|Year : 2014 | Volume
| Issue : 1 | Page : 33-38
Effect of cognitive rehabilitation for mild cognitive impairment in the geriatric population with early onset hypertension pretest -posttest design
Shamim Shaikh, Sanjiv Kumar, Anil Muragod
Department of Neuro Physiotherapy, KLE University's Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Web Publication||2-Jul-2014|
Department of Neuro-Physiotherapy, KLE University's Institute of Physiotherapy, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction and Background: Hypertension is common among elderly and the risk of becoming hypertensive is increased considerably with age. It has a direct impact on the cognitive function. Hence it is important to examine whether the cognition related problems correlates with hypertension and is cognitive rehabilitation an effective intervention for the same.
Objective: To assess and evaluate the cognitive function in early onset hypertensive geriatrics population for mild cognitive Impairment and to study the effect of cognitive rehabilitation for mild cognitive impairment.
Materials and Methods: 84 Participants above 60 years of age with early onset hypertension were screened. The total 63 participants were recruited in the study as a sample of convenience as per the inclusion criteria. The outcome measures used were Montreal cognitive examined, Addenbrooke's cognitive examination, Mini mental state examination. Cognitive rehabilitation was given for 4 weeks (3 sessions per week).
Results: Paired t-test and ANOVA was used for statistical analysis. Demographic data in relation to the outcome measures were also analyzed. The pre post analysis of all the three outcome measures, showed statistical significance results.
Conclusion: Early onset hypertensive showed mild cognitive impairment and cognitive rehabilitation was found to be effective for improving the cognitive functions among elderly.
Keywords: Hypertension, mild cognitive impairment, Alzheimer′s disease, Montreal cognitive examination, Addenbrooke′s cognitive examination, mini mental state examination
|How to cite this article:|
Shaikh S, Kumar S, Muragod A. Effect of cognitive rehabilitation for mild cognitive impairment in the geriatric population with early onset hypertension pretest -posttest design. Indian J Health Sci Biomed Res 2014;7:33-8
|How to cite this URL:|
Shaikh S, Kumar S, Muragod A. Effect of cognitive rehabilitation for mild cognitive impairment in the geriatric population with early onset hypertension pretest -posttest design. Indian J Health Sci Biomed Res [serial online] 2014 [cited 2021 Apr 23];7:33-8. Available from: https://www.ijournalhs.org/text.asp?2014/7/1/33/135032
| Introduction|| |
Hypertension or high blood pressure (BP) sometimes arterial hypertension is a chronic medical condition in which the BPs in the arteries are elevated.  Hypertension is classified as both primary (essential) hypertension constituting 90-95% and secondary hypertension 5-10%. 
Systolic blood pressure (SBP) increases to age 70 or 80 years and the diastolic blood pressure (DBP) to age 50-60 years. Between the third and seventh decades, the rise in SBP and DBP is greater for women than for men.  The prevalence of hypertension in United States increased from 24% (43 million) in year 1995 to 29% in 2004. , Recent studies in Kerala (JNC VI) reported 37% prevalence of hypertension among 30-64 age group  in 1998 and 55% was recorded among 40-60 age group  during 2000. A higher prevalence of 69% and 55% was recorded among the elderly population aged sixty and above in the urban and rural areas respectively during 2000.  Hypertension is a major risk factor for stroke, myocardial infarction, aneurysm of arteries, peripheral arterial disease and is a cause of chronic kidney disease. Even in otherwise healthy people, hypertension can lead to mild to moderate alterations in the brain's structure and function, including its ability to efficiently process information. Hypertensives elderly vary widely in physical, behavioral, cognitive and emotional characteristics as well as independence, severity of illness, and choices of medical care.  The early hypertension-related changes in the brain can be detected by sophisticated brain scans and by neuropsychological assessment of cognitive abilities.  The relationships between hypertension and cognitive impairment were strongest in untreated men. The findings add support to possibilities of intervention in early stages in cognitive decline, that is, before manifestation of dementia.  