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July2007 Vol.44 Issue:      2 Table of Contents
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Cognitive Dysfunctions and Neuroimaging Findings in Patients with Chronic Cardiovascular Diseases (UAE Sample)

Abd El-Mohsen Y.1, Fakhry H.1, Abou Hagar A.2, Salah M.3, Abou El-Abbas H.4, El Nabawy H.A.5

Departments of Psychiatry, Cairo University1; Neuropsychiatry, Suez Canal University2; Internal Medicine, Qassimi Hospital3; Diagnostic Radiology, Theodor Bilharz Research Institute4, Al Rahba Hospital5

 



ABSTRACT

Executive skills mainly presented by memory may be sensitive to chronic systemic illness. Objectives: The present study is designed to assess prevalence of cognitive problems in patients with chronic cardio-vascular diseases. A trial is made to explore whether cognitive dysfunctions are age related or, due to the effects of superimposed present chronic cardiovascular disease. Methods: 60 patients with chronic cardio-vascular diseases subdivided into two groups composed of 30 elderly cardiovascular  patients (≥65y) and another 30 cardiovascular patients of younger age group 40-60y  were selected. Two control groups of 30 healthy individuals were selected as 15 elder ≥65y and 15 of younger age 40-60y. All groups were subjected to clinical medical and laboratory examination helping physical diagnosis. Psychological assessment by HAMD-17, NPI, MMSE, MTS and CDT were also performed to exclude depression and assess cognitive functions. Patients having cognitive impairment were further evaluated using Hachinski Ischemic Score to classify dementia type. Brain Computed Tomography (CT) was done for all patients groups.  Results: The prevalence of cognitive impairment was higher in elderly with chronic cardio-vascular illness than in elderly without illness (P<0.05). Only MTS showed  statistically significant decline in the younger group of patients than the young control group. Also there were statistically significant decline in the psychological tests scores of the elder than the younger group of patients (P<0.05). Dementia of Vascular type had the highest frequency among elder patient group  (56.7%) compared to (13.3%) in the younger group. Brain CT scan results were useful in the classification of cognitive dysfunction subtypes. Conclusion: Chronic cardio-vascular diseases may increase the possibility of cognitive impairment in old  people, however aging process may have a more important influence on cognitive impairment in the elderly.

(Egypt J. Neurol. Psychiat. Neurosurg., 2007, 44(2): 545-559)

 




INTRODUCTION

 

Increasing age is the only well established risk factor for vascular dementia12. The number of persons above the age of 65 years has increased all over the world since the turn of the century. According to United Nation Statistics; the increase is from 5.4% in 1970 to 6.1% in 1990 and will reach 17.5% in the year 2020. This increase is attributed to improvement in health care services but naturally, the increase in the elderly population will be accompanied by parallel increase in the demands for health care services to deal with various problems associated with old age and to assist maintaining the highest functional level possible3. One of the major causes of disability and dependency is dementia and its prevalence increases with age25. Vascular disease is thought to be the second most common cause of dementia, following Alzheimer's disease7. However, little is known about the elderly in the United Arab Emirates (UAE), a country with both developing country features (as high fertility rate, few elderly with strong traditional cultures) and developed country characteristics (as high-income economy, urbanized population and high growth rate of people aged above 65 years)19.

 

Objectives:

The present study is designed to assess the prevalence of cognitive dysfunctions in UAE patients with chronic cardiovascular diseases. A trial is made to explore whether memory problems are the effect of age factor or of the superimposed present chronic medical illness.

 

SUBJECTS AND METHODS

 

First; an approval from IEC (Institutional Ethics Committee) of the two hospitals from which patients were selected was obtained. Getting a consent of participants in the study from the selected individuals and/or their care takers was also included.

 

Sample Selection:

This study was conducted along a duration of six months (from 1st August 2005 to 31st January 2006). Sixty patients with chronic cardiovascular diseases were the main subjects of the study. They were selected from patients visiting cardiology and medical clinics in two main governmental general hospitals; Kuwaiti Hospital “Sharjah” and “SBG & IBO hospital” in Ras Al Khaima  in UAE. The patients were subdivided into two groups: (group E) composed of 30 elderly cardiovascular  patients and another 30 cardiovascular patients of younger age group (group Y). The control group consisted of 30 healthy individuals with no evident chronic medical illness. Those control groups were selected from the community including: employees in the two hospitals, relatives and friends of patients accompanying them to the clinics. The control group was  further subdivided according to their age into two groups: (group Ec) as 15 elder individuals matched for demographic data with (group E) and (group Yc) as 15 individuals of younger age matched for demographic data with (group Y).

