Hypertension and dementia

The increase in life expectancy is associated with a sharp rise in cognitive disorders, particularly after the age of 80 years. The identification and management of risk factors for these invalidating and distressing conditions must be considered a priority. The fact that antihypertensive treatment has been demonstrated to decrease that risk offers a new opportunity to reduce the prevalence of such related disorders and promote healthy aging.     

Hypertension and dementia.

Vascular dementia (VD) is more prevalent than Alzheimer's disease (AD) in Japan, while AD is more common in Western countries. In the Hisayama study, a community-based cohort study of Japan, the prevalence of VD decreased in men during the 7-years (1985-1992) follow-up period, while the prevalence of AD remained unchanged both in men and women. The incidence of dementia increases with age, particularly AD aged 85 or older. Hypertension is a major risk factor for VD. Other risk factors include age, prior stroke, diabetes, alcohol intake, heart disease, and smoking. In contrast, age, a family history of dementia, a low educational level, and low physical activity are risk factors for AD. The role of hypertension in AD remains controversial; there has been positive, negative, or no association existed between blood pressure levels and AD. A recent clinical trial has disclosed the potential preventive effect of antihypertensive treatment on the incidence of dementia, especially of AD. Although the role of vascular factors for the pathogenesis of AD is becoming recognized, the effectiveness of antihypertensive treatment on the prevention of AD should be further clarified in the future studies.     

Hypertension, cognitive decline and dementia

Dementia is one of the most common neurological disorders in the elderly. Aging is associated with a large increase in the prevalence and incidence of degenerative (Alzheimer's disease) and vascular dementia, leading to a devastating loss of independence. In view of increasing longevity of populations worldwide, prevention and treatment of dementia has turned into a major public health challenge. In the past decade, longitudinal studies have shown a close association between high blood pressure in middle age, cognitive decline and dementia, including Alzheimer's disease, in the late life. Pathophysiologically, a summation of cerebrovascular damage, white matter changes and pre-existing asymptomatic Alzheimer's brain lesions may lead to dementia, even when each type of lesion individually is not sufficiently severe to cause it. Longitudinal studies assessing the beneficial role of antihypertensive drugs on cognitive decline and dementia have produced promising results. There are few randomised placebo controlled studies, although some of these have produced positive results. Results of three recent meta-analyses are inconsistent, possibly due to methodological issues. Further long-term randomised trials, designed especially to assess a link between antihypertensive therapy and cognitive decline or dementia are therefore needed.     

Hypertension as a risk factor of dementia and cognitive decline in the elderly

Management of dementia and cognitive decline is a major issue in geriatrics. Since the average age of society is advancing and patients of dementia are increasing, it is important to remove risk factors of dementia and cognitive decline in order to maintain quality of life in the elderly and to save cost of medicine and care. While hypertension has been known to be a risk factor of cerebrovascular events and vascular dementia, recent studies show that midlife hypertension is also a risk factor of cognitive decline and Alzheimer's disease in late life. Clinical trials and retrospective observation studies also show that treatment of hypertension decreases the risk of Alzheimer's disease. These issues are also related with the consideration of vascular factors in Alzheimer's disease. The white matter lesion as a consequence of hypertension and its meaning in Alzheimer's disease are also discussed.     

Hypertension, dementia, and antihypertensive treatment: Implications for the very elderly

A wealth of longitudinal epidemiologic evidence links high blood pressure or hypertension to cognitive decline and incident dementia. Some (but not all) studies have suggested that antihypertensive treatment is beneficial, reducing risk of decline and dementia. There are plausible mechanisms to support the possibility that hypertension may increase the risk of dementia. There is also evidence suggesting that the two dementia types thought to be most common, Alzheimer’s disease and vascular dementia, have overlapping risk factors. Seven placebo-controlled trials of antihypertensive treatment have assessed cognitive function, incident dementia, or both, with mixed outcomes. The Hypertension in the Very Elderly Trial (HYVET), despite showing reductions in mortality and stroke with active treatment, found no significant reduction of incident dementia, although the trial was stopped early. Meta-analyses used to explore this area further are inconclusive, and comparative trials are now required.     