Cognition is a term referring to the mental processes involved in gaining knowledge and comprehension, including thinking, knowing, remembering, judging and problem-solving. Hypertension affects the brain in many ways that could explain its link to cognitive difficulties.  Hypertensives exhibit reduced cerebral blood flow and metabolism, particularly in certain brain regions, such as the frontal and temporal lobes and subcortical areas. Reductions in cerebral blood flow are worse among unmedicated than medicated hypertensives. Recent findings have also shown that hypertensives show smaller cerebral blood flow responses than normotensives during memory tasks.  Mild cognitive impairment (MCI) is a recently described syndrome that is thought to constitute a transition phase between healthy cognitive aging and dementia. MCI is characterized by impairment in cognitive domains that is intermediary between normal aging and dementia. MCI has been associated with impairment in motor coordination and balance leading to an increased risk of falling with subsequent softtissue injuries and fractures.  Cognitive rehabilitation is the treatment designed to maximize recovery of the individual's abilities in the areas of intellectual functioning, visual processing, language, attention and memory.  Cognitive rehabilitation cognitive rehabilitation breaks down functions into their individual components so that the broken links can be found and addressed. Because hypertension is increasingly common as people age, the study of hypertension and cognition is pertinent to the study of cognitive aging. Thus, the following study will be intended to assess cognitive function in early onset hypertensive elderly and improving the same using cognitive rehabilitation.
| Materials and Methods|| |
After receiving the ethical clearance from the Institutional Ethical Committee the study was commenced. In this study, 84 subjects were screened suffering from early onset hypertension and 63 were recruited as per the inclusion criteria of the study. A written consent was obtained from the participants. Participants were included if diagnosed with hypertension, SBP 140 mmHg and above, DBP 90 mmHg and above, early onset hypertension, age -60 years and above, male/female, should be able to follow simple instructions, fair auditory, visual and speech functioning, minimum ability to read, write and understand and those willing to participate in the study and excluded if diagnosed with dementia and Alzheimer's disease, absolute loss of visual, auditory and speech functioning, participants on psychotropic medication, previous stroke or transient ischemic attack (defined by clinical history or physical examination). Intervention was given in the form of cognitive rehabilitation. In supine lying position, the BP was measured and noted using sphygmomanometer (manual) and stethoscope before assessment. The participants were assessed for having MCI using the assessment scales. The participants who does not fall on MCI category, but had hypertension was advised the relaxation exercises. Participants with MCI received cognitive rehabilitation for 4 weeks, 3 sessions/week for 1 h. The training includes across the following domains attention, memory, executive function, visual processing, language and problem-solving skills. , The participants were told to maintain a diary to record the maintenance of their daily activities. The purpose of maintaining the dairy was to enhance the effectiveness of cognitive rehabilitation.  Of a total of 63 participants, 3 of them discontinued the treatment after attending 2 or 3 sessions of intervention. Cognitive rehabilitation was given to all the participants focusing on the cognitive functions across all the cognitive domains. The outcome measures used in this study were; Montreal cognitive assessment. It is 30 point scales, which assess several cognitive domains includes attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation,  Addenbrooke's cognitive examination (ACE-R) ACE-R is a brief cognitive test with maximum score of 100 points.  The domain includes orientation registration, attention, recall, verbal fluency language, visuospatial abilities, perceptual abilities and mini mental state examination (MMSE) has component for assessment of orientation, registration, attention, recall and language. Pre and post assessment scoring were obtained and compared using the same outcome measures.
| Result|| |
Statistical analysis was performed by using SPSS 20 Software (IBM Company). Statistical analysis of various measures such as mean, standard deviation, and test of significance such as paired t-test and ANOVA were utilized.