 

Inclusion & Exclusion Criteria:

Patients and healthy controls sharing in the study were selected according to the following criteria: Group (E) included male and female chronic cardiovascular patients whose age was  ≥65 years; while group (Y) included male and female chronic cardiovascular patients with age range from 40 up to 60y. Group (Ec) included male and female healthy elderly people who were ≥65y years, while Group (Yc) included male and female healthy people with age range from 40 up to 60y. Patients with diabetes, hypothyroidism, de-compensated heart disease, pulmonary congestion due to left ventricular failure, chronic renal failure, de-compensated liver disease and megalo-plastic anaemia were excluded from the study, as well as delirious and depressive patients to avoid effect on memory; directly by CNS affection or indirectly by association of mood changes in depressive pseudo-dementia. Clearly diagnosed cases of severe dementia were also excluded.  Patients with past history of psychiatric disorders with or without treatment in the last two years were excluded as well to avoid effects on cognitive functions by either chronic psychiatric illness or psychotropic drugs.

 

Sharing individuals were examined as follows:

1)            Medical and cardiac examination:

All the sharing individuals in the four groups were subjected to the following examinations and investigations [to be able to diagnose their medical condition in groups E and Y, and to exclude presence of any physical illness in groups Ec and Yc]:

§       Thorough history taking with special stress on the onset of their cardiovascular disease, duration and type of medication they were using.

§       A standard clinical examination for all of them with special attention focused on the blood pressure measurement, cardiovascular examination for detecting any murmurs, rhythm disturbance or carotid bruit. Cases with de-compensated heart disease were excluded as cognitive impairment is common among them.

§       Base line routine investigations were done for all sharing subjects including electrolytes, fasting blood sugar, urea and creatinine, liver function tests including total serum proteins, serum albumin, total serum billirubin and liver enzymes (ALT& AST) and finally thyroid function tests. Diabetics, hypothyroids, patients with chronic renal failure or de-compensated liver disease were excluded. CBC including Hb, MCV, WBC, platelet count and ESR were also done and cases of megaloblastic anemia were excluded (to exclude B12 deficiency as a cause of cognitive impairment). Only cases with normal ranges of ESR were selected to join the study; to avoid presence of autoimmune disease with its possible neuro-psychiatric squeale.

§       Standard chest x-ray (PA view) was done for all subjects to evaluate cardiac size and pulmonary vasculature. All selected subjects had clear lung fields and cases with pulmonary congestion due to left ventricular failure were excluded.

§       An electrocardiogram (ECG) was done for all sharing subjects to diagnose any disturbance in the rate, rhythm, intra-ventricular conduction defects, left ventricular hypertrophy or ischemic heart disease denoted by S-T segment or T wave changes.

§       A two dimensional ECHO cardio graphic images of the heart using Siemens MHZ-M30HZ was also performed to evaluate the cardiac chamber size, the valves, the wall motion abnormalities and the ejection fraction (E.F.) where patients with low EF below 35% were excluded.

 

2)            Neurological screening:

Neurological examination was done for all groups to exclude major disabilities which may interfere with cognitive function assessment such as degenerative CNS disorders, speech problems and locomotor disabilities.

 

3)      Psychiatric examination  and psychometric assessment:

Clinical psychiatric evaluation including psychiatric history and mental status examination26 with psychometric assessment was performed for all sharing subjects to rule out cases of delirium and depression as well as severe cases of dementia. Clinical psychiatric diagnosis of cognitive disorders was done according to DSMIV4.

 

Psychometric assessment included:

§           Hamilton Depression Scale (HAMD-17) for exclusion of depression as individuals with scores above 7 were excluded.14

§           Mini Mental State Examination (MMSE) for cognitive function assessment excluding cases of severe impairment with scores less than 20.10

§           Mental Test Score (MTS) was also performed for detailed assessment of cognitive functions (Appendix 1). We used a cut point of score 27 out of 34 (which is the maximum score) to denote cognitive impairment and 25 out of 34 to denote definite dementia.16

§           We also performed Clock Drawing Test (CDT) of Freedman (Appendix 2) to provide a sensitive measure of planning and organization in addition to its visuospatial component. Evaluation ranges from (10-0) and each score is given a definition to help structured evaluation.27

§           The combined form of MMSE and CDT (Appendix 3), as modified by Thalmann B and his colleagues was applied where combined scores falling below 7 points suspect dementia31.

