How to screen and evaluate elderly patients with hypertension and cognitive impairment, this consensus gives the answer

Introduction To reduce the risk of hypertension in the elderly with cognitive impairment, the Chinese Society of Geriatrics, the Hypertension Branch of the Chinese Society of Geriatrics and the Cognitive Disorder Branch, the National Clinical Research Center for Geriatric Diseases (General Hospital of the People’s Liberation Army), and the National Clinical Research on Geriatric The Center-Geriatric Cardiovascular Disease Prevention and Control Alliance jointly invited experts in the fields of hypertension and neurocognition to co-author this consensus.

The aim is to guide relevant disciplines in the early screening, timely referral, and personalized comprehensive intervention of elderly hypertension with cognitive impairment through the summary analysis of current domestic and foreign related research and literature, and to promote and accumulate evidence-based research evidence in my country.

This article briefly summarizes the screening and evaluation of elderly hypertension with cognitive impairment.

 The screening and management process of elderly hypertension complicated with cognitive impairment is shown in the figure below.

Note: AD8: 8-item Dementia Screening Questionnaire; Mini-cog: Simple Mental State Assessment Scale; MMSE: Simple Mental State Examination; MoCA: Montreal Cognitive Assessment Scale.
Screening and evaluation of elderly hypertension with cognitive impairment There is still a lack of direct clinical research evidence that early screening and assessment of elderly hypertension combined with cognitive impairment can improve the prognosis of patients, but because the continuous increase in blood pressure is an important risk factor for cognitive impairment; and the elderly with multiple comorbidities The risks of debilitating and debilitating are all increased, which is also a factor leading to the increased risk of cognitive impairment.

Therefore, this consensus recommends that, in addition to traditional blood pressure and cardiovascular risk stratification assessments, for elderly hypertensive patients, especially those with memory impairment, the cognitive function should be actively screened and comprehensive assessment of the elderly should be carried out in order to assess Elderly people carry out early, comprehensive and comprehensive intervention.

 Recommendations: Ⅰ: For elderly hypertensive patients, especially those who complain of memory impairment and the elderly, should actively carry out cognitive function screening and comprehensive assessment including frailty assessment.

 Ⅱ: Non-neurology medical staff can use the AD8 self-rating scale and Mini-cog scale for rapid cognitive function screening.

When the AD8 or self-examination score or rapid screening is lower than normal, it can be recommended to a neurologist to further evaluate the degree of cognitive domain involvement in the elderly, as well as the ability of daily living and the cause of the disease.

 Ⅲ: In addition to clinic blood pressure monitoring and traditional cardiovascular risk stratification for elderly hypertensive patients, attention should be paid to the impact of orthostatic hypotension or blood pressure variation on cognitive impairment.

Short-term and long-term blood pressure variability can be observed through 24 h ambulatory blood pressure and home blood pressure measurement.

Comprehensive interventions for elderly hypertension with cognitive impairment The current randomized controlled trials and meta-analysis have found that the five major types of antihypertensive drugs can be used for the treatment of hypertension with cognitive impairment.

Diuretics, β-receptor blockers, calcium channel blockers (CCB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor antagonists (angiotensin Ⅱ receptor antagonist (ARB) may reduce the risk of dementia or cognitive impairment by lowering blood pressure or specific neuroprotective effects.

However, the research conclusions on the optimal blood pressure target value of the elderly of different ages with cognitive impairment and the improvement effect of different kinds of antihypertensive drugs on cognitive function are still inconsistent.

Strengthening the management of multiple medications and comprehensive intervention methods (rational diet, appropriate exercise, cognitive training, control of vascular risk factors) can obtain better cognitive improvement results.

Recommendations for blood pressure management in elderly hypertension with cognitive impairment: Ⅰ: Reasonable antihypertensive therapy has the effect of protecting cognitive function in elderly hypertensive patients, and antihypertensive therapy can be given to hypertensive patients with cognitive impairment.

 Ⅱ: For persons ≥65 years of age, such as blood pressure ≥140/90 mmHg, start antihypertensive drug therapy at the same time of life>
If it can be tolerated, it can be further reduced.

 Ⅲ: Age ≥80 years old, such as blood pressure ≥150/90 mmHg, that is, while improving life>
If it is well tolerated, blood pressure is further reduced to <140/90 mmHg.

If there is weakness, individualized blood pressure control goals should be set according to the specific conditions of the patient.

 Ⅳ: For patients living alone with severe cognitive decline or even dementia, as well as frail patients with coexistence of multiple diseases or poor general health conditions, too strict blood pressure control may have potential adverse effects on patients, and a more relaxed blood pressure should be adopted Control strategy, with <150/90 mmHg as the initial blood pressure control target.

After starting the antihypertensive drug treatment, the treatment response should be observed more closely, and the treatment intensity should be moderately reduced if necessary.

Improve the use of cognitive impairment drugs and precautions in blood pressure management Recommendations: Ⅰ: The therapeutic effect of cholinesterase inhibitors and NMDA receptor antagonists for VCI needs further clinical evaluation.

For mixed dementia with VCI and AD, cholinesterase inhibitors and memantine are treatment options.

Butylphthalide, oxiracetam, citicoline, ginkgo biloba extract and nimodipine may be effective in the treatment of VCI, but more clinical research evidence is needed.

 Ⅱ: Cholinesterase inhibitors can be used for patients with a clear diagnosis of AD.
Cholinesterase inhibitors can be switched between when the treatment is invalid or the adverse reactions cannot be tolerated.

Definitely diagnosed as moderate to severe AD patients or severe AD patients with obvious mental and behavioral abnormalities can be treated with memantine or memantine combined with donepezil and rivastigmine.

Recommendations for the management of comorbidities: We should actively seek out the treatable risk factors for elderly hypertension with cognitive impairment, and provide comprehensive management of atherosclerosis risk factors such as blood sugar and blood lipids.

Comprehensive management recommendations: Ⅰ: In the management of elderly hypertension with cognitive impairment, the beneficial effects of comprehensive interventions such as physical exercise, reasonable diet, and cognitive intervention should be emphasized.

 Ⅱ: In the perioperative period of elderly hypertensive patients, attention should be paid to blood pressure fluctuations and the influence of anesthetics on cognitive function.

 Ⅲ: For elderly patients with hypertension and cognitive dysfunction, it is necessary to strengthen social support and the management of a people-centered continuous multidisciplinary team.

Yimaitong is compiled from: Chinese Society of Geriatrics, Hypertension Branch of Chinese Society of Geriatrics, Cognitive Disorder Branch of Chinese Society of Geriatrics, etc.
Chinese Expert Consensus on the Diagnosis and Treatment of Cognitive Impairment in the Elderly with Hypertension (2021 Edition)[J].
China Cardiovascular Journal, 2021, 26(2): 101-111.
DOI: 10.
3969/j.
issn.
1007-5410.
2021.
02.
001.