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   CARDIOVASCULAR 03.02.2015   
      
   Low BP Might Speed Mental Decline in Dementia   
      
   Systolic pressure of 128 mmHg or less on antihypertensives questioned in   
   cohort study.   
      
       
       
       
       
       
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   by Crystal Phend    
   Senior Staff Writer, MedPage Today   
      
   This article is a collaboration between MedPage Today® and:   Medpage Today   
   Action Points   
   Antihypertensive regimens that perhaps work a little too well were linked to   
   faster cognitive decline among older adults with pre-existing dementia or mild   
   cognitive impairment (MCI) in a cohort study.   
   Patients in the lowest tertile of daytime systolic blood pressure (128 mmHg   
   or less) showed a greater decline in Mini-Mental State Examination (MMSE)   
   score over a median 9 months than those in the middle tertile (129 to 144   
   mmHg) or those in the top    
   tertile of 145 mmHg or higher -- mean -2.8 points on the 30-point MMSE scale   
   versus -0.7 in both higher groups (P=0.002 and P=0.003, respectively).   
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   The results suggested "that strict control of systolic blood pressure may   
   negatively affect cognition, with daytime systolic blood pressures of 130 to   
   145 mmHg being the most appropriate therapeutic targets," Enrico Mossello, MD,   
   PhD, of the University    
   of Florence, Italy, and colleagues found.   
   The associations were significant only among individuals on antihypertensives   
   and were independent of age, vascular comorbidity score, and baseline   
   cognitive level, the group reported online in JAMA Internal Medicine.   
   The lower blood pressure ranges were also not associated with better   
   health-related outcomes in this cohort of 172 people ages 65 and older (mean   
   79) attending two memory clinics in Italy that offered 24-hour ambulatory   
   blood pressure monitoring    
   regardless of baseline hypertension diagnosis.   
   Among participants, 68.0% had dementia and 32.0% had MCI. About 70% were being   
   treated with antihypertensive medications.   
   Prior evidence has been mixed, Behnam Sabayan, MD, PhD, and Rudi G.   
   J.Westendorp, MD, PhD, both of Leiden University Medical Center in the   
   Netherlands, noted in an accompanying editorial.   
      
   "The link between blood pressure and cognitive impairment is a complex beast,"   
   they wrote.   
   "Given the observational design, it cannot be concluded that antihypertensive   
   therapy is directly responsible for the link between low daily systolic blood   
   pressure and cognitive decline," they cautioned.   
   "It is likely that individuals receiving antihypertensive therapy had higher   
   loads of overt and covert cardiovascular pathologies, which could   
   independently lead to accelerated cognitive decline," they added.   
   While randomized clinical trials are needed to address confounding by   
   indication, it may be time to move from a "one-size-fits all" approach to one   
   individualized by age, hemodynamics, and degree of systemic and    
   erebrovascular damage, Sabayan and    
   Westendorp suggested.   
   Guidelines have tussled over antihypertensive treatment of seniors overall.   
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   The American Heart Association/American College of Cardiology recommendations   
   urge physicians to stick with the Seventh Joint National Committee (JNC7)   
   thresholds of 140/90 mmHg.   
   A controversial 2014 report from some members of a panel appointed to update   
   those recommendations (commonly but unofficially known as JNC8) called on   
   physicians to loosen the treatment goal to 150/90 mmHg for people ages 60 and   
   older without diabetes or    
   chronic kidney disease.   
   No guidelines have specifically addressed older adults with cognitive   
   impairment or dementia.   
   One study of elderly nursing home residents showed no prognostic effect of   
   blood pressure, which "raised doubts regarding the clinical meaning of office   
   blood pressure in cognitively impaired older adults," Mossello's group noted.   
   That study also showed a poor correlation between in-office blood pressure and   
   ambulatory measurements, which appeared to be true in the memory clinic cohort   
   as well.   
      
   Office blood pressures had a weaker association with MMSE score change. Other   
   ambulatory blood pressure monitoring variables, such as nighttime systolic or   
   diastolic pressure and dipping, were not associated with MMSE score change.   
   "Owing to its greater simplicity, office blood pressure measurement should be   
   the first step, although we advise routine use of ambulatory blood pressure   
   monitoring before starting or upgrading antihypertensive treatment in this   
   frail population if    
   office systolic blood pressure is elevated," Mossello's group suggested.   
   That agreed with recent draft recommendations from the U.S. Preventive   
   Services Task Force.   
   Limitations of the study included its small sample size, short follow-up   
   period, and "the setting of an outpatient memory clinic,which does not allow   
   direct generalization of results to primary or acute care," they noted.   
   From the American Heart Association:   
   An Effective Approach to High Blood Pressure Control: A Science Advisory From   
   the American Heart Association, the American College of Cardiology, and the   
   Centers for Disease Control and Prevention   
   Vascular Cognitive Impairment and Dementia   
   The study was supported by Cassa di Risparmio di Pistoia and Pescia Foundation.   
      
   The researchers disclosed no relevant relationships with industry.   
      
   Sabayan and Westendorp disclosed no relevant relationships with industry.   
   Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of   
   Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse   
   Planner   
   LAST UPDATED 03.02.2015   
   Primary Source   
   JAMA Internal Medicine   
   Source Reference: Mossello E, et al "Effects of low-blood pressure in   
   cognitively impaired elderly patients treated with antihypertensive drugs"   
   JAMA Intern Med 2015; DOI: 10.1001/jamainternmed.2014.8164.   
   Secondary Source   
   JAMA Internal Medicine   
   Source Reference: Sabayan B, Westendorp RGJ "Blood pressure control and   
   cognitive impairment -- why low is not always better" JAMA Intern Med 2015;   
   DOI: 10.1001/jamainternmed.2014.8202.   
      
      
      
   http://www.medpagetoday.com/Cardiology/Hypertension/50272   
      
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