§           Neuropsychiatric Inventory (NPI) (Appendix 4) was used for exclusion of severe cases of dementia scoring more than 48 out of 144.8

 

4)            Neuroimaging:

Brain imaging by CT scan was performed for all groups searching for evidences of volumetric changes, size and location of infarcts9. Both patients and controls were scanned by multidetector CT scanner (MDCT) [Siemens, Somotom Sensation 16] with 5mm slice thickness without I.V. contrast injection in axial plane. The diagnostic CT criteria for Degenerative Dementia is the presence of parietal and temporal cortical atrophy with disproportionate hippocampal volume loss. It predominates in medial temporal and parietal lobes23. On The other hand Ischaemic Dementia has different CT criteria. Multi-infarct Dementia appears as multifocal hypodensities involving the cortical gray matter,subcortical and deep white matter as well as the basal ganglia and pons20,11. Lacunar infarctions are defined as small (≤ 1.5 cm) hypodensities in the deep gray matter, brain stem and deep white matter of the hemispheres supplied by the perforating arteries5. Large infarctions appear as parynchymal hypodensities assuming a larger arterial territory distribution and involving the gray and white matter with loss of interface distinction5.

 

5)      Neurological re-assessment using Hachinski Ischemic Scale:

Sharing individuals having cognitive impairment according to psychometric scales were evaluated further for subtle focal neurological signs which is a mandatory step for their assessment using Hachinski Ischemic Scale which included: unilateral weakness, sensory loss, asymmetric reflexes, or a Babinski sign. Other neurological signs may include primitive reflexes, homonymous hemianopia, pseudobulbar palsy, or a gait disorder22.

Hachinski Ischemic Score (Appendix 5) which may identify the greatest number of patients with “Vascular Dementia” (VaD) in spite of not including neuroimaging criteria. A score of <4 is suggestive of “Alzheimer Dementia” (AD) or other non-vascular causes of dementia, while a score of > 7 is supportive of a diagnosis of “Vascular Dementia” (VaD), a score of 4-7 suggests mixed dementia22.

 

Statistical methods:

Student’s t-test: A statistical test that compares between two population means.  If the calculated t-value is greater than the statistical significance (0.05), then there is no difference between the means of the two groups and if it is smaller than  the statistical significance (0.05), then there is difference between the two groups.

Test of Proportionality: A statistical test that compares between two population proportions.  Statistical analysis was employed accordingly.

Numerical data were presented as mean and standard deviation values. Categorical data were presented as frequencies and percentages.

Comparison between percentages was carried out by applying the critical ratio and significant values were those exceeding 1.96 at the level (0.05).

 

RESULTS

 

Table (1) demonstrates comparison of the demographic data (age, sex and education) of patients and controls in the four groups shows no statistically significant differences between old patients and healthy controls (groups E and Ec) as well as between young patients and healthy controls (groups Y and Yc).

This figure showed that heart disease alone had the highest frequency among patients in group E 14 (46.7%)  vs. 11 (36.7%) patients in  group Y, while hypertension (HTN) alone had the highest frequency among patients in group Y 13(43.3%)  vs. 12(40 %) patients in  group E. However, no statistically significant difference between the two groups regarding types of chronic medical illness were found (P>0.05).

Comparing psychometric assessment of cognitive function for patients  and controls  in the four groups as shown in table (2) revealed significant decline of the scores of MMSE, CDT and the combined form of both MMSE & CDT as well as MTS scores in elder patients in group (E) more than the healthy elder persons in group Ec (p<0.05). Also significant decline of the scores of MMSE, CDT as well as MTS scores in younger patients in group (Y) more than the healthy controls in group Yc is noticed (p>0.05), but the difference in the scores of the combined form of both MMSE & CDT was non-significant between both groups (p>0.05). However, comparing psychometric assessment of cognitive function for patients  in the two groups (E and Y) in table (3) revealed significant decline of the scores of MMSE, CDT and the combined form of both MMSE & CDT as well as MTS scores in elder patients in group (E) more than the younger patients in group Y (p<0.05).

