Chronic stress and age-related pattern of blood pressure: A cross-sectional study in rural China.

OBJECTIVE: Chronic stress is a risk factor for hypertension in adults. However, there is conflicting evidence for older adults. We hypothesized that age-related arterial stiffening, which leads to a lower blood pressure (especially diastolic blood pressure [DBP]), is more pronounced among older adults with high vs low stress. The objectives of this study were (a) to investigate age-related trends in systolic and DBPs among adults in rural Fujian, China, and (b) to examine differences in age-related blood pressure trends according to levels of stress by using Epstein-Barr virus (EBV) antibody titer as a marker of chronic stress status. METHODS: We collected cross-sectional data from 764 rural community-dwelling adults in rural Fujian, China (mean age = 59.4). Participants were categorized into high and low stress groups by median split of EBV antibody titer. A least-squares regression analysis was used to investigate the association between age and blood pressures. RESULTS: We observed an inverted U-shaped association between age and DBP, while there was a linear association between age and systolic blood pressure in the overall sample. When stratified by stress, the inverted U-shaped associations with age (both systolic and DBPs) were seen only among those with high stress; DBP peaked at the age of ~68 years, and the declining trend later in life was more clearly observed among those with high chronic stress. DISCUSSION: Decrease of DBP was more pronounced among older adults with high vs low chronic stress in rural China.

Lower Blood Pressure, Small-Vessel Disease, and Apathy in Older Persons With Mild Cognitive Deficits.

BACKGROUND: In older persons, both high and low blood pressure (BP) levels are associated with symptoms of apathy. Population characteristics, such as burden of cerebral small-vessel disease (CSVD), may underlie these apparently contradictory findings. We aimed to explore, in older persons, whether the burden of CSVD affects the association between BP and apathy. DESIGN: Cross-sectional study. SETTING: Primary care setting, the Netherlands. PARTICIPANTS: Community-dwelling older persons (mean age = 80.7 years; SD = 4.1 years) with mild cognitive deficits and using antihypertensive treatment, participating in the baseline measurement of the magnetic resonance imaging substudy (n = 210) of the Discontinuation of Antihypertensive Treatment in the Elderly Study Leiden. MEASUREMENTS: During home visits, BP was measured in a standardized way and apathy was assessed with the Apathy Scale (range = 0-42). Stratified linear regression analyses were performed according to the burden of CSVD. A higher burden of CSVD was defined as 2 or more points on a compound CSVD score (range = 0-3 points), defined as presence of white matter hyperintensities (greater than median), any lacunar infarct, and/or two or more microbleeds. RESULTS: In the entire population, those with a lower systolic and those with a lower diastolic BP had more symptoms of apathy (ß = -.35 [P = .01] and ß = -.66 [P = .02], respectively). In older persons with a higher burden of CSVD (n = 50 [24%]), both lower systolic BP (ß = -.64, P = .02) and lower diastolic BP (ß = -1.6, P = .01) were associated with more symptoms of apathy, whereas no significant association was found between BP and symptoms of apathy in older persons with a lower burden of CSVD (n = 160). CONCLUSIONS: Particularly in older persons with a higher burden of CSVD, lower BP was associated with more symptoms of apathy. Adequate BP levels for optimal psychological functioning may vary across older populations with a different burden of CSVD. J Am Geriatr Soc 68:1811-1817, 2020.

Association between quality of life and various aspects of intradialytic hypotension including patient-reported intradialytic symptom score.

