Elsevier

Ageing Research Reviews

Volume 18, November 2014, Pages 41-52
Ageing Research Reviews

Review
Cognitive impairment and cardiovascular diseases in the elderly. A heart–brain continuum hypothesis

https://doi.org/10.1016/j.arr.2014.07.003Get rights and content

Highlights

  • Cardiovascular diseases affect the development of cognitive impairment in the elderly.

  • Hypertension, coronary artery disease, atrial fibrillation and chronic heart failure are connected by a cardiovascular continuum.

  • Thrombo-embolic and/or reduction of cardiac output appear to be the main mechanism.

  • Interventional studies are necessary in order to prevent cognitive decline in patients with cardiovascular diseases.

Abstract

The aging population is increasing and, therefore, a higher prevalence of cardiac disease is emerging; including hypertension, coronary artery disease, atrial fibrillation and chronic heart failure. Large cohort studies have revealed a relationship among increased risk for cognitive impairment and dementia in cardiovascular diseases probably due to embolic stroke or chronic cerebral hypoperfusion. Thus, the aim of the present review is to overview the studies that investigate the presence and/or the development of cognitive impairments and dementia in patients with varied types of cardiovascular disease. Finally, a continuum among hypertension, coronary artery disease, atrial fibrillation and chronic heart failure with to the development of cognitive impairment and progression to dementia has been hypothesized.

Introduction

Cardiovascular diseases (CVD) including hypertension, coronary artery disease (CAD), atrial fibrillation and chronic heart failure (CHF) are highly prevalent in the elderly (Aronow, 2002). Moreover, CVDs are strongly related to cognitive impairment and dementia (Kerola et al., 2011, Eggermont et al., 2012). Although the etiology of cognitive changes in CVD disease remains unknown, the main mechanism of this relationship seems to involve embolic stroke or chronic cerebral hypoperfusion (Kalaria, 2012). Of course, cognitive impairment and dementia reduce the ability to manage the care of a complex chronic illness and reduced medication adherence (Insel et al., 2006). Interestingly, CVDs are capable of producing both Alzheimer's disease (AD) (de la Torre, 2002) and vascular dementia (VaD) (Román, 2002), the most common forms of dementia in the elderly.

We used MEDLINE, the National Research Register, Embase (1980–2006, OVID online) to search for studies that investigated the relationship between CVD and cognition, and which were published until May 2013. The search included the following key words: cardiovascular diseases; hypertension; heart failure; coronary artery disease; atrial fibrillation; cognitive impairment, dysfunction, deficit; neuropsychological functions; dementia, Alzheimer's disease, vascular dementia.

Section snippets

Cognitive function and cognitive impairment

Cognitive function involves various specific aspects referring to memory, attention, executive functioning, psychomotor speed, language, and visuo-spatial ability and it is a critical function for the consciousness of situation, needs, and goals (Borson, 2010). The Mini-Mental State Examination (MMSE) has been used as a screening measure for global cognitive performance in several studies studying the relationship between CVD and cognitive impairment (Vogels et al., 2007a, Vogels et al., 2007b

Hypertension and cognitive impairment

Among people aged 65 years and over, the prevalence is estimated to be around 8% for dementia and 65% for hypertension (Qiu et al., 2005, Kearney et al., 2005). Moreover, hypertension represents the major risk factor for vascular dementia although vascular factors may be also involved in Alzheimer dementia (Launer, 2002, de la Torre, 2002). Thus, mixed vascular and neurodegenerative dementia has emerged as the leading cause of age-related cognitive impairment (Iadecola, 2013).

CAD and cognitive impairment

The aging of the population will result in a sizeable increase in CAD incidence, prevalence, mortality, and costs (Odden et al., 2011). Over time, Coronary Artery By-pass Grafting (CABG) has been a commonly prescribed cardiac procedure for CAD patients. Unfortunately, stroke is estimated to occur in 2–6% and encephalopathy in up to ∼13% following CABG predisposing elderly CAD patients to cognitive impairment (Caplan, 2009).