Non-contrast CT scan of the brain showed positive findings in 22 subjects as in table (4). Degenerative changes were observed in 6 subjects (4 in group Ec and 2 in group Y) Ischaemic changes were documented in 16 patients (9 in  group E and 7 in group Y).

MDCT criteria for degenerative changes found were generalized and diffuse cerebral atrophy most severe in temporal lobes with widened sulci and enlarged lateral ventricles. The sylvian fissures and temporal horns of the lateral ventricles were the most severely affected. The disproportionate atrophy of the temporal lobes particularly the hipppocampal formations was the pathognomonic criteria of Alzheimer Disease.

Ischemic changes reflected by white matter hypodensities appeared in 5 patients of group E and 4 patients of group Y in the form of patchy and punctate foci in the subcortical regions displaying low density in the NECT (Non-enhanced CT) or rounded, linear or patchy areas of hypodensity in the corona radiata and centrum semiovale (Fig. 2).

Lacunar infarcts appeared as minute hypodense areas in the periventricular and basal ganglia regions in 2 patients in of group E (Fig. 3) and 2 patients in group Y (Fig. 4).

Larger infarcts appeared  as hypodense areas involving the gray and white matter in 2 patients from group E (Fig. 5) and 1 patient in group Y. However, statistically significant difference was only found between the radiological findings of the younger group of patients (Y) and its control group (Yc) [c.r. was > 1.96].

Table (5) showing the distribution of diagnoses of cognitive dysfunction according to DSM-IV and Hachinski Scale  in the four groups. Mild Neurocognitive Disorder of DSM-IV could be diagnosed in the four groups; while dementia of vascular type had the highest frequency among elder group of patients 17 (56.7%) in  group E compared to 4 (13.3%) in the younger patients in group Y. Alzheimer dementia was diagnosed only among elder control group in 4 (26.7%) of group (Ec).

However, neurological re-assessment of DSM-IV already diagnosed persons using Hachinski scale revealed differences in the distribution of diagnosis of dementia especially regarding Alzheimer and Mixed types in cardiovascular patients in groups E & Y. In the E group there were 19 patients showing cognitive dysfunction according to the psychometric tests and were further classified as 7 (36.8%) vascular, 1(5.2%) degenerative (non vascular) and 11(57.8%)mixed dementia according to Hachiniski Scale. In the Y group there were 9 patients showing cognitive dysfunction according to the psychometric tests and were further classified as 7 (77.7%) vascular and 2 (22.2%) degenerative (non vascular) dementia according to Hachiniski Scale. Seven subjects in group Ec showed cognitive dysfunction according to the psychometric tests and were further classified as 4 (57.1%) degenerative (non vascular) and 3 (42.8%) mixed dementia according to Hachiniski Scale. The 2 subjects in group Ec who showed cognitive dysfunction according to the psychometric tests, were classified as degenerative (non vascular) dementia according to Hachiniski Scale.


Table 1. Comparison of demographic data of patients and controls  in the four groups.

 

Demographic  data

Group (E)                  (n=30)

Group (Ec)    (n=15)

p

Group (Y)    (n=30)

Group (Yc)

(n=15

p

Age (in years):     

٠minimum

٠maximum

٠mean

 ± SD

 

65

79

71.17

4.04

 

65

79

71.20

4.57

 

 

 

0.980

 

 

41

58

49.10

6.04

 

40

75

49.20

5.92

 

 

 

0.958

 

Sex :                      

٠male

٠female

 

19(63.3%)

11(36.7%)

 

8(53.3%)

7(46.7%)

 

0.75

0.25

 

20 (66.7%)

10 (33.3%)

 

9(60%)

6(40%)

 

0.68

0.31

Education:            

٠Illiterate.

٠Read and write.

٠Primary.

٠Secondary.

٠University.

 

12 (40%)

8 (26.7%)

7 (23.3%)

2 (6.7%)

1 (3.3%)

 

6(40%) 4(26.7%)

3(20%)

1(6.7%)

1(6.7%)

 

0.5

0.5

0.59

0.5

0.43

 

6 (20%)

4 (13.3%)

9 (30%) 8(26.7%)

3 (10%)

 

5 (33.3%)

4 (26.7%)

4 (26.7%)

0 (0 %)

2 (13.3%)

 

0.166

0.14

0.603

0.98

0.38

Total

30(100%)

15(100%)

 

30(100%)

15(100%)

 

 

 

 

Fig. (1): Profile of the chronic physical illness of groups E & Y.