BACKGROUND: There is increasing awareness that, besides patient survival, Quality of Life (QOL) is a relevant outcome factor for patients who have a chronic disease. In haemodialysis (HD) patients, intradialytic hypotension (IDH) is considered one of the most frequent complications, and this is often accompanied by symptoms. Several studies have investigated QOL in dialysis patients, however, research on the association between intradialytic symptoms and QOL is minimal. The goal of this study was to determine whether the occurrence of IDH has an influence on the perception of QOL. METHODS: During 3 months, haemodynamic data, clinical events, and interventions of 2623 HD-sessions from 82 patients were prospectively collected. The patients filled out a patient-reported intradialytic symptom score (PRISS) after each HD session. IDH was defined according to the EBPG as a decrease in SBP ≥20 mmHg or in MAP ≥10 mmHg associated with a clinical event and need for nursing interventions. Patient's self-assessment of QOL was evaluated by the 36-Item Short-Form Health Survey. RESULTS: There were no significant associations between the mental summary score or the physical summary score and the proportion of dialysis sessions that fulfilled the full EBPG definition. A lower PRISS was significantly associated with the proportion of dialysis sessions that fulfilled the full EBPG definition (R = - 0.35, P = 0.0011), the proportion of dialysis sessions with a clinical event (R = - 0.64, P = 0.001), and the proportion of dialysis sessions with nursing interventions (R = - 0.41, P = 0.0001). The physical component summary and mental component summary were significantly negatively associated with the variable diabetes and positively with PRISS (P = 0.003 and P = 0.005, respectively). UF volume was significantly negatively associated with mental health (P = 0.02) and general health (P = 0.01). CONCLUSIONS: Our findings suggest that the EBPG definition of IDH does not capture aspects of intradialytic symptomatology that are relevant for the patient's QOL. In contrast, we found a significant association between QOL and a simple patient-reported intra-dialytic symptom score, implying that how patients experience HD treatment influences their QOL.

Cerebral blood flow modulations during proactive control in chronic hypotension.

In addition to complaints including fatigue, mood disturbance, dizziness or cold limbs, chronic low blood pressure (hypotension) is associated with reduced cognitive performance. Deficiencies in cerebral blood flow regulation may contribute to this impairment. This study investigated cerebral blood flow modulations during proactive control in hypotension. Proactive control refers to cognitive processes during anticipation of a behaviourally relevant event that allow optimization of readiness to react. Using functional transcranial Doppler sonography, bilateral blood flow velocities in the middle cerebral arteries were recorded in 40 hypotensive and 40 normotensive participants during a precued Stroop task. Hypotensive participants exhibited smaller bilateral blood flow increases during response preparation and longer response time. The group differences in blood flow and response time did not vary by executive function load, i.e. congruent vs. incongruent trials. Over the total sample, the flow increase correlated negatively with response time in trials with a higher executive function load. The findings indicate reduced cerebral blood flow adjustment during both the basic and more complex requirements of proactive control in hypotension. They also suggest a general deficit in attentional function and processing speed due to low blood pressure and cerebral hemodynamic dysregulations rather than particular impairments in executive functions.

Association of low blood pressure with suicidal ideation: a cross-sectional study of 10,708 adults with normal or low blood pressure in Korea.

BACKGROUND: Whether constitutional low blood pressure (BP) causes substantive health problems has been controversial, and subjects with hypotension exhibit a range of symptoms, from mild typical conditions such as tiredness and dizziness to more specific psychological conditions and even cognitive disorders. This study investigated whether low BP is associated with suicidal ideation in the general population. METHODS: Four years of data from the 2010-2013 Korean National Health and Nutrition Examination Survey were used. Among the 23,163 participants, aged 19-101 years, 10,708 with normal or low BP were included in the analysis of the association between low BP and suicidal ideation. The criterion used for low BP was systolic BP (SBP) < 100 mmHg, and in comparative analyses, the criteria used for low BP were SBP < 110, < 95, and < 90 mmHg. The association of prehypertension or hypertension with suicidal ideation was also examined. Suicidal ideation was assessed by a questionnaire. RESULTS: Compared with the normotensive reference group, the odds ratios (ORs) for suicidal ideation were significantly higher in the three hypotensive groups after adjusting for sex, age, body mass index, total cholesterol level, household income, educational level, marital status, current smoking status, alcohol intake, and the interaction between sex and age (OR = 1.29, 95% confidence interval [CI], 1.08 to 1.55; OR = 1.44, 95% CI, 1.14 to 1.82; and OR = 1.71, 95% CI, 1.11 to 2.62 for SBP < 100, SBP < 95, and SBP < 90 mmHg, respectively). Adding the clinical morbidities of diabetes mellitus, stroke, myocardial infarction/angina pectoris, and depression as covariates had little effect on the strength of the associations (OR = 1.25, 95% CI, 1.04 to 1.50; OR = 1.43, 95% CI, 1.13 to 1.81; and OR = 1.74, 95% CI, 1.14 to 2.68 for SBP < 100, < 95, and < 90 mmHg, respectively). CONCLUSIONS: Low SBP showed an association with suicidal ideation in the general Korean population. The association was significant for low BP, defined as a SBP < 100 mmHg, and the strength of the association increased as the criteria for low BP increased in strictness.