Atrial fibrillation and cognitive impairment

Atrial fibrillation is an arrhythmia with high prevalence in geriatric age; approximately 10% of subjects older than 65 years and 5% of subjects older than 80 years old suffer from such arrhythmia (Aronow, 2002, Chatap et al., 2002). The high prevalence atrial fibrillation comes from the frequent association with heart disease that characterize the elderly, such as CAD, hypertension and CHF, which often represent the etiopathogenetic substrate (Aronow, 2002, Chatap et al., 2002). These diseases

CHF and cognitive impairment

CHF is a mounting health problem that affects up to 10% of people over the age of 65 and it is associated with frequent hospital admissions, reduced quality of life, significant morbidity, and increased mortality in the developed world; CHF patients have also a high readmission rates ranging from 40 to 50% within 6 months (Abete et al., 2013). Some readmissions may be the consequence of the presence of cognitive impairment which is particularly common in CHF patients ranging from 30% to 80% (

CVD, self-care and cognitive impairment

Self-care maintenance in CVD patients represents a critical point of the treatment adherence including reducing risk factors, following dietary restrictions, taking multiple medications, performing daily weights, exercising to prevent deconditioning, and having a good social support (Mazzella et al., 2010, Harkness et al., 2014). However, cognitive impairment may represent a serious obstacle in the management of the patient with cognitive decline. It has been demonstrated in 60 hypertensive

CVD, mortality and cognitive impairment

Controversial data is available on the association between mortality, CVD and cognitive impairment in the elderly. In a cross-sectional survey with a 6-year mortality evaluation conducted in a region of southern Italy, involving elderly subjects with and without cognitive impairment. Mortality shows a linear relationship with pulse blood pressure and a U-curve shape for diastolic blood pressure. This phenomenon was more evident in subjects with cognitive impairment showing the greatest risk of

The heart–brain continuum hypothesis

Advances in pathophysiological research suggest that the cardiovascular disease continuum begins with risk factors (hypertension, dyslipidemia, obesity, diabetes, smoking, etc.) that initiate the process that leads to tissue damage (Dzau et al., 2006). In this context, the role of hypertension through all stages of cardiovascular disease has been clearly illustrated by a prospective longitudinal analysis of 36-year follow-up data from the Framingham Heart Study. This analysis showed that the

Conclusions

The analysis of the data allows concluding that:

  • -

    CVD affect the development of cognitive impairment in the elderly;

  • -

    some discrepancies are mainly related to selection bias of the study populations;

  • -

    hypertension, CAD, atrial fibrillation and CHF and appear to be connected by a cardiovascular continuum;

  • -

    thrombo-embolic and/or reduction of cardiac output appear to be the main mechanisms in the determination of cognitive impairment in the elderly with cardiovascular disease;

  • -

    CVD patients have great

References (179)

  • M.F. Elias et al.

    Atrial fibrillation is associated with lower cognitive performance in the Framingham offspring men

    J. Stroke Cerebrovasc. Dis.

    (2006)
  • P. Forti et al.

    Atrial fibrillation and risk of dementia in non-demented elderly subjects with and without mild cognitive impairment (MCI)

    Arch. Gerontol. Geriatr.

    (2007)
  • A. Hofman et al.

    Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer's disease in the Rotterdam Study

    Lancet

    (1997)
  • C. Iadecola

    The pathobiology of vascular dementia

    Neuron

    (2013)
  • B.A. in’t Veld et al.

    Antihypertensive drugs and incidence of dementia: the Rotterdam Study

    Neurobiol. Aging

    (2001)
  • A. Jozwiak et al.

    Association of atrial fibrillation and focal neurologic deficits with impaired cognitive function in hospitalized patients < or ≥65 years of age

    Am. J. Cardiol.

    (2006)
  • M.R. Karlsson et al.

    A nurse-based management program in heart failure patients affects females and persons with cognitive dysfunction most

    Patient Educ. Couns.

    (2005)
  • P.M. Kearney et al.

    Global burden of hypertension: analysis of worldwide data

    Lancet

    (2005)
  • S.P. Kennelly et al.

    Blood pressure and the risk for dementia: a double edged sword

    Ageing Res. Rev.

    (2009)
  • T. Kerola et al.

    The complex interplay of cardiovascular system and cognition: how to predict dementia in the elderly?

    Int. J. Cardiol.

    (2011)
  • L.J. Launer et al.

    Midlife blood pressure and dementia: the Honolulu-Asia aging study

    Neurobiol. Aging

    (2000)
  • L.J. Launer

    Demonstrating the case that AD is a vascular disease: epidemiologic evidence

    Ageing Res. Rev.

    (2002)
  • A.S. Malik et al.

    Patient perception versus medical record entry of health-related conditions among patients with heart failure

    Am. J. Cardiol.

    (2011)
  • F. Mazzella et al.

    Social support and long-term mortality in the elderly: role of comorbidity

    Arch. Gerontol. Geriatr.