Table 2. Comparison of psychometric assessment of cognitive function for patients and controls  in the four groups.

 

Psychometric Test

Group (E)                  (n=30)

Group (Ec)    (n=15)

p

Group (Y)    (n=30)

Group (Yc)

(n=15)

p

MMSE                 

minimum

maximum

mean

± SD

(N=30)

20

28

23.10

2.62

(N=15)

22

27

24.6667

1.7995

 

 

 

0.04

(N=30)

22

29

26.20

2.02

(N=15)

24

30

27.47

2.36

 

 

 

0.068

CDT                      

minimum

maximum

mean

± SD

(N= 25)*

2

10

5.32

2.16

(N= 10)*

7

9

7.70

0.82

 

 

 

0.002

(N=27)*

6

10

9.3

1.04

(N=12)*

7

10

9.17

1.03

 

 

 

0.645

Combined  MMSE & CDT     

minimum

maximum

mean

± SD

(N=25)*

2

10

4.16

1.95

(N=10)*

5

9

7.7

0.82

 

 

 

<0.0001

(N=27)

4

9

8.48

1.22

(N=12)*

6

9

8.00

1.48

 

 

 

0.336

MTS                     

minimum

maximum

mean

± SD

(N=30)

20

30

24.8

3.2842

(N=15)

25

31

28.4

1.8822

 

 

 

0.000

 

(N=30)

25

33

29.77

2.28

(N=15)

28

34

31.33  

1.84

 

 

 

0.018

*Patients included are only those who could do CDT.

    

Table 3. Comparison of psychometric assessment of cognitive function  for patients in groups A & B.

 

Psychometric Test

Group (E)    

(n=30)

Group (Y)   

(n=30)

p

MMSE                 

minimum

maximum

mean

± SD

(N=30)

20

28

23.10

2.62

(N=30)

22

29

26.20

2.02

 

 

 

<0.0001

 

CDT                      

minimum

maximum

mean

± SD

(N= 25 )*

2

10

5.32

2.16

(N=27)*

6

10

9.33

1.04

 

 

 

<0.0001

Combined  MMSE & CDT     

minimum

maximum

mean

± SD

(N=25)*

2

10

4.16

1.95

(N=27)*

4

9

8.48

1.22

 

 

 

<0.0001

MTS                    

minimum

maximum

mean

± SD

(N=30)

20

30

24.8

3.2842

(N=30)

25

33

29.77

2.29

 

 

 

<0.0001

* Patients included are only those who could do CDT.

Table 4. Comparison of the CT findings of patients and controls in the four groups.

 

Brain CT Findings

Group E                  (n=30)

Group Ec       (n=15)

 

c.r.

Group Y

(n=30)

Group Yc

(n=15)

c.r.

+ve  findings:

1. Degenerative changes

2. Ischaemic changes:

 a- white matter hypodense foci

 b- lacunar infarcts

 c- larger infarcts

-ve   findings:

9 (30%)

0 (0%)

9 (30%)

5 (16.6%)

2(6.7%)

2(6.7%)

21(70%)

4(26.7%)

4 (26.7%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

11(73.3%)

0.26

 

 

 

 

 

0.23

9 (30%)

2 (6.7%)

7( 23.3%)

4(13.3%)

2(6.7%)

1(3.3%)

21(70%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

0 (0%)

15(100%)

2.38*

 

 

 

 

 

2.38*

              Total

30 (100%)

15(100%)

 

30(100%)

15(100%)

 

* Significant statistically.

 

 

Table 5. Distribution of diagnoses of cognitive dysfunction according to DSM-IV and Hachinski Scale  in the four groups.

 

Diagnostic approach

Group

(E)                  (n=30)

Group

(Ec)

(n=15)

Group

(Y)

(n=30)

Group

(Yc)

(n=15)

DSMIV                             

§  Mild neurocognitive disorder.

§  Vascular Dementia:

o      Vascular Dementia, uncomplicated.

o      Vascular Dementia with delusions.

o      Vascular Dementia with behavioral disturbance.

o      Vascular Dementia with delusions and behavioral disturbance.

