Mariachiara Pieraccioli

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.

OBJECTIVE: Recent guidelines have widened clinical indications for out-of-office blood pressure measurement, including home blood pressure monitoring and ambulatory blood pressure monitoring (ABPM), suggesting the latter as recommended method in cognitively impaired patients. There is, however, a widespread belief that ABPM could be poorly tolerated in dementia, often leading to withdraw from its use in these patients. AIM: To assess the actual tolerability of ABPM in a group of cognitively impaired elderly, affected by dementia or mild cognitive impairment (MCI). METHODS: We evaluated 176 patients aged 65 + years, recruited in two different memory clinics, with a Mini Mental State Examination (MMSE) between 10 and 27. Behavioral and psychological symptoms were assessed with Neuropsychiatric Inventory (NPI). A patient was considered tolerant if able to keep the device on continuously for 24 h. The minimum number of correct measurements required was 70% of the predicted total number. RESULTS: 16% of patients wore the device for less than 24 h. Dividing the study population in tertiles of MMSE performance, 29% failed to tolerate the device in the lowest, 12% in the middle and 7% in the highest tertile (p < 0.01). Dividing the study population in tertiles of NPI performance, 30% of patients failed in the highest, 19% in the middle and 8% in the lowest tertile (p = 0.02); 31% of patients who tolerated the device did not achieve the minimum number of measurements required, with a mean number of 63% of predicted measurements. CONCLUSION: The ABPM proved a generally well-tolerated technique even in cognitively impaired elderly. Only a minority of subjects with poorer cognitive performances and greater behavioral symptoms did not tolerate the monitoring. Among most patients who failed to achieve the minimum number of measurements needed, the number of valid measurements was very close to the minimum required.

The elderly population living in nursing home is quite peculiar because of its high prevalence of comorbidity, disability and incidence of cognitive impairment. At present there are no data on the specific effects of hypertension in this population. Aim of the study was to verify the prevalence of hypertension in patients living in nursing homes and to evaluate the relation between clinical blood pressure and ambulatory blood pressure monitoring in this population (ABPM). Methods: study population was composed by 273 patients (mean age 81 years) divided in three groups: Group A: composed by hypertensive outpatients (N = 100); Group B: frail elderly admitted in nursing home (N = 100) Group C: patients admitted to the rehabilitation ward of the same centre (N = 73). Clinical and pharmacological data were collected for all patients as well as clinical blood pressure (OBP) and 24 hour ABPM (Spacelabs 90207). Definitions: ¡°White coat hypertension¡ ±: OBP≥140/90 and ABPM <135/85 mmHg; ¡°masked hypertension¡ ±: OBP<140/90 mmHg and ABPM≥135/85 mmHg). Results: Patients of group A had the higher prevalence of clinical hypertension (Group A 71%, Group B 51%; Group C 70%). We found a good correlation between blood pressure values measured clinically an with ABPM only in Group A (PAS: r = 0,54; p = < 0,001; PAD r = 0,70, p = <0,001), while the correlation was poor in Group B (PAS: r = 0,3 and p = 0,02; PAD: r = 0,11 and p = 0,2). In Group C the correlation was intermediate (PAS: r = 0,62; p = <0,001; PAD 0,44; r < 0,001). The prevalence of white coat hypertension was 14% in Group A, 57% in Group C and of 70% in Group B. Circadian rhythm analysis was preserved only in 22% both in Groups B and C. In Group A we found a higher percentage of patients with preserved circadian rhythm (33%). Conclusions: This study demonstrated a poor correlation between clinical and ambulatory blood pressure, with an high prevalence of white coat hypertension. The hypertensive patient in nursing home is very peculiar and deserves a careful management for what concerns diagnosis and treatment.