    (2010)
  • P. Abete et al.

    Treatment for chronic heart failure in the elderly: current practice and problems

    Heart Fail. Rev.

    (2013)
  • Y. Agmon et al.

    Independent association of high blood pressure and aortic atherosclerosis: a population-based study

    Circulation

    (2000)
  • O.P. Almeida et al.

    Congestive heart failure and cognitive functioning amongst older adults

    Arq. Neuropsiquiatr.

    (2001)
  • M.L. Alosco et al.

    Cognitive impairment is independently associated with reduced instrumental activities of daily living in persons with heart failure

    J. Cardiovasc. Nurs.

    (2012)
  • T.C. Alves et al.

    Localized cerebral blood flow reductions in patients with heart failure: a study using 99mTc-HMPAO SPECT

    J. Neuroimaging

    (2005)
  • L. André-Petersson et al.

    A comparison of cognitive ability in normotensive and hypertensive 68-year-old men: results from population study ‘men born in 1914’ in Malmö, Sweden

    Exp. Aging Res.

    (2001)
  • R. Antonelli Incalzi et al.

    Verbal memory impairment in congestive heart failure

    J. Clin. Exp. Neuropsychol.

    (2003)
  • E.P. Anyukhovsky et al.

    Age-associated changes in electrophysiologic remodeling: a potential contributor to initiation of atrial fibrillation

    Cardiovasc. Res.

    (2005)
  • K.A. Arntzen et al.

    Impact of cardiovascular risk factors on cognitive function: the Tromsø study

    Eur. J. Neurol.

    (2001)
  • W.S. Aronow

    Management of the older person with atrial fibrillation

    J. Gerontol. A: Biol. Sci. Med. Sci.

    (2002)
  • L.C. Bauer et al.

    Cognition in heart failure: an overview of the concepts and their measures

    J. Am. Acad. Nurse Pract.

    (2011)
  • L. Bauer et al.

    A brief neuropsychological battery for use in the chronic heart failure population

    Eur. J. Cardiovasc. Nurs.

    (2012)
  • S.J. Bennett et al.

    Cognitive deficits in patients with heart failure: a review of the literature

    J. Cardiovasc. Nurs.

    (2003)
  • A.D. Bohannon et al.

    Relationship of race/ethnicity and blood pressure to change in cognitive function

    J. Am. Geriatr. Soc.

    (2002)
  • F. Cacciatore et al.

    The role of blood pressure in cognitive impairment in an elderly population. Osservatorio Geriatrico Campano Group

    J. Hypertens.

    (1997)
  • F. Cacciatore et al.

    Congestive heart failure and cognitive impairment in an older population

    J. Am. Geriatr. Soc.

    (1998)
  • F. Cacciatore et al.

    Mortality and blood pressure in elderly people with and without cognitive impairment

    Gerontology

    (2005)
  • F. Cacciatore et al.

    Role of ventricular rate response on dementia in cognitively impaired elderly subjects with atrial fibrillation: a 10-year study

    Dement. Geriatr. Cogn. Disord.

    (2012)
  • J. Cameron et al.

    Does cognitive impairment predict poor selfcare in patients with heart failure?

    Eur. J. Heart Fail.

    (2010)
  • L.R. Caplan

    Translating what is known about neurological complications of coronary artery bypass graft surgery into action

    Arch. Neurol.

    (2009)
  • H. Chang-Quan et al.

    The association of antihypertensive medication use with risk of cognitive decline and dementia: a meta-analysis of longitudinal studies

    Int. J. Clin. Pract.

    (2011)
  • G. Chatap et al.

    Atrial fibrillation in the elderly: facts and management

    Drugs Aging

    (2002)
  • A. Cherubini et al.

    Hypertension and cognitive function in the elderly

    Am. J. Ther.

    (2007)
  • B.S. Chin et al.

    Prognostic value of interleukin-6, plasma viscosity, fibrinogen, von Willebrand factor, tissue factor and vascular endothelial growth factor levels in congestive heart failure

    Eur. J. Clin. Invest.

    (2003)
  • J.A. Claassen et al.

    Altered cerebral hemodynamics in early Alzheimer disease: a pilot study using transcranial Doppler

    J. Alzheimers Dis.

    (2009)
  • A. Corsonello et al.

    Health status in older hospitalized patients with cancer or nonneoplastic chronic diseases

    BMC Geriatr.

    (2005)
  • Cited by (0)

    View full text