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By Dr Alex Dregan

Do vascular risk factors such as high blood pressure and smoking make us forgetful?

As our bodies start to show the signs of ageing, our brain is naturally ageing too. But some older people can become forgetful and have trouble remembering common words or organising daily activities more than others. There are few proven interventions to prevent this kind of cognitive decline in older adults, although treating modifiable risk factors for vascular disease and stroke, such as cholesterol and body mass index (BMI), has been suggested as a promising approach to preventing or delaying cognitive impairment for a growing UK population of older adults. So is there a link between high blood pressure and forgetfulness?

Despite much recent interest, studies to date have reported inconsistent relationships between blood pressure and cognitive functioning. Evidence suggests that people diagnosed with high blood pressure levels tend to perform more poorly on most domains of cognitive functioning, including memory, learning, attention, and reasoning. However, clinical trials have so far failed to demonstrate that antihypertensive drugs used to lower or control high blood pressure levels are effective in preventing cognitive decline in older adults.  This inconsistent evidence poses a challenge when developing recommendations for the prevention of cognitive ageing.

Cognitive ageing, such as symptoms of forgetfulness, is increasingly seen as the result of the joint effect of several vascular disease risk factors, including high blood pressure, BMI, cholesterol levels, and smoking. However,  the combined influence of these on cognitive decline is less commonly explored among older adults at increased risk of both cardiovascular disease and cognitive decline.

In a recent paper, we looked at Framingham stroke and cardiovascular risk scores (a measure used to assess an individual’s probability of developing stroke or cardiovascular disease over a 10-years period) and investigated their association with cognitive decline in older adults. The study included over 8,000 adults aged 50+ living in private households in England. Participants with the highest risk of future stroke or cardiovascular events, based on their risk factors values, were found to perform more poorly on tests of memory and executive functioning after a four year period. This adds weight to the theory that the combined effects of risk factors for vascular disease and stroke may be associated with more rapid cognitive decline in older adults. In other words, those at greater risk of cardiovascular problems were likely to experience a more rapid onset of symptoms associated with cognitive decline, such as forgetfulness.

We believe that these findings support the need for a multifaceted approach when seeking to prevent cognitive decline. The main implication of this is the need for addressing the combined effect of multiple risk factors, including lowering high blood pressure and high cholesterol levels, weight loss, and stopping smoking. Thus, healthcare professionals should encourage older people to adopt healthy lifestyles that would include stopping smoking and increased exercise (as well as improved diet not investigated here) and taking prescribed medicines aimed at controlling high blood pressure and high cholesterol levels. Such recommendations could potentially prevent or delay future declining memory or reasoning capacities in older adults, particularly those in higher risk groups.

The results also suggest that a harmful effect of high blood pressure on memory or reasoning abilities may develop over a prolonged period of time. This may be one reason why short-term trials have failed to show a consistent benefit from antihypertensive treatment on cognitive decline. For instance, since the negative impact of high blood pressure on memory or reasoning abilities takes place over a prolonged period of time, short-term treatment may not be sufficient to reverse or delay its adverse influence. Therefore, we would expect that any potential cognitive benefits from lowering blood pressure may only be observed over substantial periods of time.

These new results suggest that attention to the combined effects of multiple vascular risk factors may hold some promise as a strategy to prevent cognitive decline in older adults.

Dr Alex Dregan is a Lecturer in Translational Epidemiology within the NIHR Biomedical Research Centre at the Guy’s and St Thomas’ NHS Trust and King’s College London. He trained in Public health at the Institute of Education, University of London. His research interests are in translational epidemiology research as applied to public health. He is co-author of the paper Cardiovascular risk factors and cognitive decline in adults aged 50 and over: a population-based cohort study for the Age and Ageing journal,  and this has been made freely available for a limited time.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

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Numero Uno by Alex Dorros and Arthur Dorros. Illustrated by Susan Guevara. Abrams Books for Young Readers. $16.95.