The mean height (cm) of the participants in this study was found to be 154.60 ± 5.29 with mean weight (kg) 55.13 ± 9.90 and body mass index (BMI) (kg/m 2 ) of 22.92 ± 2.93, which doesn't show any statistically significance difference [Table 1]. Gender distribution of sample male and female participated in the study was 26 males constituting 43.33% and 34 females constituting 56.67% females of the total participants. Age of the subjects participated in this study was between 60 and 85 years with the mean age of 68 ± 6.04. Out of the total of 60 participants 44 of them fall into the age group of 61-70 years, 14 of them fall under the age group of 71-81 years and 2 of them were above 80 years. [Figure 1] shows the duration of hypertension in this study varied from 8 years to >30 years with 42 (70.00%) participants of duration 11-20 years and 13 (21.67%) participants of duration 21-30 years. The level of education varied from primary to graduate with 21 (35%) participants of high school, 18 (30%) participants of primary group, 12 (20%) participants of pre university group and 9 (15%) graduate participants.
|Figure 1: (a) Mean age, height, weight and body mass index, (b) Study flow chart|
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Pretest posttest outcomes of Montreal cognitive, Addenbrooke's cognitive examination-R and mini mental state examination
The mean of pre-posttest for Montreal cognitive assessment, ACE-R and MMSE was 20.62 ± 2.26 and 27.65 ± 1.53, 21.03 ± 1.97 and 28.17 ± 1.14, 21.03 ± 1.97 and 28.17 ± 1.14 respectively with the P < 0.001, which suggest that there was statistically significance improvement [Table 2] and [Figure 2].
|Figure 2: Pre post assessment of Montreal cognitive, Addenbrooke's cognitive examination-R and mini mental state examination|
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Comparison of improvement in Montreal cognitive assessment, Addenbrooke's cognitive examination-R and mini mental state examination scale among different sexes-comparison among difference sexes was done using t-test
The mean value of male 6.81 ± 1.36 and females was 7.21 ± 1.49 in Montreal cognitive assessment (MoCA) with the P = 0.292, which doesn't show statistical significance with the present study (P < 0.05). The mean value of male and female in ACE-R was 12.50 ± 3.34 and 12.62 ± 3.14, respectively with the P = 0.887, which was not statistically significant (P < 0.05).The mean value of male/female in MMSE was 6.96 ± 1.40 and 7.26 ± 1.42, respectively with the P = 0.887, which was also not significant.
Comparison of improvement in Montreal cognitive assessment Addenbrooke's cognitive examination-R and mini mental state examination scale among different age group
This comparison of improvement among different age group was done using ANOVA. The age groups were divided into 61-70 years, 71-80 years and 80 years and above. The mean value in the MoCA was highest for the above 80 years age group that is 8.00 ± 1.41, ACE-R and MMSE was greater in age group >80 and 71-80 years respectively with the P > 0.05, which does not any statistical significance in this study.
Comparison of improvement in MoC with BMI was done using ANOVA. The mean values of MoC for 18.50-22.99, 23.00-24.99 and 25.00-29.99 was 7.14 ± 1.41, 7.18 ± 1.51 and 6.92 ± 1.31, respectively. The mean value of ACE-R was also highest in the range of 18.50-22.99 with 13.38 ± 3.29. The P < 0.05 in all the three outcomes measures showed no statistical significant. Similarly, comparison of improvement with duration of hypertension in MoC, ACE-R and MMSE was also done. The P value of MoC, ACE-R and MMSE was 0.780, 0.462 and 0.797 respectively. The P value (P < 0.05) of all the three does not show any statistical significance. Comparison of improvement was also done according to the education level in these study participants for MoCA, ACE-R and MMSE scale. The P value of MoC, ACE-R and MMSE was found to be 0.836, 0.139 and 0.369 respectively which doesn't show any statistical significance with the P < 0.05.
