International Stroke Conference
February 19–21, 2020
Session: “Screening for Cognition and Factors Related to Brain Health,” Thursday, February 20, 2020
Moderators: Dr. Ronald M. Lazar, Birmingham, AL; and Dr. Rebecca F. Gottesman, Baltimore, MD
Abstract: It is increasingly recognized that vascular risk factors promote cognitive decline, both independently and interactively with neurodegenerative disease. Because these risk factors are modifiable, evaluation in the setting of primary care represents a unique opportunity for early detection and treatment.
Shashank Shekhar, MD, MS
The session had four presentations. Dr. Walter N. Kernan Jr. from New Haven, CT, led the first talk on “Evaluating cognition in elderly at primary care.” He explained why primary care is important in recognizing cognitive issues. He went on to explain the spectrum of cognitive impairment, which ranges from subjective, mild cognitive impairment (annual risk of progression?), dementia (annual risk of progression 7%). He then laid out a simple flow chart of evaluating cognition in the primary setting: identifying the 1) signal, 2) case finding, 3) Classification and management. The signal could be in the form of reporting by patient or family, the observation by a physician, or casual inquiry. Case finding refers to using assessment tools such as Memory Impairment screen, MMSE, MOCA, etc., to screen for cognition. The final step is to confirm the diagnosis, identify any treatable causes, identify functional impairment, classify etiology, and further neuropsychiatric assessment.
Dr. Virginia J. Howard from Birmingham, AL, gave the second presentation on “Considerations in cognitive assessment in disparate populations.” Her talk focused on disparities related to sex, age, disability, socioeconomic status, and geographic locations. She identified barriers to recruitment and retention at different levels, i.e., individual to research institutions. She suggested engaging community leaders in the research process and using community outreach programs, and that preparing a realistic budget would greatly help achieve the goal. Changes are also required in the study design, i.e., in-home evaluations, and identifying all levels of influences and barriers at the institution and community would help with more recruitment and higher retention.
In the second section of the talk, Dr. Howard stressed the need for more prospective data with higher cohort retention. She talked about methodological issues such as cognitive assessment, which include the comprehensive nature of the neuropsychological exam, variation in functional competence, cost, and time of the clinical exam. She stressed the need for focused longitudinal studies, which also look at additional risk factors such as environmental factors. She highlighted overcoming linguistic and cultural barriers.
In the third section, Dr. Howard discussed the shortage of ethnic minority neuropsychologists/providers trained in cross-cultured neuropsychology. Here she discussed the main barriers such as limited exposure in graduate school, lack of mentors and funding, etc. She suggested that by early exposure during high school, inviting guest speakers, increasing recruitment of minority students and faculties, and increasing the funding mechanism, more and more of the minority population will be interested in joining as providers and neuropsychologists.
Dr. Sudha Seshadri from San Antonio, TX, gave the third captivating talk on “Modifying cognitive risk factors.” She started with gene-environment interactions. “Things such as neurodegeneration, vascular injury, inflammation, trauma that injures the brain overcome its resilience/reserve,” she said. Brain reserve is higher for a cognitively active population. Dr. Seshadri discussed how good prenatal care, education and nutrition could increase brain reserves. Certain factors like sleep, physical activity, diet, social support, and cognitive engagement are a good measure that could potentially help. She discussed unpublished data to support that a good lifestyle could potentially modify genetic risk. She further discussed the results of a meta-analysis of antihypertensive medications and the risk of incident dementia and Alzheimer’s, and also discussed the SPRINT MIND trial. She showed the result of various studies that showed the benefit of physical activity on brain volume and dementia risk, risk of sugar and artificial sweeteners, circulating metabolites.
She further showed how exercise and social network are neuroprotective by increasing BDNF, and how greater emotional support lowers 10-year risk of dementia by 30%. Dr. Seshadri highlighted some multidomain intervention trials like FINGER, MAPT, and PreDIVA. The results from her own paper from the Framingham study showed that over the last three decades, the incidence of dementia is declining, which could be due to better stroke prevention and treatment. New studies are now testing if using polypills could reduce dementia and reduce cost by better blood pressure control.
Dr. Philip B. Gorelick from Lincolnwood, IL, gave the final talk on “Optimal blood pressure for brain health: lessons from SPRINT MIND.” He first talked about the SPRINT study, which was intensive (Goal SBP<120 mmHg vs. Standard Blood pressure <140mm Hg). The primary outcome was MI, acute coronary syndrome, heart failure and showed 25% reduction (cumulative hazard ratio was 0.75 (95% CI, 0.64, 0.89)); death from any cause showed 27% reduction (HR was 0.73 (95% CI, 0.60, 0.90)). The BP measurement in SPRINT was an average of 3 office readings. One was sitting with back supported, 5 minutes of rest, and no conversation and during rest. The device was automated manometer (Omron healthcare) preset to wait for 5 minutes prior to BP reading. The author suggested following the study protocol because BP may be overestimated if not following the SPRINT format.
The next focus was SPRINT MIND, a randomized controlled trial to study the effect of intensive vs. standard blood pressure control on probable dementia. The study required 3-steps cognitive screening using MoCA, leaning and memory and processing speech evaluations. The results showed the intensive therapy group reduced the risk of probable dementia by 17% (HR 0.83, 95% CI 0.67-1.04, 0.10), but intensive blood pressure control showed statistically significant benefits in secondary outcomes, including a 19% lower rate in mild cognitive impairment (HR 0.81, 95% CI 0.69-0.95, 0.007). The results from MRI volumetric data suggested that intensive blood pressure treatment was associated with a smaller increase in cerebral white matter volume and a greater decrease in total brain volume, but the difference was smaller. A meta-analysis by Ruth Peters et al. published in Neurology in 2019 suggests that blood pressure-lowering on dementia outcomes has an overall relative risk of 0.88 (CI 95% 0.78, 0.98). His talk ended with more open questions. Is it safe to lower BP in a very elderly person? What should be the BP target for patients who have cognitive impairment or diabetes?