Hypertension, hypotension, longevity and dementia.

High blood pressure at midlife has been consistently identified as a risk factor for dementia in late life, while dementia onset is typically associated with a subsequent decline of blood pressure values. A previous meta-analysis of randomized controlled studies of anti-hypertensive treatment in old age has shown a borderline effect of active treatment in reducing the risk of dementia. The cognitive sub-studies of SPRINT (SPRINT-MIND) and of HOPE-3, published in 2019, were aimed at assessing the cognitive effect of aggressive antihypertensive treatment. In SRINT-MIND, that included subjects with high vascular risk, the risk of dementia (primary outcome) did not differ between groups, but the risk of mild cognitive impairment was significantly reduced in the treatment group. Conversely in HOPE-3, that included subjects with intermediate vascular risk, no significant cognitive effect was observed, with a trend for a better outcome in the placebo arm in the subgroup with lower baseline systolic blood pressure. These data add to observational studies showing detrimental cognitive effect of lower blood pressure values in very old subjects, with cognitive impairment, disability, and complex health problems. Regarding longevity, observational studies confirm protective effects of lower blood pressure values, although systolic blood pressure <130 mmHg are associated with greater mortality risk in subjects with cognitive and/or motor impairment. On the whole antihypertensive treatment might decrease the risk of cognitive impairment in older, robust, high vascular risk subjects. Yet the presence of cognitive impairment might modify the prognostic effect of antihypertensive treatment and advise against aggressive blood pressure lowering

High blood pressure in older subjects with cognitive impairment

High blood pressure and cognitive impairment often coexist in old age, but their pathophysiological association is complex. Several longitudinal studies have shown that high blood pressure at midlife is a risk factor for cognitive impairment and dementia, although this association is much less clear in old age. The effect of blood pressure lowering in reducing the risk of dementia is only borderline significant in clinical trials of older subjects, partly due to the insufficient follow-up time. Conversely, dementia onset is associated with a decrease of blood pressure values, probably secondary to neurodegeneration. Prognostic effect of blood pressure values in cognitively impaired older subjects is still unclear, with aggressive blood pressure lowering being potentially harmful in this patients category. Brief cognitive screening, coupled with simple motor assessment, are warranted to identify frail older subjects who need a more cautious approach to antihypertensive treatment. Values obtained with ambulatory blood pressure monitoring seem more useful than clinical ones to predict the outcome of cognitively impaired older subjects. Future studies should identify the most appropriate blood pressure targets in older subjects with cognitive impairment.  Riassunto Ipertensione arteriosa e decadimento cognitivo spesso coesistono in età avanzata, sebbene la loro associazione sia complessa dal punto di vista fisiopatologico. Diversi studi longitudinali hanno mostrato che elevati valori pressori in età adulta rappresentano un fattore di rischio per decadimento cognitivo e demenza, sebbene tale associazione sia molto meno chiara in età avanzata. L’effetto della terapia antiipertensiva è risultato ai limiti della significatività statistica nel ridurre il rischio di demenza negli studi di intervento su soggetti anziani, in parte a causa della durata insufficiente del follow-up. D’altra parte, l’insorgenza di demenza è associata con una riduzione dei valori pressori, probabilmente secondaria alla neurodegenerazione. L’effetto prognostico dei valori pressori in anziani con decadimento cognitivo non è stato ancora chiarito, in presenza di un possibile effetto dannoso di un trattamento antiipertensivo aggressivo in questa categoria di pazienti. Un breve screening cognitivo, associato con una semplice valutazione motoria, è raccomandato per identificare gli anziani fragili, che necessitano di un approccio più cauto alla terapia antiipertensiva. I risultati del monitoraggio della pressione arteriosa nelle 24 ore sembrano più utili della misurazione clinica per predire la prognosi degli anziani cognitivamente compromessi. Studi futuri dovrebbero identificare gli obiettivi pressori più appropriati nel trattamento di anziani con decadimento cognitivo

personality and survival in older age the role of lifestyle behaviors and health status

Objective We intended to assess the relationship between personality and survival in an older population and to explore the role of lifestyle behaviors and health status as potential mediators. Design Population-based cohort study. Setting Swedish National Study of Aging and Care in Kungsholmen, Sweden. Participants 2,298 adults aged 60 or more years, without dementia or depression, followed for 11 years. Measurements Personality (extraversion, neuroticism, and openness) was assessed with a shortened version of the NEO-Five Factor Inventory. We tested whether personality affected mortality and examined the potential mediating effect of health status (body mass index, number of chronic diseases, impairment in instrumental activities of daily living, and C-reactive protein) and lifestyle behaviors (leisure activities, social network, smoking, and alcohol consumption). Results Over 11 years of follow-up, higher levels of extraversion were associated with a 14% reduction in mortality. Examination of different combinations of personality traits showed that independent of levels of neuroticism and openness, high extraversion were associated with up to 65% lower mortality. Decomposing the effect of extraversion on mortality, we found that the majority (44%) of the beneficial effect was mediated by healthy lifestyle behaviors. Health status accounted for 5% of the association. Conclusions Extroverted people, who are characterized by higher optimism and high self-efficacy, are prone to healthier behaviors and better health, which may result in longer survival. These results highlight the importance of a healthy lifestyle in survival

Biomarkers of Alzheimer's Disease: From Central Nervous System to Periphery?

