Abstract
Objectiveaims of the current study were 1) to evaluate global cognitive function in patients with autonomic failure (AF) of peripheral origin and 2) to investigate the effect of a documented fall in blood pressure (BP) fulfilling the criteria for orthostatic hypotension (OH) on cognitive performances.Methodswe assessed 12 consecutive patients (10 males, 68±7 years old) with pure AF (PAF) or autoimmune autonomic neuropathy (AAN) and 12 age- and gender-matched controls. All patients had no clinical signs of central nervous system involvement and normal brain CT/MRI scan. Cognitive function was assessed on two consecutive days in 3 conditions: on day 1, while sitting, by means of a comprehensive battery of neuropsychological tests; on day 2, while tilted (HUT) and during supine rest (supine) in a randomized manner. BP and heart rate (HR) were continuously recorded non-invasively for the whole duration of the examination.Resultspatients with PAF or AAN displayed a preserved global cognitive function while sitting. However, compared to supine assessment, during HUT patients scored significantly worse during the Trail Making Test A and B, Barrage test, Analogies test, Immediate Visual Memory, Span Forward and Span Backward test. Pathological scores, with regard to Italian normative range values, were observed only during HUT in the Barrage test and in the Analogies test in 3 and 6 patients respectively. On the contrary, in healthy controls, results to neuropsychological tests were not significantly different, during HUT compared to supine rest.Conclusionsthese data demonstrate that patients with PAF and AAN present a normal sitting global cognitive evaluation. However, their executive functions worsen significantly during the orthostatic challenge, possibly because of transient frontal lobes hypoperfusion.
Highlights
IntroductionOrthostatic hypotension (OH) is defined as a systolic blood pressure (SBP) fall of at least 20 mmHg or a diastolic blood pressure (DBP) fall of at least 10 mmHg within 3 min of standing or head-up tilt (HUT) to at least 60u [1].Previous cross-sectional studies reported an association betweenOH and cognitive decline in various conditions, including central neurodegenerative disorders with autonomic failure (AF) [2,3,4].prospective studies failed to demonstrate that OH was a risk factor for cognitive decline, possibly because of the confounding effects of age, concomitant disorders, medications, cerebrovascular or neurodegenerative processes [4,5,6].Data on cognitive function in peripheral autonomic disorders, rare conditions characterized by AF without central nervous system (CNS) involvement, are scant
In a preliminary non-randomized study based on 10 patients with central and peripheral causes of autonomic failure (AF) we demonstrated that, despite a normal sitting global cognitive evaluation, our patients presented a significant worsening of global and executive cognitive functions during head-up tilt (HUT) [9]
Patients were classified as pure AF (PAF) on the basis of symptoms associated with Orthostatic hypotension (OH), of results of cardiovascular reflexes and negative cerebrospinal fluid (CSF)
Summary
Orthostatic hypotension (OH) is defined as a systolic blood pressure (SBP) fall of at least 20 mmHg or a diastolic blood pressure (DBP) fall of at least 10 mmHg within 3 min of standing or head-up tilt (HUT) to at least 60u [1].Previous cross-sectional studies reported an association betweenOH and cognitive decline in various conditions, including central neurodegenerative disorders with autonomic failure (AF) [2,3,4].prospective studies failed to demonstrate that OH was a risk factor for cognitive decline, possibly because of the confounding effects of age, concomitant disorders, medications, cerebrovascular or neurodegenerative processes [4,5,6].Data on cognitive function in peripheral autonomic disorders, rare conditions characterized by AF without central nervous system (CNS) involvement, are scant. Patients and controls underwent neuropsychological assessment on 2 separate days in 3 different conditions: first, while seated, by means of the Brief Mental Deterioration Battery (BMDB), Word and Semantic Fluency and the Stroop Color Word Test, to evaluate global cognitive function [11,12,13]; the day after, by means of a selection of neuropsychological tests during supine rest (supine) and head-up tilt (HUT) to assess the effect of OH on attention and executive function These tests were selected, on the basis of our previous experience [9], in order to reduce the time needed for this evaluation and made it feasible for our patients during the HUT. This selection included the Digit Span Forward and Backward for immediate and working memory, Barrage test for visual search function, Immediate Visual Memory for visual memory, Analogies test for verbal abstract thinking, Trail Making
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