You know what instantly sounds like an awful idea for a picture book? A father-son writing team. Even worse, a father-son writing team where the son wrote a book when he was twelve and then the dad signed on later and got it made. Sounds icky-sticky sweet without any possible redeeming qualities, doesn’t it? And your mind probably wouldn’t be changed too much if you knew that the author in question was Arthur Dorros of “Abuela” fame either. Even good authors of picture books have been known to be suckered into poor writing decisions at the hands of their darling beloved offspring. But then, what if I told you that the illustrator was Susan Guevara? Which is to say The Great Susan Guevara? The woman who brought Gary Soto’s “Chato” books so swimmingly to life? Certainly you’d be swayed neither way when I told you that the book, “Numero Uno” was a fable, but then you might actually get a chance to pick up and read the book. And in doing so your skepticism would just melt out of your ears, I assure you. Dorros and Son (as they shall hitherto be known) make a pretty good team. Add in a magnificent illustrator and a solid storyline and what once felt like an awful idea for a picture book turns into a fairly swell idea instead.

In a small village in Mexico lived two men of monumental ego. On the one hand was Hercules. He thought himself a pretty primo guy due to his manly physical prowess. On the other hand there was Socrates. He’s scoffed at the notion of muscles, placing his trust entirely in the realm of the cranium. As it happened, Hercules was in the construction business and Socrates the architectural side. So when a bridge needed to be built across the local river, both fellows felt they were of the greatest importance to the villagers. So vehemently did they fight about this that a contest was thought up by a local boy. Both men would leave the village and the people remaining would try to build the bridge without them. Whoever they missed more would be of the greatest importance to everyone. Well that’s all well and good but that means that these two rivals have to spend time together in the wilderness. Bickering all the way, they find food, warmth, and shelter with a combination of brawn and brains, never realizing how much they rely on one another. Inevitably, when they return home they’ve both been equally missed. The bridge is completed with their help and there is at least one thing everyone can agree on. They may have missed their intelligence and strength but when it comes to arguing, nobody missed Hercules and Socrates one little bit.

The writing doesn’t feel like a twelve-year-old came up with it. Obviously Dorros Sr. did some cleaning up in that particular area, leaving a tidy little story in his wake. Spanish words are worked effortlessly into the text, cropping up best where they make the most sense. There’s also enough repetition to keep the story hopping along. The old man in the village often says, “Basta!”. Socrates and Hercules rely mostly on the word, “Yo!” And I can’t help but think that this kind of repetition would make for a pretty good readaloud. Just get half of the kids in the audience to say whatever Hercules says while the other half takes the side of Socrates (the parents or teachers could take the part of the old man). Not only would that make for a more interesting reading, you’d actually get the kids actively interested in who’s going to win the contest. After all, they’re going to believe that they will either end up the winning side or the losing side, as chosen by the book.

I don’t know if I would have immediately have thought that this was a Susan Guevara book if I hadn’t been told. It’s a quieter effort on the artist’s part. Guevara’s paintings for “Numero Uno” don’t have the raw intensity of her Chato books. That’s due in part to the change of location. Instead of gritty city streets and back barrios we’re in the countryside now. According to the bookflap, Ms. Guevara has been studying plein air painting with the Canadian landscape painter Ian Roberts. “Numero Uno”, therefore, gave her a chance to try her hand at capturing hills, valleys, streams, and fields. It’s a quiet cool style that shifts perspective constantly. One moment you see Hercules and Socrates being rowed out onto the river by a clearly jaded young boy. The next we’re soaring high, just above an owl with a world of greens and blues, and yellows stretching away below us. In this particular scene we can also see several different versions of the two men on their own separate paths, trying to reach their destination before the other. Whenever they talk, words leap from their mouths. Of course, being the fellows they are, that usually consists of the “Yo!”, “No!” and “Si!”. Guevara’s is a blotchy style and won’t be to everyone’s liking. For this book, however, it matches the narrative and dialogue just fine.

The moral is nothing new and kids will guess at it long before the self-absorbed heroes do. The ending could have stood a little more oomph, but as it stands this is a lovely little book. Insofar as the human race continues to argue the brains vs. brawn question (and they will) this book will continue to have a lot of cache in the years to come. An worthy addition to any folktale section of libraries, both personal and public.