Alzheimer's Disease (AD) is the most frequent form of dementia and represents one of the main causes of disability among older subjects. Up to now, the diagnosis of AD has been made according to clinical criteria. However, the use of such criteria does not allow an early diagnosis, as pathological alterations may be apparent many years before the clear-cut clinical picture. An early diagnosis is even more valuable to develop new treatments, potentially interfering with the pathogenetic process. During the last decade, several neuroimaging and cerebrospinal fluid (CSF) parameters have been introduced to allow an early and accurate detection of AD patients, and, recently, they have been included among research criteria for AD diagnosis. However, their use in clinical practice suffers from limitations both in accuracy and availability. The increasing amount of knowledge about peripheral biomarkers will possibly allow the future identification of reliable and easily available diagnostic tests

Neurocognitive profile of patients with continuous flow Left Ventricular Assist Device

The increase of severe heart failure and the consequent reduction of the organ availability for transplantation has led to, in recent years, the introduction of the LVAD as replacement therapy to heart transplantation. Severe Heart Failure patients show cognitive deficits in various domains especially in executive functions, memory and speed of proceedings, due to different neurophysiopathological processes including chronic hypoperfusion and subsequent damage to hippocampal and para-hippocampal cortical areas. It is also known that these deficits improve after heart transplantation. We carried out a literature review selecting studies that analyzed the cognitive changes in patients with severe heart failure after implantation of the Continuous Flow Left Ventricular Assist Device. According to the inclusion criteria, we selected four studies since 2005 that presented a comprehensive neurocognitive assessment. The results show that the cognitive profile, with the implantation of LVAD improves in memory and executive domains, and this improvements results stable in short- medium time. The effects would also be independent of the type of flow produced by the device (pulsatile vs continuous). We believe that further studies are required to explore the relationship between LVAD and cognitive function in severe heart failure

Understanding Factors Associated With Psychomotor Subtypes of Delirium in Older Inpatients With Dementia

Objectives: Few studies have analyzed factors associated with delirium subtypes. In this study, we investigate factors associated with subtypes of delirium only in patients with dementia to provide insights on the possible prevention and treatments. Design: This is a cross-sectional study nested in the "Delirium Day" study, a nationwide Italian point-prevalence study. Setting and participants: Older patients admitted to 205 acute and 92 rehabilitation hospital wards. Measures: Delirium was evaluated with the 4-AT and the motor subtypes with the Delirium Motor Subtype Scale. Dementia was defined by the presence of a documented diagnosis in the medical records and/or prescription of acetylcholinesterase inhibitors or memantine prior to admission. Results: Of the 1057 patients with dementia, 35% had delirium, with 25.6% hyperactive, 33.1% hypoactive, 34.5% mixed, and 6.7% nonmotor subtype. There were higher odds of having venous catheters in the hypoactive (OR 1.82, 95% CI 1.18-2.81) and mixed type of delirium (OR 2.23, CI 1.43-3.46), whereas higher odds of urinary catheters in the hypoactive (OR 2.91, CI 1.92-4.39), hyperactive (OR 1.99, CI 1.23-3.21), and mixed types of delirium (OR 2.05, CI 1.36-3.07). We found higher odds of antipsychotics both in the hyperactive (OR 2.87, CI 1.81-4.54) and mixed subtype (OR 1.84, CI 1.24-2.75), whereas higher odds of antibiotics was present only in the mixed subtype (OR 1.91, CI 1.26-2.87). Conclusions and implications: In patients with dementia, the mixed delirium subtype is the most prevalent followed by the hypoactive, hyperactive, and nonmotor subtype. Motor subtypes of delirium may be triggered by clinical factors, including the use of venous and urinary catheters, and the use of antipsychotics. Future studies are necessary to provide further insights on the possible pathophysiology of delirium in patients with dementia and to address the optimization of the management of potential risk factors

"Delirium Day": a nationwide point prevalence study of delirium in older hospitalized patients using an easy standardized diagnostic tool

To date, delirium prevalence in adult acute hospital populations has been estimated generally from pooled findings of single-center studies and/or among specific patient populations. Furthermore, the number of participants in these studies has not exceeded a few hundred. To overcome these limitations, we have determined, in a multicenter study, the prevalence of delirium over a single day among a large population of patients admitted to acute and rehabilitation hospital wards in Italy