| Discussion|| |
This study was conducted to evaluate early onset hypertensive geriatrics for having MCI and to study the effect of cognitive rehabilitation for the same. 63 participants with the history of early onset hypertension having MCI were participated out of which three of the participants discontinued the treatment after two or three sessions of therapy as they were unfit. Cognitive rehabilitation intervention was given for the duration of 4 weeks, which showed a highly significant improvement for the following outcome measures Montreal cognitive assessment, ACE and MMSE. In this study, the age of the participants ranges 60 years and above and is supported by the study done by Sharifi et al. on 211 elderly aged 65 years or older with aMMSE score >10. The study was carried out to investigate the association between hypertension at baseline and cognitive impairment after 24 months of follow-up in the elderly. The result of the study declared that total of 63.5% of patients had impaired cognition (61% and 63.9% in normotensive and hypertensive patients, respectively).  Another study done by the US researchers on nearly 20,000 people aged 45 and over found that those with high DBP were more likely to have cognitive impairment, where thinking and memory ability is reduced, than people with normal diastolic pressure.  Some studies also suggest that midlife high BP is a risk factor for late-life cognitive impairment and dementia, and that low diastolic pressure and very high systolic pressure in older adults may be associated with subsequent development of dementia and Alzheimer's disease.  Several other studies also quoted that hypertension is not only the risk factor for the vascular dementia, but also leads to the degenerative changes in the brain causing cognitive changes in the brain causing cognitive decline and ultimately leading to dementia such as Alzheimer's disease suggesting that the treatment of hypertension could reduce the risk of dementia. Hence, the study participants selected for this study were early onset hypertensives with age 60 years and above. The total sample of this study consisted of 60 participants 26 males and 34 females that are 43.33% males and 56.67% females. As the findings suggest that the total number of female participants exceeds the male participants due to the high prevalence of hypertension in females compared with the males. A study done by Mark Stibich stated that cognitive risk factors for both male and female were different according to the risk profiles.  The mean height, weight and BMI of the participants in this study do not show any statistical significance.
The duration of onset of hypertension ranges from 10 years to almost >30 years. As per this study, all of the participants showed improvement in the cognitive functioning after the intervention of 4 weeks cognitive rehabilitation. It suggests that the duration of hypertension does not have any statistical significance on the participants with MCI. This was in contrast with the study done by Swan et al. who investigated the association between midlife SBP and late-life cognitive decline and brain morphology in a sample of community-dwelling elderly men 68-79 years of age. The results of this study concluded that subjects with high midlife SBP experienced a greater decline in cognitive performance and decreased brain parenchyma and increased white matter hyper intensities volumes were associated with decline in neurobehavioral functioning as measured in late-life independent of age, education, and baseline levels of cognition.  The education level of the participants in this study varied from primary to graduate with maximum participants falling into the high school group (35%). There was no statistical significance seen in all the three outcome measures that is MoC, ACE-R and MMSE. The effect of education on all the outcome measure remains stable in this study. In a study done by Schofield et al. to investigate the association of subjective memory complaints with subsequent cognitive decline in community-dwelling elderly individuals with baseline cognitive impairment. Memory complaints of 364 nondemented, community-dwelling elderly individuals were recorded as present or absent at the baseline evaluation and after 1 year, 169 subjects were reevaluated. Standardized neurologic and neuropsychological evaluations were used at each assessment to classify subjects as normal or cognitively impaired. The baseline evaluation for both groups that with memory complaint and with no memory complaint consisted of sex, age of the participants (years), education (years), Hamilton depression scale score, orientation memory concentration, functional assessment and total recall. The mean education for the no memory complaint participants was 8.2 ± 4.1 and for the memory complaint was 6.6 ± 4.2, which like our study had no statistical Significance. 
In this study, participants having early onset hypertension were screened for having MCI by using the three outcome measures. To support our study several studies have concluded the association of hypertensives have faster cognitive decline in MCI. Goldstein et al. to determine the association of high BP with faster cognitive decline conducted a study on 1385 participants with diagnosis of MCI and measured BP values at baseline and two annual follow-up visits. The study design was prospective cohort study. The outcome measures used in this study was neuropsychological test scores and Clinical Dementia Rating Sum of Boxes (CDR Sum) score. Subjects with SBP H140 mmHg or DBP H90 mmHg were included in the study. It was found that the participants with MCI with two or three annual occasions of high BP values had significantly faster decline on neuropsychological measures of visuomotor sequencing, set shifting, and naming than those who were normotensive on all three occasions it was also seen that the high SBP values were associated as well with faster decline on the CDR Sum score.  The participants in this study were on medications as they were clinically diagnosed having hypertension by the physicians. Indeed case-control studies have suggested that untreated or untreated and unaware persons with hypertensives performed more poorly on test of cognitive function than do normotensives persons and that those treated for hypertension perform better than those untreated for hypertension but still less well than those who are normotensives. However, the independent effects of antihypertensive medication on cognitive function are thought to be small and are likely of less importance than achieving good BP control across the lifespan. Cognitive rehabilitation is the rehabilitation effective in improving individuals abilities that is memory, attention, visual processing and language.