Does baseline hypotension predict incident depression in a cohort of community-dwelling older people? Data from The Irish Longitudinal Study on Ageing (TILDA).

Background: hypotension is now recognised as a risk factor for syncope, cardiovascular events and mortality, but it may also represent a risk factor for late life depression (LLD). The aim of this study was to clarify the longitudinal relationship between hypotension and incident LLD. Methods: this is a longitudinal study involving community-dwelling participants aged ≥50 years, using data from The Irish Longitudinal Study on Ageing. The Centre for Epidemiological Studies Depression Scale (CES-D) was administered at baseline and at follow-up 2 years later. Blood pressure (BP) was measured at baseline. Participants with a CES-D score ≥16 at baseline and those taking antidepressants were excluded and considered to have a current diagnosis of depression. A score of ≥16 at follow-up was used to define incident depression. Results: about 4,525 participants were included and 200 participants had diagnosis of incident LLD. The incident depression group had lower systolic BP at baseline than the non-depressed group (132.8 ± 1.43 mm Hg vs. 136.0 ± 0.30 mm HG, P = 0.025). Logistic regression showed those with systolic BP <130 mm HG had an unadjusted odds ratio of 1.31 (1.01-1.68) for incident depression. This persisted after adjustment for confounding factors. Conclusion: systolic BP <130 mm Hg increased the likelihood of incident depression in a cohort of community-dwelling older adults. These findings are important because systolic hypotension may represent a potentially modifiable risk factor for LLD. They are also relevant in the context of BP treatment targets for older people.

A U-shaped Association Between Blood Pressure and Cognitive Impairment in Chinese Elderly.

OBJECTIVES: Higher or lower blood pressure may relate to cognitive impairment, whereas the relationship between blood pressure and cognitive impairment among the elderly is not well-studied. The study objective was to determine whether blood pressure is associated with cognitive impairment in the elderly, and, if so, to accurately describe the association. DESIGN: Cross-sectional data from the sixth wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS) conducted in 2011. SETTING: Community-based setting in longevity areas in China. PARTICIPANTS: A total of 7144 Chinese elderly aged 65 years and older were included in the sample. MEASURES: Systolic blood pressures (SBP) and diastolic blood pressures (DBP) were measured, pulse pressure (PP) was calculated as (SBP) - (DBP) and mean arterial pressures (MAP) was calculated as 1/3(SBP) + 2/3(DBP). Cognitive function was assessed via a validated Mini-Mental State Examination (MMSE). RESULTS: Based on the results of generalized additive models (GAMs), U-shaped associations were identified between cognitive impairment and SBP, DBP, PP, and MAP. The cutpoints at which risk for cognitive impairment (MMSE <24) was minimized were determined by quadratic models as 141 mm Hg, 85 mm Hg, 62 mm Hg, and 103 mm Hg, respectively. In the logistic models, U-shaped associations remained for SBP, DBP, and MAP but not PP. Below the identified cutpoints, each 1-mm Hg decrease in blood pressure corresponded to 0.7%, 1.1%, and 1.1% greater risk in the risk of cognitive impairment, respectively. Above the cutpoints, each 1-mm Hg increase in blood pressure corresponded to 1.2%, 1.8%, and 2.1% greater risk of cognitive impairment for SBP, DBP, and MAP, respectively. CONCLUSION: A U-shaped association between blood pressure and cognitive function in an elderly Chinese population was found. Recognition of these instances is important in identifying the high-risk population for cognitive impairment and to individualize blood pressure management for cognitive impairment prevention.

Affective impairment in chronic low blood pressure.