Clinical findings in Alzheimer dementia and multi-infarct dementia

From 1969 to 1989, 63 patients with dementia of the Alzheimer-type (DAT), 84 patients with multi-infarct dementia (MID), and 52 mixed type patients were treated. Two-thirds of the patients were women. Among the 66 men, 23% belonged to the DAT-group, and 56% to the MID-group. While the DAT-group, with regard to the age at on-set of dementia, showed a bimodal distribution with peaks at 51-55 years and at 71-75 years, in the MID-patients and in the MB-patients an age-related increase up to the age of 80 years was evident. Compared to the MID-patients, in the DAT-patients pathological EEG findings were less serious, even if a considerable brain atrophy was already evident. Psychic unbalance and states of temporary mental confusion, however, were more frequent in the MID-patients.     

Depression, dementia, and reversible dementia.

This article reviews the syndromic concepts of depression and dementia and the concurrence of these common entities. In DAT, depression appears to be a reversible source of excess disability, amenable to pharmacologic as well as environmental interventions. In the vascular dementias, depression appears to be a specific complicating feature, in which localization of the lesion plays a significant role. The abulic state should not be mistaken for a depressive syndrome, although its presence should alert the clinician to evaluate for dementia and depression. Depression is especially prevalent in the subcortical dementias. Future studies using dynamic neuroimaging will help define the limits of this important concept. Reversible forms of dementia are much less common than previously suspected. The clinician's task is to identify causes of excess disability due to superimposed illnesses while avoiding diagnostic or therapeutic nihilism. The appropriate use of medication and the ongoing surveillance for adverse drug reactions are the foremost tasks of today's clinician treating the elderly patient.     

Pain and dementia

Dementia and pain are both common in the elderly and then frequently associated. The literature review shows that pain in dementia is underdiagnosed and consequently undertreated. This can be linked to: 1) the difficulty of pain assessment in patients with cognitive disorders and altered communication skills; 2) changes of pain processing and especially in the motivational-affective domain; 3) modified efficacy of analgesic drugs. This has been documented in Alzheimer's disease but remains to be investigated in the other types of dementia in order that all patients can be treated whatever their diagnosis, illness duration and type of pain (acute versus chronic).     

Pain and dementia

Purpose

The aim was to present current knowledge about pain assessment in people with dementia and to discuss special challenges and possible solutions.

Methods

A literature search in MEDLINE? was performed.

Results

Due to the changing demographics of an aging population, an increasing number of people with dementia is expected. Many of these people will simultaneously suffer pain. Under-detection and under-treatment of pain in persons suffering from dementia is often described. As dementia progresses, the ability of the sufferer to verbally communicate his/her pain is often compromised, complicating the task of recognizing and treating pain. To improve pain recognition in dementia, many pain assessment tools have been developed. However, psychometric properties have to date been insufficiently examined.

Implications

Self-report ratings should be performed as long as justifiable. Behavioural pain assessment tools should be used in advanced dementia despite their current imperfections: in particular, the PAINAD for daily use and the PACSLAC at longer intervals. All available additional information about pain should be considered.     

Snoring and dementia

The frequency of snoring was studied in 46 patients with Alzheimer's disease (AD), 37 with multiinfarct dementia (MID), and in a random sample of 124 elderly community residents without known diseases affecting higher cortical functions. The demented patients were reported to snore twice as frequently as the control subjects (P less than 0.05). No difference in the frequency of snoring was present between the patients with AD and MID. In contrast to younger populations, snoring was not significantly associated with cardiovascular morbidity in this elderly population.     

Statins and dementia

The incidence and prevalence of dementia are increasing. Dementia is a major cause of disability. Alzheimer’s disease (AD) is the most common type of dementia. There are no good prevention or treatment options. Experimental animal and laboratory studies have suggested that cholesterol metabolism in the brain is important in the causal pathway for dementia, possibly by modifying amyloid metabolism. A few studies have showed a possible relationship between mid-life blood cholesterol levels and risk of dementia, including AD. Case-control studies report that patients with AD were less likely to use lipid-lowering drugs, especially statins. Longitudinal epidemiology studies have not demonstrated a decreased risk of AD among statin users versus nonusers. Two clinical trials of statin therapy to reduce cardiovascular disease have not shown any reduction in risk of cognitive decline or dementia. The results of two secondary prevention trials will be reported shortly. In spite of negative studies, the possibility remains that statin therapy may reduce risk of dementia and AD. Primary prevention trials are difficult and expensive and will likely not be done in the United States.     