The intervention of cognitive rehabilitation was given for 4 weeks in this study which is similar to the study done by Alexander Kurz. who recommended cognitive rehabilitation for patients with cognitive complaints, MCI and preclinical dementia.  This study explains that the present study supports the literature. Cognitive rehabilitation regained the cognitive abilities of the participants in this study, it was organized in a manner to improve the functions at home practice and developing strategies for compensating for any residual deficits. In the current study participant showed more of the affection in memory, attention and visuospatial abilities domains. The reason for the visuospatial affection in this study was may be due to the poor eye hand control in the elderly population or poor ability to draw or design the diagram.
Pre-post analysis of this study showed significant difference in all the three outcome measures used in this study. The outcome measures used were Montreal cognitive assessment, ACE and MMSE. The P value was highly significant (P ≤ 0.001) for Montreal cognitive assessment, ACE and MMSE. Major limitation faced that there was no follow-up period after the intervention of 4 weeks, hence the long-term effect of the intervention could not be seen. The intervention period of the study was long so it was inconvenient for the geriatric population to continue the treatment regularly. In this study, no specific cognitive domains were assessed and evaluated by using their respective outcome measures.
| Conclusion|| |
The present study concluded that early onset hypertensive showed MCI, which was evaluated by using MoCA, ACE-R and MMSE.
The study also proved that cognitive rehabilitation is an effective intervention to improve cognition in early onset hypertensives.
| References|| |
|1.||Laragh JH, Brenner BM. Hypertension Pathophysiology, Diagnosis and Management. 2 nd ed.: Lippincott Williams & Wilkins; 1994.p. 227-8. |
|2.||Carretero OA, Oparil S. Essential hypertension. Part I: Definition and etiology. Circulation 2000;101:329-35. |
|3.||Vasan RS, Beiser A, Seshadri S, Larson MG, Kannel WB, D'Agostino RB, et al. Residual lifetime risk for developing hypertension in middle-aged women and men: The Framingham Heart Study. JAMA 2002;287:1003-10. |
|4.||Burt VL, Cutler JA, Higgins M, Horan MJ, Labarthe D, Whelton P, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. Hypertension 1995;26:60-9. |
|5.||Ostchega Y, Dillon CF, Hughes JP, Carroll M, Yoon S. Trends in hypertension prevalence, awareness, treatment, and control in older U.S. adults: Data from the National Health and Nutrition Examination Survey 1988 to 2004. J Am Geriatr Soc 2007;55:1056-65. |
|6.||Kutty VR, Soman CR, Joseph A, Kumar KV, Pisharody R. Random capillary blood sugar and coronary risk factors in a south Kerala population. J Cardiovasc Risk 2002;9:361. |
|7.||Zachariah MG, Thankappan KR, Alex SC, Sarma PS, Vasan RS. Prevalence, correlates, awareness, treatment, and control of hypertension in a middle-aged urban population in Kerala. Indian Heart J 2003;55:245-51. |
|8.||Hypertension Study Group. Prevalence, awareness, treatment and control of hypertension among the elderly in Bangladesh and India: A multicentre study. Bull World Health Organ 2001;79:490-500. |
|9.||Waldstein SR. The relation of hypertension to cognitive function. Curr Dir Psychol Sci 2003;12:9-13. |