OBJECTIVE: Physical complaints such as faintness, dizziness, cold limbs and headaches have been well-established in chronic low blood pressure (hypotension). This study investigated the occurrence of adverse emotional states and the symptoms of depression in this condition. As autonomic dysregulation, particularly diminished sympathetic tone, is believed to be involved in the etiology of hypotension, the impact of different facets of autonomic cardiovascular control on mood and depressive symptoms was also explored. METHODS: Forty individuals with chronic hypotension and forty normotensive control persons were presented with the Mood Scale and Beck Depression Inventory. Stroke volume, cardiac output, pre-ejection period, Heather index and aortic peak blood flow velocity were recorded under resting conditions as indices of beta-adrenergic inotropic drive. Respiratory sinus arrhythmia and baroreflex sensitivity were additionally obtained. RESULTS: Hypotensive individuals scored markedly higher on both questionnaire scales than controls, indicating an adversely affected emotional state and more severe depressive symptoms. In the entire sample, cardiac output, Heather index, and aortic peak blood flow velocity correlated negatively with the questionnaire scores; according to regression analysis, the Heather index explained the largest proportion of test score variance. CONCLUSION: Although hypotension does not constitute a serious medical condition, the findings of an adverse affective state and increased burden with depressive symptoms corroborate the view that it can have a considerable impact on wellbeing and quality of life. The correlations of the beta-adrenergic indices with the questionnaire scales indicate that cardiac sympathetic regulation plays a key role in the psychophysiological mediation of hypotension-related mood impairment.

Autonomic Cardiovascular Control and Executive Function in Chronic Hypotension.

BACKGROUND: Chronic low blood pressure (hypotension) is characterized by complaints such as fatigue, reduced drive, dizziness, and cold limbs. Additionally, deficits in attention and memory have been observed. Autonomic dysregulation is considered to be involved in the origin of this condition. PURPOSE: The study explored autonomic cardiovascular control in the context of higher cognitive processing (executive function) in hypotension. METHODS: Hemodynamic recordings were performed in 40 hypotensive and 40 normotensive participants during execution of four classical executive function tasks (number-letter task, n-back task, continuous performance test, and flanker task). Parameters of cardiac sympathetic control, i.e., stroke volume, cardiac output, pre-ejection period, total peripheral resistance, and parasympathetic control, i.e., respiratory sinus arrhythmia and baroreflex sensitivity, were obtained. RESULTS: The hypotensive group exhibited lower stroke volume and cardiac output, as well as higher pre-ejection period and baroreflex sensitivity during task execution. Increased error rates in hypotensive individuals were observed in the n-back and flanker tasks. In the total sample, there were positive correlations of error rates with pre-ejection period, baroreflex sensitivity and respiratory sinus arrhythmia, and negative correlations with cardiac output. CONCLUSIONS: Group differences in stroke volume, cardiac output, and pre-ejection period suggest diminished beta-adrenergic myocardial drive during executive function processing in hypotension, in addition to increased baroreflex function. Although further research is warranted to quantify the extent of executive function impairment in hypotension, the results from correlation analysis add evidence to the notion that higher sympathetic inotropic influences and reduced parasympathetic cardiac influences are accompanied by better cognitive performance.

Systematic Review: The Association between Late Life Depression and Hypotension.

BACKGROUND: Late life depression (LLD), defined as depressive illness in people aged 60 years or older, is more complex than depression presenting in earlier life, with different clinical features and a poorer response to therapy. Different biological factors underlie LLD and hypotension may be an important modifiable risk factor. The aim of this systematic review is to clarify the relationship between hypotension and LLD. METHODS: A systematic search was conducted in PubMed and Embase for articles published up to December 31, 2015. Key search terms were "depression," "depressive disorder," "hypotension," and "blood pressure." Studies were included if they were published as a primary research paper in a peer-reviewed journal, involved participants with a mean age of 60 years or more, and examined the relationship between hypotension and depression. RESULTS: The initial combined search retrieved 2268 nonduplicate articles. Of these, 116 full texts were assessed for eligibility, of which 19 were included in this systematic review. Nine cross-sectional studies examined the association between hypotension and LLD, with 8/9 indicating a positive association between the 2. Five cross-sectional studies examined the relationship between orthostatic hypotension (OH) and LLD, with each study finding a positive association between the 2. Five longitudinal studies examined the relationship between hypotension and LLD, with discordant findings between studies. There were no longitudinal studies examining the relationship between OH and LLD. DISCUSSION: This systematic review found that cross-sectional studies demonstrated a consistent relationship between hypotension and LLD, but longitudinal data to date is less consistent, with discordant findings. There are several methodological limitations of published longitudinal data that may explain these differences, including differences in age at enrollment, depression and blood pressure assessment, and controlling for covariates. Further longitudinal studies to clarify the role of these potentially modifiable factors in the development of this complex illness are essential.