Depression and dementia

Data from the literature devoted to the relationships between dementia and depression are controversial on account of numerous methodological biases (community studies or from neurological or psychiatric departments), categorical versus dimensional approaches and variability of assessment tools for depression, aim of the study (depression versus dementia or versus Alzheimer's disease, AD). The difficulty to discriminate depression from AD is largely overestimated due to the confusion between depression, depressive symptomatology and apathy. The distinction is greatly facilitated by taking into account the qualitative differences of the memory deficits and cerebral imagery. Distinction of depression from frontotemporal or subcortical dementias could be much more difficult. Relationships between depression and AD are controversial. Most reports of depression as a risk factor for AD in the subsequent years, actually describe depressed symptomatology linked to apathy in preclinical AD. However, some studies found a relationship between AD and depression occurring more than 10 years before the onset of AD symptomatology, suggesting some common risk factors. The so-called symptoms of depression in AD are more related to apathy and affective disturbances than to dysphoria. The frequency of major depressive episode (MDE), greatly varies according to studies, but the frequency of suicide is low. Depression in dementia is related to neurobiological factors as well as to psychological mechanisms. Therefore, its treatment should associate antidepressant drugs and psychological support directed to the patient and family.     

Sexuality and dementia

Sexuality, love, companionship and intimacy remain important parts of life in older people and demented patients. The most frequent sexual disorder reported by spouses of patients with dementia is sexual indifference related to apathy and blunted affect. Increase of sexual demands is rare and many behaviors considered as inappropriate or expressing hypersexuality actually express affective needs or result from cognitive disturbances. Permanence of sexual activity is most often a factor of adjustment for married dementia sufferers and their caregivers. However, some sexual behaviors are stressing for the spouses, mainly women spouses. In nursing homes or long term care facilities, expressing sexuality by demented subjects and dealing with inappropriate sexual expression are source of concerns for the nursing staff, other residents, and families. Information about sex and dementia and a psychobehavioral approach can decrease the strain of families and caregivers.     

Comorbidity and dementia

Epidemiological data suggest a strong association between aging, dementia and comorbidity such as cancer, chronic renal failure or undernourishment. These chronic conditions may lead to invasive diagnosis procedures as well as to difficult therapeutic management. When they occur in elderly patients with cognitive disorders or dementia, physicians and caregivers should apply specific care program. For example, if an adjuvant chimiotherapy is discussed for an old demented patient with cancer, informed consent and details about the treatment program should be carefully provide. At the onset of a chronic disease, the assessment of its prognosis as well as its impact on the autonomy or quality of life is particular when the patient is also demented. We discuss the specific characteristics about management of demented elderly patients who require high risk treatment because of severe and lethal diseases.     

Smoking and Hypertension

Coronary heart disease is the most common cause of death in hypertensives—about twice as common as stroke. Smoking increases this raised risk of hypertension by some 2 to 3 times. Surprisingly perhaps, this increased risk from smoking declines rapidly on quitting—within 2–3 years.

Smoking increases the risks of vascular damage by increasing sympathetic tone, platelet stickiness and reactivity, free radical production, damage to endotherlium, and by surges in arterial pressure. The latter may interfere with the action of some hypotensive agents.

Persuading hypertensive patients not to smoke is the single most effective measure we can take to reduce their risk.     

Hypertension and stress

Stress and adjustment to stress involve pathophysiological processes operating in the cardiovascular system, particularly concerning high blood pressure. Stress and high blood pressure are closely linked. Stress induces transient psychosomatic-related increases in blood pressure, but can also induce more permanent rise in blood pressure when associated with other environmental, psychological, or genetic risk factors. Symptomatic treatment of high blood pressure requires medicinal antihypertensive therapy; anti-stress therapy is an effective but not sufficient complement.