Relationship Between Neurocognitive
Profile and Cardiovascular Risk Factors
María de la P Scribano-Parada1,2*, María del C Baez1, Ariel Balceda1, Mariana D Tarán1, Carla Buonanotte2, Sergio Blencio1, Federico Buonanotte2 and Mónica Moya1
1 Cátedra de Física Biomédica, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina
2 Cátedra y Servicio de Neurología, Hospital Nacional de Clínicas, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina
Submission: October 26, 2018; Published: January 16, 2019
*Corresponding author: María de la Paz Scribano Parada, Cátedra de Física Biomédica, Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina. Santa Rosa 1085. Bº Alberdi. Córdoba, Córdoba, Argentina
How to cite this article: María P S P, María C B, Ariel B, Mariana D T, Carla B, et al. Relationship Between Neurocognitive Profile and Cardiovascular Risk Factors.
J Cardiol & Cardiovasc Ther. 2019; 12(5): 555848. DOI: 10.19080/JOCCT.2019.12.555848
Introduction Relationship between Cardiovascular Risk Factors (CVRF) and Neurocognitive Disorders (ND) is important, since the first are modifiable. It was studied the influence of cardiovascular risk factors in the neurocognitive profile.
Patients and Methods: Transversal analytic prospective study. Patients attended by cognitive symptoms were included. CVRF were recorded. According to Montreal Cognitive Assesment (MoCA) (cutoff of 26 points) two groups were made: Without cognitive disorder (NoCD) and cognitive disorder (CD). Cognitive Domains (CD) were evaluated. Risk groups were established (No CVRF, 1 CVRF, 2 CVRF, 3 or more CVRF). The relation between risk groups with invidual cd and with CD and noCD groups, was established. Chi Square for attributes. ANOVA and Kruskal-Wallis for differences between groups, significance level p<0.05.
Results: 66 patients (female 57/86%). Age 63.7±16 years. Most prevalent CVRF: physical inactivity, hypertension, smoking. MoCA average of 20.91±5.78. The CD group (n=48) received lower score in MoCA and worst performers in every cd. Groups 2 and 3CVRF able worst performance, and visuospatial/executive function were the most affected.
Conclusion: People over 65 years with increased cardiovascular risk, have poorer cognitive performance. The factors with the greatest implication would be female, age, years of schooling and summation of cardiovascular risk factors. The cd most affected are visuospatial and attention.
The advance of the medicine of last century has had its consequences to epidemiological level favoring to population aging. In this context it is that the neurocognitive disorders have acquired great importance [1,2]. The Neurocognitive Disorders (NCD) is a syndrome, which includes different entities. According to global statistics the dementia duplicates its frequency every 5 years from the 60, coming to 30-40% in the major ones of 85 years old affecting more than 35 million persons in the whole world, being Alzheimer’s Disease (EA) the most frequent reason followed by the NCD of vascular causes [1-3]. In Argentina the prevalence of dementia in general is estimated in 12.18 % in subjects major of 65 años . The NCD refers to a cognitive significant decline compared with the previous level of performance in one or more cognitive domains. The cognitive deficits must interfere with the Activities of Daily Living (ADL). It is necessary to reject a confusional syndrome and/or a mental disorder (for example:
major depressive disorder, schizophrenia, etc.,) as reasons of the
symptoms [1-3,5]. At present there are no effective treatments to confront the NCD. Because of that for the last years has been done special emphasis to its prevention. Inside the risk of factors mentioned for the development of the cognitive problems it finds hypertension (HBP) diabetes (DBT), dyslipidemia, smoking, sedentary lifestyle, low socioeconomic status, low educational level among others.
The recent finding of the relation between the cardiovascular risk factors (CVRF) and the NCD has provoked special interest since these are potentially modifiable factors. With the aim to recognize the relevancy of these factors population studies began in different parts of the world as United States [6-14], United Kingdom [15-18], Sweden , España [20,21] between others. Therefore, the purpose of the present work is to study the relationship between the neurocognitive profile and the cardiovascular risk factors in outpatients who consult for cognitive symptoms in our population.