§  Alzheimer Dementia

o      Alzheimer Dementia with delusions.

o         Alzheimer Dementia with delusions and behavioral disturbance.

(N=19)

2

17

6

1

4

6

0

0

0

(N=7)

3

0

0

0

0

0

4

2

2

(N=9)

5

4

4

0

0

0

0

0

0

(N=2)

2

0

0

0

0

0

0

0

0

Hachniski Scale          

§                Vascular dementia

§                Alzheimer  or Non-vascular    dementia

§                Mixed types of dementia

(N=19)

7

1

11

(N=7)

0

4

3

(N=9)

7

2

0

(N=2)

0

2

0

* Hachinski Scale was done only for cases with definite cognitive impairment according to DSM-IV   criteria to classify dementia type.

 

 

Fig. (2)

 

Fig. (3)

 

 

 

 

Fig. (4)

 

Fig. (5)


DISCUSSION

 

This prospective study was designed to investigate cognitive functions in patients with cardiovascular diseases as a risk factor for cognitive impairment in two groups of patients; above and below 65 years and in two healthy control groups matching the age of the study groups. We were more concerned with the age as a risk factor for developing dementia as it is the only well established risk factor for vascular dementia compared to the gender status which remains controversial12.

Cases with de-compensated heart disease were excluded as cognitive impairment was mentioned to be common among congestive heart failure patients32. Also due to the fact that attention underlies performance in virtually all other areas of cognitive functioning26, all sharing subjects were medically examined and investigated for exclusion of all causes of delirium. We also ruled out depression in all sharing individuals because most of literature and researches emphasize on the fact that depression is an influencing factor that is often associated with memory deficits among elderly people2,6,26. As this work was intended to study early cognitive dysfunctions in cardiovascular patients to detect even early unnoticed defects, so severe cases of dementia were excluded. To compensate for the alleged crudeness of MMSE1,2 MTS and CDT were used.

Cognitive impairment was found significantly more in the elder group of patients compared to elder control and younger patients. Similar results obtained by Abd El-Mohsen Y and his colleagues2, who used MMSE to study cognitive functions in chronic physically ill elderly patients. However, this study showed highly significant differences which could be related to many facts. First, heterogeneity in types of physical illness in their study compared to similarities  in our group being all of cardiovascular patients. Also, the use of more elaborative tests as MTS, CDT and the combined form of MMSE and CDT which is mentioned to be sensitive in 80% and specific in 10% of dementia cases31.

As for cognitive impairment in the younger group of patients (Y) and the age matched controls (Yc) comparison revealed variable results on the different tests used in our study. MMSE & CDT together with their combination form showed non-significant differences. These findings might in accordance with the results of Grubb NR et al.13, who found no significant memory impairment in stable persons with prior MI (myocardial infarction). However, the detailed MTS scores used in our study; showed statistically significant difference between the younger patients (group Y) compared to their controls (group Yc) which might be an indication of increased risk in this population later in life as concluded by Whitmer RA et al.33, denoting that midlife cardiovascular diseases are risk factors of dementia in late life.

The significant cognitive impairment in the younger group of patients (Y) compared to the age matched controls (Yc) could be due to the presence of vascular risk factors especially hypertension which was present in 19 (63.3%) of the younger group of patients. Hypertension is the most important remediable risk factor for stroke (especially lacunar infarction) and vascular dementia18. There is substantial evidence to suggest that elevated blood pressure earlier in life is a risk factor for dementia in later life, while late-life cognitive impairment can be associated with normal or low-normal blood pressure28. Thus, blood pressure may be an important early-life predictor of dementia, and control of blood pressure may prevent or delay dementia onset21.

CT scan of the brain was used as an imaging modality to detect any changes in the density of the brain parenchyma. It proved higher incidence of brain abnormalities in cardiovascular patients (nine patients in each group E&Y) compared to their controls (only four in group Ec and no one in group Yc). However, the outstanding findings in CT scanning was observed in the degenerative group where four individuals showed CT criteria of degenerative changes in the older control group (Ec). On the other hand, two of the young patients (Y) showed CT criteria of degenerative changes.

