorbidities), interaction between daytime SBP and use of antihypertensives was independently associated with greater cognitive decline, for both\u00a0MCI and dementia subgroups<\/p>\n

–the association between office-based SBP and MMSE change was weaker\u00a0than the ambulatory SBP, not reaching statistical significance.<\/p>\n

–for the secondary outcome: both ADL and IADL decreased, but there was no relationship between any of the blood pressure measurements.<\/p>\n

–adverse events were pretty high: 26.2% had at least one fall, 6.8% had syncope, 23.7% were hospitalized. There was a nonsignificant trend for a higher incidence of syncope and hospitalization with decreasing daytime SBP (eg, the rates of syncope went from 10.5% in the lowest SBP tertile to 6.8% in the intermediate to 3.4% in the highest tertile. for hospitalizations, it went from 33.3% to 21.7% to 17.2%). \u00a0My guess is that this was too small a study to achieve statistical\u00a0significance for these outcomes.<\/p>\n

So, a few points:<\/p>\n

–This was not an RCT, where patients were stratified to different blood pressure goals and cognitive decline was measured. So it is hard to draw firm conclusions. ie, did those with lower achieved SBP have more cognitive decline because those patients\u00a0had\u00a0their blood pressure lowered more easily\u00a0(eg, their vasculature was fundamentally different, leading to lower achieved blood pressure in those having\u00a0more cognitive decline — and, by the way, there are some data finding that\u00a0the\u00a0onset of overt dementia is associated with spontaneous lowering of blood pressure)? And\u00a0would the same group with more\u00a0blood pressure lowering\/more cognitive decline\u00a0have had less cognitive decline if they were randomized to higher\u00a0target blood pressures? One possible model is that more aggressively treating\u00a0early hypertension\u00a0is cognitively\u00a0beneficial; but later on, the vascular changes from long-standing hypertension and its effects on cerebral blood flow autoregulation, endothelial function, etc\u00a0could lead to impaired cognitive function, especially in the presence of dementia (ie, in the absence of cerebral blood flow autoregulation, lowering the blood pressure leads to more cerebral hypoperfusion and decreased functioning). So, there might be different BP\u00a0targets in people of the same age group who have normal cognition, MCI, or dementia.<\/p>\n

–This study reinforces the utility of ambulatory blood pressure monitoring. I posted\u00a0many blogs over the past 3-4 years with data showing the superiority of\u00a0ABPM —\u00a0for diagnosis (about 30% of those in the mild hypertension range by office-based blood pressure do not have hypertension on ABPM), for cardiovascular\u00a0clinical outcomes (the correlation between hard clinical cardiovascular endpoints in several studies were only significant for APBM and not for office-based blood pressure), and now this study suggests ABPM is a better predictor of cognitive decline. For more extensive discussion of ABPM, see here\u200b<\/a>.<\/p>\n

–This study also reinforces the significance of the JNC8 targets being increased in elderly to <150\/90\u00a0(see here<\/a> for my previous blog on JNC8).<\/p>\n

–And, again, I would like to reinforce that\u00a0in elderly patients postural blood pressure changes should be assessed pretty regularly. Given changes in vasculature as noted above\u00a0and increases in\u00a0autonomic neuropathy with aging, it is very common (at least in my practice) to see older patients with even somewhat\u00a0high\u00a0SBP but having\u00a0dramatic BP decline\u00a0on standing. The immediate concern is falling, but I am also concerned about cardiovascular events (decreased myocardial perfusion) and cerebrovascular effects (hypoperfusion, or more\u00a0vascular dementia from micro or macro infarcts).<\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest\u00a0 An Italian prospective cohort study of elderly\u00a0patients (>65 yo)\u00a0with baseline cognitive impairment\u00a0assessed the association between achieved blood pressure in those who were hypertensive\u00a0and the rate of cognitive decline (see\u00a0JAMA Intern Med. 2015;175(4):578-585\u200b). Details: –172 patients followed in 2 outpatient memory clinics, mean age 79, 63.4% female,\u00a0mean mini-mental status exam (MMSE) baseline\u00a0score […]<\/p>\n

Read More…<\/a><\/p>\n","protected":false},"author":148,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[14283],"tags":[],"class_list":["post-683","post","type-post","status-publish","format-standard","hentry","category-archive"],"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/683","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/users\/148"}],"replies":[{"embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/comments?post=683"}],"version-history":[{"count":0,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/posts\/683\/revisions"}],"wp:attachment":[{"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/media?parent=683"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/categories?post=683"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/wp-json\/wp\/v2\/tags?post=683"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}