Neurocardiovascular Instability and Cognition.

Neurocardiovascular instability (NCVI) refers to abnormal neural control of the cardiovascular system affecting blood pressure and heart rate behavior. Autonomic dysfunction and impaired cerebral autoregulation in aging contribute to this phenomenon characterized by hypotension and bradyarrhythmia. Ultimately, this increases the risk of falls and syncope in older people. NCVI is common in patients with neurodegenerative disorders including dementia. This review discusses the various syndromes that characterize NCVI icluding hypotension, carotid sinus hypersensitivity, postprandial hypotension and vasovagal syncope and how they may contribute to the aetiology of cognitive decline. Conversely, they may also be a consequence of a common neurodegenerative process. Regardless, recognition of their association is paramount in optimizing management of these patients.

Excess maternal salt or fructose intake programmes sex-specific, stress- and fructose-sensitive hypertension in the offspring.

The Western diet is typically high in salt and fructose, which have pressor activity. Maternal diet can affect offspring blood pressure, but the extent to which maternal intake of excess salt and fructose may influence cardiovascular function of the offspring is unknown. We sought to determine the effect of moderate maternal dietary intake of salt and/or fructose on resting and stimulated cardiovascular function of the adult male and female offspring. Pregnant rats were fed purified diets (± 4% salt) and water (± 10% fructose) before and during gestation and through lactation. Male and female offspring were weaned onto standard laboratory chow. From 9 to 14 weeks of age, cardiovascular parameters (basal, circadian and stimulated) were assessed continuously by radiotelemetry. Maternal salt intake rendered opposite-sex siblings with a 25-mmHg difference in blood pressure as adults; male offspring were hypertensive (15 mmHg mean arterial pressure (MAP)) and female offspring were hypotensive (10 mmHg MAP) above and below controls, respectively. Sex differences were unrelated to endothelial nitric oxide activity in vivo, but isolation-induced anxiety revealed a significantly steeper coupling between blood pressure and heart rate in salt-exposed male offspring but not in female offspring. MAP of all offspring was refractory to salt loading but sensitive to subsequent dietary fructose, an effect exacerbated in female offspring from fructose-fed dams. Circadian analyses of pressure in all offspring revealed higher mean set-point for heart rate and relative non-dipping of nocturnal pressure. In conclusion, increased salt and fructose in the maternal diet has lasting effects on offspring cardiovascular function that is sex-dependent and related to the offspring's stress-response axis.

Effects of low blood pressure in cognitively impaired elderly patients treated with antihypertensive drugs.

IMPORTANCE: The prognostic role of high blood pressure and the aggressiveness of blood pressure lowering in dementia are not well characterized. OBJECTIVE: To assess whether office blood pressure, ambulatory blood pressure monitoring, or the use of antihypertensive drugs (AHDs) predict the progression of cognitive decline in patients with overt dementia and mild cognitive impairment (MCI). DESIGN, SETTING, AND PARTICIPANTS: Cohort study between June 1, 2009, and December 31, 2012, with a median 9-month follow-up of patients with dementia and MCI in 2 outpatient memory clinics. MAIN OUTCOMES AND MEASURES: Cognitive decline, defined as a Mini-Mental State Examination (MMSE) score change between baseline and follow-up. RESULTS: We analyzed 172 patients, with a mean (SD) age of 79 (5) years and a mean (SD) MMSE score of 22.1 (4.4). Among them, 68.0% had dementia, 32.0% had MCI, and 69.8% were being treated with AHDs. Patients in the lowest tertile of daytime systolic blood pressure (SBP) (≤ 128 mm Hg) showed a greater MMSE score change (mean [SD], -2.8 [3.8]) compared with patients in the intermediate tertile (129-144 mm Hg) (mean [SD], -0.7 [2.5]; P = .002) and patients in the highest tertile (≥ 145 mm Hg) (mean [SD], -0.7 [3.7]; P = .003). The association was significant in the dementia and MCI subgroups only among patients treated with AHDs. In a multivariable model that included age, baseline MMSE score, and vascular comorbidity score, the interaction term between low daytime SBP tertile and AHD treatment was independently associated with a greater cognitive decline in both subgroups. The association between office SBP and MMSE score change was weaker. Other ambulatory blood pressure monitoring variables were not associated with MMSE score change. CONCLUSIONS AND RELEVANCE: Low daytime SBP was independently associated with a greater progression of cognitive decline in older patients with dementia and MCI among those treated with AHDs. Excessive SBP lowering may be harmful for older patients with cognitive impairment. Ambulatory blood pressure monitoring can be useful to help avoid high blood pressure overtreatment in this population.