|10.||Kilander L, Nyman H, Boberg H, Hansson L, Lithell H. Hypertension is related to cognitive impairment: A 20-year follow-up of 999 Men. Hypertension 1998;31:780-6. |
|11.||Waldstein SR, Katzel LI. Hypertension and cognitive function. In: Waldstein SR, Elias MF, editors. Neuropsychology of Cardiovascular Disease. Mahwah, NJ: Erlbaum; 2001. p. 15-36. |
|12.||Jennings JR, Muldoon MF, Ryan CM, Mintun MA, Meltzer CC, Townsend DW, et al. Cerebral blood flow in hypertensive patients: An initial report of reduced and compensatory blood flow responses during performance of two cognitive tasks. Hypertension 1998;31:1216-22. |
|13.||Krishnamoorthy ES, Martin J. Prince and Jeffrey Cummings' Dementia a Global Approach. 1 st ed.: Cambridge University Press; 2010. p. 7,8. |
|14.||Yudofsky SC, Hales RE. The American Psychiatric Publishing Textbook of Neuropsychiatry and Behavioral Neurosciences. 5 th ed.: American Psychiatric Press; p. 124-6. |
|15.||Sohlberg MM, Mateer CA. Effectiveness of an attention-training program. J Clin Exp Neuropsychol 1987;9:117-30. |
|16.||Cicerone KD, Langenbahn DM, Braden C, Malec JF, Kalmar K, Fraas M, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil 2011;92:519-30. |
|17.||Marcus BH, Dubbert PM, Forsyth LH, McKenzie TL, Stone EJ, Dunn AL, et al. Physical activity behavior change: Issues in adoption and maintenance. Health Psychol 2000;19:32-41. |
|18.||Nasreddine ZS, Phillips N, Chertkow H. Montreal cognitive assessment (MoCA). Version 7.2 alternate version. Available from: http://www.mocatest.orghttps://pdbp.ninds, http://www.mocatest.orghttps://pdbp.ninds.nih.gov/assets/crfs/Montreal%20Cognitive%20Assessment%20(MoCA)7_1.pdf. [Last accessed on 2013 Jan 21]. |
|19.||Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke's Cognitive Examination Revised (ACE-R): A brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006;21:1078-85. |
|20.||Sharifi F, Hedayat M, Fakhrzadeh H, Mahmoudi MJ, Ghaderpanahi M, Mirarefin M, et al. Hypertension and cognitive impairment: Kahrizak elderly study. Int J Gerontol 2011;5:212-6. |
|21.||Tsivgoulis G, Alexandrov AV, Wadley VG, Unverzagt FW, Go RC, Moy CS, et al. Association of higher diastolic blood pressure levels with cognitive impairment. Neurology 2009;73:589-95. |
|22.||Qiu C, Winblad B, Fratiglioni L. The age-dependent relation of blood pressure to cognitive function and dementia. Lancet Neurol 2005;4:487-99. |
|23.||Stibich M. Preventing Cognitive Impairment Risk Factors Differ for Men and Women, 2010. Available from: http://www.longevity.about.com/od/mentalfitness/a/cognitive_impai.htm. [Last accessed on 2013 Jan 25]. |
|24.||Swan GE, DeCarli C, Miller BL, Reed T, Wolf PA, Jack LM, et al. Association of midlife blood pressure to late-life cognitive decline and brain morphology. Neurology 1998;51:986-93. |
|25.||Schofield PW, Marder K, Dooneief G, Jacobs DM, Sano M, Stern Y. Association of subjective memory complaints with subsequent cognitive decline in community-dwelling elderly individuals with baseline cognitive impairment. Am J Psychiatry 1997;154:609-15. |
|26.||Goldstein FC, Levey AI, Steenland NK. High blood pressure and cognitive decline in mild cognitive impairment. J Am Geriatr Soc 2013;61:67-73. |
|27.||Kurz A, Pohl C, Ramsenthaler M, Sorg C. Cognitive rehabilitation in patients with mild cognitive impairment. Int J Geriatr Psychiatry 2009;24:163-8. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]