1. Describe the demographic variables: sex, age, level of
education, marital status.
2. Detect the presence or absence of cognitive impairment
from an appropriate test.
3. Analyze the differences in performance in the different
neurocognitive domains (visuospatial/executive function, delay
memory, language, identification, abstraction) in patients with
and without cognitive impairment.
4. Establish the prevalence of CVRF (DBT, HBP, Dyslipemia,
sedentary lifestyle, smoking) in the patients studied.
5. Define the relationship between performance in different
neurocognitive domains and the presence of cardiovascular risk
A prospective, descriptive cross - sectional study was carried
out with patients who spontaneously attended the Clinical
Neurology Service of the National Hospital of Clinics for 12
months from March 2014 to March 2015. We included all subjects
who agreed to participate in the study voluntarily after being
properly informed about it and signing a standard informed
consent, approved by the hospital ethics committee. At all times
the fundamental principles laid down in the Helsinki declaration
The information was collected in a form that included the
personal and demographic data of each subject, the antecedents
that could constitute a risk factor for the development of vascular
cognitive impairment: hypertension, DBT, dyslipidemia, smoking,
sedentary lifestyle . The DBT was defined from the antecedent
manifested by the patient or accompanying family member, or the
use of oral antidiabetic drugs or insulin or both, or information
recorded in the clinical history by competent professional [23-25].
The presence of hypertension was defined according to what
was reported by family or patient, the use of antihypertensive
medication, or diagnosis certified by a medical professional in the
clinical history [3,26].
Dyslipidemia was defined as cholesterolemia values greater
than 200 mg/dL, low density lipoprotein (less than 40 mg/dL in
men or, less than 50 mg/dL in women) or triglycerides greater
than 150 mg/dL or use of lipid-lowering drugs, or diagnosis
supported by medical history [2,23]. Performing physical exercise
in the previous year was assessed through the clinical interview
defining as “sedentary” those individuals who performed less
than 30 minutes daily of regular exercise and/or less than 3 days
a week [27,28]. It was considered that the patient was smoker
when the answer to the question: Do you smoke? was affirmative
[28,29]. A neurological clinical examination was performed,
which included a cognitive impairment test through the Montreal
Cognitive Assesmen (MoCA), which has a maximum score of 30
points [22,30]. Based on the results of the application of this test,
and taking into account a cut-off point of 26 points, the following
groups were formed: Group A: Patients without cognitive
impairment (NoDC); Group B: Patients with cognitive impairment
(CD). In each group, individual scores were evaluated for each
of the cognitive domains evaluated by the MoCA, which are:
Visuospatial/executive function (0-5 points), Identification (0-3
points), Attention (0-6 points), Language (0-3 points), Abstraction
(0-2 points), Deferred memory (0-5 points) and Temporospatial
orientation (0-6 points). In both groups, the relationship between
the performance in the tests performed and the presence of the
CVRF above mentioned was established.
The comparison between means was carried out using the
Student test, for the quantitative data. The attributes variables
will be analyzed by Chi square test. We used the ANOVA test and
the Kruskal-Wallis test to find differences between the groups.
The INFOSTAT 2014 program was used. A significance level of p
<0.05 was established.
Sixty-six patients were evaluated, predominantly female
(86%, n = 57). The mean age was 63.69 ± 15.91. The mean of years
of schooling was 8.65 ± 5.25. With a high percentage of patients
with less than 12 years of schooling (73%). Most of the patients
were married (55%, n = 55), while 32% (n = 21) were widowed
and only 14% were single (n = 9).
Regarding the presence of cardiovascular risk factors (Figure
1), sedentary lifestyle (73%; n=48) and hypertension (50%; n =
33) were the most frequent in the group of study. DBT was the
situation that obtained the lowest percentage (18%, n = 12).
Regarding the central tendency indices of MoCA test obtained by
the patients studied, it can verify that the media score and the
median for the same are close, standing at a value of 20.91 and
22 respectively. Patients studied express values between 8 and 30
points, being the maximum score for this test of 30. Regarding the
dispersion of the sign can say that the pointers oscillate between
values of variance and the deviation is 32.90 and 5, 78 respectively.