Beyond survival; influences of blood pressure, cerebral perfusion and anesthesia on neurodevelopment.

Neonates have a higher perioperative mortality risk largely due to the degree of prior illness of the infants, the complexity of their surgeries, and infant physiology. It is important to consider contributing anesthetic factors during the perioperative period that may affect cerebral perfusion and neurocognitive outcome, such as alterations in hemodynamics and ventilation. Limitations of blood pressure as a marker for cerebral perfusion are discussed, as well as the effect of hypocapnia on the brain.

Aortic stiffness and hypotension episodes are associated with impaired cognitive function in older subjects with subjective complaints of memory loss.

OBJECTIVE: Though CV risk factors and markers of arterial aging are recognized risky for cognition, no study has simultaneously investigated the impact of multiple cardiac, arterial (large and small vessels), and hemodynamic parameters on cognitive function in older subjects. METHODS: Two hundred eighty older subjects with subjective complaints of memory loss and no previous stroke (mean age 78.3 ± 6.3 years) were studied. Global cognitive function was evaluated with the Mini-Mental State Examination (MMSE). Cognitive impairment was defined as a MMSE < 21. We measured: traditional CV risk factors; aorta stiffness (Pulse Wave Velocity, PWV); LV mass; presence of WML at neuroimaging; episodes of hypotension (SBP <100 mmHg during 24 h Ambulatory Blood Pressure Monitoring). RESULTS: In both cross-sectional and longitudinal analyses PWV, WML, and episodes of hypotension were significantly associated with poorer cognitive function-controlling for age, sex, education, depression, traditional CV risk factors, and medications. LV mass was no longer associated with cognition in multiple regression. Older subjects with stiffer arteries or episodes of hypotension presented a 4-fold and an 11-fold, respectively, greater odds for progression from normal cognitive function to cognitive impairment. A synergistic effect between PWV, WML, and hypotension was observed: the occurrence of any two of PWV, WML, or hypotension was accompanied by lower MMSE; in the presence of all three factors, a further significant decline in cognitive function was observed. INTERPRETATION: Systemic hemodynamic parameters (higher PWV and hypotension) together with cerebral microvascular damage (WML) are significantly associated with poorer cognitive function and may identify older subjects with subjective complaints of memory loss at higher risk of cognitive decline.

B-type natriuretic peptide and severity of cognitive disorder.

BACKGROUND: Natriuretic peptides have been linked to cognitive disorder in previous studies. The aim of this study was to examine the association between the severity of cognitive disorder and the levels of B-type natriuretic peptide (BNP) in an older general population. MATERIAL AND METHODS: This study is a part of the larger population-based, multidisciplinary Kuopio 75+ health study. A total of 601 subjects aged 75 or older participated in the study. A subgroup of 126 individuals was diagnosed with cognitive disorder, and the severity of the disease was assessed. The participants were tested for BNP. Analysis of covariance was carried out to study the relationship between BNP and the stage of cognitive disorder. RESULTS: The association between the level of cognitive disorder and BNP resembled an inverse U-shaped curve, with higher levels of BNP observed among participants with mild cognitive disorder when compared to cognitively intact participants or counterparts with more severe cognitive disorder. This effect remained after adjustment for age (P = 0.02). However, association between BNP and level of cognitive disorder was lost in further adjustment with covariates connected to the levels of BNP. CONCLUSION: The previously reported elevation of natriuretic peptides among individuals with diagnosed cognitive disorder was found only in people with milder stages of the disorder.