Cognitive Impairment and Slow Gait Speed in Elderly Outpatients with Arterial Hypertension: The Effect of Blood Pressure Values

To the Editor: The prevalence of cognitive impairment and mobility limitation is high in elderly adults, and these conditions are often associated and related. Hypertension is the most common cardiovascular disease in elderly adults and is a risk factor for cognitive decline. Nevertheless, the relationships between blood pressure and cognitive impairment are tangled and still debated.1 Moreover, hypertension and other cardiovascular risk factors are associated with mobility limitation in older adults.2 Usual gait speed has been shown to be an easy, useful marker and predictor of functional decline and survival,3 and there is evidence that high blood pressure accelerates gait slowing in older adults4 and that slow gait predicts cognitive decline.5 The aim of the current study was to examine the association between cognitive impairment, gait speed, and blood pressure in elderly outpatients with arterial hypertension. Fifty-six elderly adults with hypertension consecutively examined at a geriatric outpatient clinic were enrolled in the study. Exclusion criteria were a previous diagnosis of dementia and inability to walk. All individuals signed informed consent and underwent clinical and instrumental evaluation, including clinic blood pressure (BP) measurement in a seated position and in orthostatism (BP was measured 1 and 3 minutes after standing, and the lower value was considered). Cognitive status was evaluated using the Short Portable Mental Status Questionnaire (SPMSQ);6 0 points were assigned to wrong answers and 1 point to correct answers. The score proposed divides individuals into four categories: 0–2, severe cognitive impairment; 3–4, moderate cognitive impairment; 5–7, mild cognitive impairment; 8–10, intact intellectual functioning. Gait speed was evaluated over a marked distance of 4 m at a usual pace7 starting from a standing position. A gait speed of less than 0.8 m/s was interpreted as an indicator of frailty. Statistical analyses were performed using MedCalc version 10.3 (MedCalc Software bvba, Ostend, Belgium). T-tests and Pearson correlation analysis were used. Multiple regression analysis was performed to investigate the relationship between a dependent variable and explanatory variables. Data were presented as means and standard deviations for normally distributed values. All results were considered significant at P < .05. Table 1 shows the main characteristics of participants. The median value of clinic systolic blood pressure (SBP) was 140 mmHg and of orthostatic SBP was 135 mmHg. Statistically significantly lower values of SPMSQ were found in participants with a clinic SBP less than 140 mmHg (5.9 ± 1.9) and orthostatic SBP less than 135 mmHg (6.3 ± 0.4) than in those with a clinic SBP of 140 mmHg or greater (7.6 ± 2.0) (P = .01) and orthostatic SBP of 135 mmHg or greater (7.8 ± 0.5) (P = .03). Significant correlations were found between SPMSQ and age (correlation coefficient (r) = −0.45, P < .001), gait speed (r = 0.49, P < .001), clinic SBP (r = 0.25; P = .05), orthostatic SBP (R = 0.29; P = .02), and orthostatic diastolic BP (r = 0.32; P = .01). A significant correlation between gait speed and estimated glomerular filtration rate (eGFR) (r = 0.33, P = .02) was found. From multivariate analysis, gait speed was found to be directly correlated with SPMSQ (P = .002) after adjustment for blood pressure and eGFR. Participants had many comorbidities and used many drugs an on average had mild cognitive impairment and slow gait speed. Nevertheless, they had an overall satisfactory compensation of hypertension. Participants with median clinic SBP less than 140 mmHg and orthostatic SBP less than 135 mmHg had poorer cognitive performance. Participants with greater cognitive decline were older and had slower gait speed and lower BP. Conversely, participants with better cognitive status had higher seated and orthostatic SBP, with the highest SBP detected being 160 mmHg. Hypertension is associated with white matter hyperintensities (WMHs), and WMHs may influence mobility, cognition, and mood,8 although excessive reduction of BP promotes progression of brain WMHs and cognitive impairment.9 These findings support the idea that BP values play a critical role in the association between slow gait speed and cognitive impairment in older adults with arterial hypertension. In very old adults, the target for BP should not be too strict, because of the negative effect of lower BP on cognitive function and mobility. Walking speed may be a useful way to identify elderly adults with arterial hypertension with poor prognosis.10 Physicians who treat elderly adults with arterial hypertension should always assess gait speed and cognitive status using simple, validated, reliable, rapid, inexpensive tests. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Basile: study concept, preparation and revision of manuscript. Catalano, Mandraffino: analysis and interpretation of data. Crucitti, Ciancio: acquisition of data, bibliographic research. Morabito and Lasco: interpretation of data, revision of manuscript. Sponsor's Role: None.

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