The data presented previously are reflected in Figure 2, which
shows the distribution and function of the variable cognitive
impairment measured by the MoCA test (Figure 2).
Taking the cut-off point of the test of 26 points, the patients
were separated into two groups: Cognitive Impairment (CI) and
no cognitive impairment (NoCI), forming the first group with
those who obtained 25 points or less. The results could be seen
in the Table 1. The demographic factors that were associated with
NCD were female (OR = 7.50, CI = 1.77- LS = 31.73, p = 0.0043), low
educational level (p = 0.0002) and widowhood (p = 0.011). In the
linear regression analysis, a decrease of 2,44 points in the MoCA
test was observed for each less years of schooling (p = 0.0005). In
the analysis of the cognitive domains evaluated by the MoCA test
it can be seen that the CI group obtained lower scores in all the
explored domains. However, the difference was not significant for
the orientation domain Table 2.
When these values were compared with cardiovascular risk
factors, it was observed that patients with 3 or more CVRF were
the ones that obtained the lowest scores in all cognitive domains
(Table 2). These differences between groups were significant for
all domains except for orientation and delayed recall. Performance
in the different cognitive domains is affected more by the sum
of the risk factors than by the presence of one individual, since
patients with a single risk factor obtained the highest scores in
each individual domain than those without any risk factors (Table
2). Orientation and delayed recall did not seem to be affected the
by the presence of cardiovascular risk factors and did not have
significant results (Table 2).
By associating the presence of risk factors with the overall
performance in the test, a strong association between NCD and
CVRF is observed as can be seen in Figure 3. The group with
cognitive impairment presented 36 patients who presented 2 or
3 or more CVRF, whereas the group without cognitive impairment
did not have patients with 3 or more CVRF. These differences were
statistically significant (p = 0.0028) (Figure 3).
According to the results obtained, patients older than 65 years
with a history of cardiovascular disease are related to a lower
cognitive performance when there are no clinical manifestations
of cerebrovascular disease. The factors that would have the mayor
imply would be sex, age, years of schooling and the sum of CVRF.
The most affected cognitive domains are visuospatial functions
and attention, while orientation does not appear to be influenced
by any of the factors aforementioned. The patients evaluated in
this study had similar age averages and gender distribution as
the observations in other studies [1-4,26,31]. The relationship
of these factors to the NCD was maintained according to the
literature: age, low educational level, widowhood and female sex,
predispose to the development of NCD [6,24,29]. Regarding the
prevalence of CVRF, DBT was not frequently presented in contrast
to what was observed in other studies, whereas hypertension was
present in half of the patients studied. However, research has also
found that CVRF, especially HBP and DBT, already have effects on
cognition in adults of that age range [1,3,26,15,32-34]. The high
prevalence of sedentary lifestyle coincides with the latest records
on chronic non-communicable diseases in Argentina where it was
detected that up to 75% of the population did not practice any
physical activity in the regular way or in the inadequate way .
In the sample studied only 23% of the patients were active
smokers but the figures for the population in Argentina provide
higher data. Chronic exposure to tobacco causes atherosclerosis
and subsequent hypertension. The relationship between smoking
and negative changes in the Mini-Mental State Examination
(MMSE) was evaluated in the European Community Concerted
Action Epidemiology of Dementia (Eurodem) study, and a
significant decrease in MMSE was found in subjects who smoked
against non-smokers. This is why it is currently recognized as a
risk factor for cognitive impairment [23,29,36]. Dyslipemia was
present in 41% of the patients studied, and although it was not
part of the formal registry, most of the patients did not receive
adequate treatment or complete with an appropriate diet. hypercholesterolemia increases the formation of amyloid beta,
increasing the formation of the amyloid precursor protein. In
addition, it favors the conversion of fibrillar amyloid beta to the
formation of neuritic plaques, for that reason the importance of
its control [1,2,26]. Regarding the cognitive performance of the
patients, 72% (n = 48) presented poor performance in the applied
test. The patients studied in the CI group had lower scores in all
cognitive domains compared to the control group. The domains
of visuospatial/executive function and language were the most
severely affected, while in orientation they obtained very similar
scores and the differences were not significant. By contrasting the
performance in the different domains in the different risk groups
we see that the scores do not follow the expected pattern, and that
the group with a single risk factor scored higher than the group
without risk factors.