Our data suggests that cardiovascular disorders especially ischemic heart disease and hypertension are risk factors for the development of dementia. This could be explained by (1) the development of vascular dementia, (2) an increase of the burden of cognitive impairment of early Alzheimer type by the development of cerebrovascular insults due to the presence of risk factors as explained by Snowden DA et al.29, who studied pathologically proven cases of AD and found that the prevalence and severity of dementia was increased in cases with cerebral infarcts as compared to those without infarction. Hoffman A, et al(15)suggested that several factors might play a role in the interaction of these two disease processes as sharing common risk factors e.g. increase of atherosclerosis in both conditions. On the other hand, vascular and degenerative pathology may interact leading ultimately to cognitive decline.

Both groups of patients (E & Y) had statistically significant cognitive impairment compared to their controls (Ec & Yc). Ischemic heart disease was present in more than half the sample 18 (60%) in elder group (E) and 17(56.7%) in the younger group (Y). This finding could be explained by the fact that ischemic heart disease is strongly associated with atherosclerosis in cerebral and peripheral arteries and thus may be another marker of the generalized and severe nature of atherosclerotic disease. Ischemic heart disease may also play a causative role in stroke, generally in the form of thromboembolism. Also, the gradual development of collateral circulation is an important protective mechanism for the brain against cerebral infarction. Hypotension from reduced cardiac output can render these anastomotic channels ineffective, thereby functionally removing this protective collateral supply. Possibly, the presence of heart disease in these patients played such a role24. Another explanation was mentioned by Sparks DL et al.30, as they found that non demented patients dying with or as a result of critical coronary artery disease had more abundant senile plaques compared with subjects without heart disease.

The debate in classification of dementia was clear using two disciplines for diagnosis DSM-IV and Hachiniski scale. Neurological re-assessment of DSM-IV already diagnosed persons using Hachiniski scale revealed differences in the distribution of diagnosis of dementia especially regarding Alzheimer and Mixed types in cardiovascular patients in groups E & Y. This is because of the criteria in DSM-IV denoting that the presence of cerebrovascular disease in a demented individual paradoxically excludes the diagnosis of Alzheimer and instead the condition is classified as Vascular Dementia. This was already criticized by JC de la Torre17, who mentioned that this differentiation have been based on expert opinion rather than a critical review of the scientific evidence and moreover considered AD as a vascular disorder initiating its pathology through cerebral microvascular abnormalities. This might explain the presence of the degenerative changes in f our cardiovascular patients as proven in neuroimaging by brain CT (2 patients in group Y).

The significant decline of all psychometric scores in patients in group (E) more than the healthy elder persons in group Ec (p<0.05) and the significant decline of the scores of MMSE, CDT as well as MTS scores in younger patients in group (Y) more than the healthy controls in group Yc (p>0.05) suggests that chronic cardio-vascular disease may increase the possibility of cognitive impairment. However, significant decline of the scores of MMSE, CDT and the combined form of both MMSE & CDT as well as MTS scores in elder patients in group (E) more than the younger patients in group Y (p<0.05)may be ushering to the increased importance of the aging process as a causative factor for this impairment.

Although neuroimaging by CT brain documented radiological findings in a similar number of  patients in both patient groups E (9 patients showing ischemic changes) & Y (9 patients; 7 of them had ischemic changes and 2 had degenerative changes); but still  the results of  psychometric assessment as well as Hachiniski Scale scores supports more evidences for importance of aging more than cardiovascular illness in affecting cognitive functions. However, further researches in the field using functional neuroimaging techniques are recommended to detect early functional pathological findings even before anatomical changes take place.

 

Conclusions:

Our data suggests that cardiovascular disorders especially ischemic heart disease and hypertension are risk factors for the development of dementia. As both groups of patients (E & Y) had statistically significant cognitive impairment on psychometric tests compared to their controls (Ec & Yc). However, cognitive impairment was found significantly more in the elder group of patients compared to younger patients.

Cardiovascular disease may be an important early life predictor for dementia. It is at least partially preventable and treatable. So, increasing awareness of this association may decrease the incidences of developing dementia later in life. Aging process may be more important than correlated negative effects of chronic cardiovascular disease on cognitive functions of the elderly.