This is probably due to the fact that these groups were very
homogeneous in terms of years of schooling (No CVRF: 11.33 ±
6.03, 1 CVRF 10.00 ± 6.00), and sex. But a more in-depth analysis
specifically assessing which risk factor is involved would have
been enriching at this point. However, the study design that valued
these as categorical variables does not allow this type of analysis
to obtain values with the necessary precision. In a Spanish study
the comparison between the low, mild and moderate risk groups
indicated that the moderate risk group was the only one that
showed cognitive differences, similarly to what occurred with
group 1 CVRF in the present study. In this study, performance
in visuoconstructive functions in moderate risk group was
significantly lower with respect to the low risk group. As in our
study for group 1 CVRF, a small number of patients were also
observed for the moderate risk group (n = 10) .
However, for the groups with 2 or 3 or more risk factors the
difference was clear, they showed low performance in all domains,
low level of schooling and means of age higher than the other
groups which would demonstrate that the effect of the CVRF
would seem to be more sensitive to the sum of these. Finally, when
assessing the global cognitive function and contrasting the NoCD
and CD groups with the different risk groups, it is observed that the
CD group is composed mainly of patients with more risk factors,
and the relationship of these was significant in the same way
observed in different population studies. In our country, studies
that systematically investigate the relationship between NCD and
CVRF have not yet been performed. In Spain, a small study was
carried out on 90 people, in which cardiovascular risk was assessed
through the REGICOR scale (validated Framingham score for the
Spanish population) and cognitive redemption. This study showed
that at a higher cardiovascular risk, the most affected functions
were visuoconstructive and psychomotor speed/coordination
similar to what occurred in the sample [32,33]. In the Framingham
cohort study the alterations were also seen in visuospatial
memory, organization and tracking, attention, concentration
and abstract reasoning. In ELSA (English Longitudinal Study of
Aging) study carried out in the United Kingdom, however, they
do not coincide with the results of the previous studies nor with
the present work since it refers alterations in verbal memory,
semantic verbal fluency, processing speed and general cognitive
functioning this may be due to differences in the composition
characteristics of the samples in terms of age, sex, and sample size,
which could modify cardiovascular risk patterns [32,33,37,38].
In Framingham and ELSA studies, participants were 50 years or
older. In addition, these studies did not exclude people with mild
cognitive impairment, which may have overestimated cognitive
However, it is common in most studies that visuomotor
function is most affected. This is the ability most closely related to
the integrity of the cerebral white matter. Cerebral white matter
is particularly susceptible to cerebral hypoperfusion. Probably,
the negative effect of CVRF on the integrity of the cerebral white
matter would be the pathophysiological mechanism involved. In
the DBT microvascular involvement, the proinflammatory state
leading to endothelial dysfunction and the presence of oxidative
stress and alterations in the metabolism of amyloid beta and tau
protein would be the mechanism that would bind the presence
of NCD [1,2,23,24,32,33]. While in the hypertensive patients the
increase of the atherosclerotic load alters the cerebral flow which
accelerates the degeneration due to an inefficient metabolism.
The lesions occur mainly in the white matter in neocortex and
hippocampus. This has been associated with hippocampal and
tonsillar atrophy predisposing to the development of NCD type
Alzheimer’s disease [32,37,38]. A follow-up of the cognitive state
with larger sample size would allow us to evaluate if this group of
patients produces a higher incidence of cognitive impairment and
dementia in the medium and long term, when comparing different
risk groups and other variables [39-42]. This work supports
the current recommendations that emphasize that adequate
prevention in low-risk cardiovascular groups would decrease the
incidence not only of cardiovascular events but also of NCD.
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