APPENDICES

 

Appendix (1):

Mental Test Score (MTS) is a test for assessment of mental impairment composed of 28 items covering the same aspects of MMSE but in more elaborating detailed manner both in the tested items and its significance in scoring.16

 

Appendix (2):

Clock Drawing Test (CDT) of Freedman is another informative test that is widely used to provide a surprisingly sensitive measure of planning and organization in addition to its visuospatial component. In a standard manner; a patient is offered a single sheet of unlined paper and asked to draw a clock, put all the numbers on the clock and set the time needed (written as on board). Evaluation ranges from 10 (best) to 0 (worst); 10-6 means that drawing of clock face with circle & numbers is generally intact. Each score (10-0) is given a definition to help structured evaluation27.


 

Appendix (3): Combined form of MMSE & CDT.

 

Scoring Criteria                                                                                               Weights

MMSE ≥ 27?                                                                                                        3

CDT

    1.         Is the number "12" at the top?                                                                    3

    2.         Are exactly 12 numbers present?                                                                 1

    3.         Are there two distinguishable hands?                                                          1

    4.         Did the subject read the time correctly?                                                      1

    Maximum                                                                                                          9

Interpretation

0–6 points  Dementia should be suspected; referral to specialist is recommended.  7-9  points  Unless clinical judgment indicates a suspicion of dementia, no comprehensive evaluation is necessary at this time.

Note: CDT= Clock Drawing Test; MMSE= Mini Mental State Examination.31

 


Appendix (4):

Neuropsychiatric Inventory (NPI) is a relatively brief interview assessing 10 behavioral disturbances: delusions; hallucinations; dysphoria; anxiety; agitation/aggression; euphoria; disinhibition; irritability, lability; apathy and aberrant motor behavior. It is used as screening strategy distinguishing severity of cases of  dementia.8


Appendix (5):22

    Hachinski Ischemic Score

Abrupt onset

Stepwise deterioration

Fluctuating course

Nocturnal confusion

Relative preservation of personality

Depression

Somatic complaints

Emotional incontinence

History of hypertension

History of strokes

Associated atherosclerosis

Focal neurological symptoms

Focal neurological signs

   Maximum score

·       Vascular range

·       Mixed range

·       Degenerative range

2
1
2
1
1
1
1
1
1
2
1
2
2

18

·         7 - 18

·         5 - 6

·         0 - 4

            

 


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الملخـص العربى

 

القدرات المعرفية ممثلة في الذاكرة حساسة للأمراض المزمنة

 

الهدف من الدراسة : تم تصميم هذه الدراسة لاستبيان مدى انتشار قصور القدرات المعرفية ضمن حالات أمراض القلب والدورة الدموية المزمنة.تم أجراء استكشاف عما إذا كان القصور في القدرات المعرفية مرتبط بالسن أو ناتج عن تأثير مرض القلب والدورة الدموية المزمن. اجري البحث على 60 مريض قلب مزمن تم تقسيمهم إلى  مجموعتين حسب السن إلى مرضى مسنين (> 65 سنة) 30 مريض و الأصغر سنا (< 65 سنة) 30 مريض.تم اختيار مجموعتين من الأصحاء (15 مريض لكل مجموعة) من نفس المجموعات السنية للمرضى للمقارنة. تم فحص جميع المشاركين إكلينيكيا مع التحاليل اللازمة لتأكيد التشخيص .تم إجراء القياسات النفسية بواسطة مقياس هاملتون و NPI و  MMSEو CDT و MTS لاستبعاد حالات الاكتئاب وقياس القدرات المعرفية لدي المرضى. تم تصنيف المرضى المصابين بقصور في القدرات المعرفية بواسطة مقياس Hachinski لتصنيف خرف الشيخوخة. تم إجراء فحص الأشعة المقطعة للدماغ لكل المرض.

 

أظهرت النتائج الاتى :

·                     انتشار القصور في القدرات المعرفية في المسنين  المصابين بأمراض القلب بالمقارنة مع المسنين الأصحاء.

·                     انتشار القصور في القدرات المعرفية في المرضى المسنين بالمقارنة مع المرضى الأصغر سنا.

·                     اظهر اختبار MTS  تأثر القدرات المعرفية في المرضى الأصغر سنا  بالمقارنة بالأصحاء الأصغر سنا . 

·                     زيادة معدل الإصابة بخرف قصور الدورة الدموية في المسنين (56.7%) بالمقارنة مع المرضى الأصغر سنا (13.3%).

 

من ذلك نستنتج زيادة معدل إصابة مرضي القلب بقصور في القدرات المعرفية مع التأكيد بدور عامل التقدم في السن بالتأثير على تلك القدرات.



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