Hypertensive and Non-hypertensive Hospital Admission Blood Pressure Association with Cognitive Function in Stroke Patients

ABSTRACT


INTRODUCTION
The prevalence of stroke is estimated at 101 million people worldwide, and deaths due to stroke are estimated at 6.55 million people. 1 According to the Ministry of Health's 2018 Basic Health Research, the stroke prevalence in Indonesia was estimated to be 10.9 per mile, with East Java Province having a stroke prevalence of 12.4 per mile. 2 The stroke mortality rate in 2019 is expected to be 37.0 per 100,000 occurrences, a 6.6% decrease over the previous decade. 3igh blood pressure is a risk factor for strokes.This condition can impair cognitive function by triggering damage to the white matter, microinfarctions, microbleedings, amyloid buildup, and left frontal lobe atrophy of the brain. 4High blood pressure is also known to cause atrophy of the hippocampus. 5A study found that high blood pressure works synergistically with crown amyloid beta (Aβ) and tau in the cerebrum. 6owering mortality rates from stroke is a sign that public health is getting better.This is due to a number of factors, such as fewer cases and deaths, better health services, and better control of risk factors. 7In Indonesia, primary care doctors have a moderate or sufficient level of awareness about acute stroke, as well as good knowledge of how to respond to it. 8troke can induce problems other than death, such as neurological complications, infections, immobility difficulties, pain, psychological complications, and others.Cognitive impairment is one manifestation of psychological complications. 9ccording to the American Psychiatric Association, there are six domains of cognitive function in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), namely perceptualmotor function, executive function, attention complex, social cognition, learning and memory, and language. 10Post-stroke cognitive impairment is a common occurrence in the first year after a stroke, with various degrees of severity and the potential for reversal. 11 study in Scotland found that 36% patients in the hospital had problems such as impaired cognitive function.According to this figure, cognitive function decrease is the most common psychological complications, followed by depression, emotions, and anxiety. 9A cohort study of post-stroke cognitive impairment (PSCI) within 2-6 months after stroke found a frequency value of 44% for decline in general cognitive function and 30-35% for decline in one domain of cognitive function. 12ognitive impairment in stroke is defined as a decrease in function in one or several cognitive domains.The prevalence of decreased functioning varies by domain.Decreased functioning in each domain has a different prevalence. 13Decreased cognitive function in each domain varies in severity. 146][17][18] The MMSE is generally used as a screening tool for patients with mild cognitive impairment (MCI). 16Nevertheless, the MMSE can be used well to diagnose cognitive decline in acute stroke patients. 15n stroke patients, hospital admission blood pressure is one of the factors that influence the probability of successful reperfusion and the patient's clinical condition. 19Blood pressure at hospital admission is also known to be related to the annual medical costs for stroke patients. 20Given the relationship between hospital admission blood pressure and stroke patient condition, it is not impossible that it could be related to stroke patient cognitive function.However, the association between hospital admission blood pressure and cognitive function in stroke patients has not yet been widely discussed.

OBJECTIVE
The objective of this study was to find out if there was a difference in the category of cognitive function measured on the MMSE (Mini-Mental State Examination) between hypertensive and nonhypertensive hospital admission blood pressure stroke patients.Clinically, it could be a consideration to determine the potential value of hospital admission blood pressure as a predictor of cognitive function in stroke patients after the acute phase.

METHODS
This study used a cross-sectional design with a consecutive sampling method to include patients who had an acute stroke in the Seruni A neurological ward at Dr. Soetomo General Academic Hospital, Surabaya, between February and July 2023 and met the inclusion and exclusion criteria.The inclusion criteria were patients diagnosed with stroke, having hospital admission blood pressure data, being willing to take part in the study, and being aged 18 years or more.Exclusion criteria were stroke patients with decreased consciousness, aphasia, and sepsis.
Patients diagnosed with stroke exhibit rapid onset of neurological deficits lasting for over 24 hours and/or have the potential to cause death due to vascular factors, without any other clear cause. 21ospital admission blood pressure data is the systolic and diastolic blood pressure values measured in mmHg units when the patient was first admitted to the hospital for a stroke.Indicating the patient's willingness in the informed consent form serves as proof of the patient's willingness to participate in the research.The patient's identity card's birth date serves as evidence of the patient's age.Stroke patients are classified as having decreased consciousness if their Glasgow Coma Scale score is less than 15 (4-5-6), in order to exclude patients who are unable to complete the MMSE from calculation.Patients are categorized as having aphasia if they experience language problems due to damage to the brain.Patients are diagnosed with sepsis if they meet the Quick Sequential Organ Failure Assessment (qSOFA) criteria.
Assessment of the cognitive function degree with the MMSE was carried out after the acute phase of stroke.The MMSE assessment is carried out in the range of 1-18 days after the onset of stroke.Cognitive function is divided into 3 categories: no cognitive impairment (MMSE 24-30), mild cognitive impairment (MMSE 18-23), and severe cognitive impairment (MMSE <18). 22Hospital admission blood pressure is divided into 2 categories: non-hypertensive and hypertensive (SBP ≥ 130 mmHg and/or DBP ≥ 80 mmHg). 23he analysis of research variable data was carried out using IBM SPSS Statistics 25.The nominalordinal data comparative analysis process was carried out using the Mann-Whitney U test. 24
Data analysis of blood pressure in the form of hypertension or non-hypertension with cognitive function in the form of no cognitive impairment, mild cognitive impairment, or severe cognitive impairment using the Mann-Whitney test revealed no significant difference in cognitive function between hypertensive and non-hypertensive subjects (p = 0.561) (Table 2).

DISCUSSION
According to the findings of this study, the mean age of the patients was 58.38 ± 1.29 years.Male patients had a mean age of 56.10 ± 1.98 years, while females had a mean age of 60.65 ± 1.52 years.These results align with previous studies, which have shown that strokes occur at a younger age in males and at an older age in females. 25,26his study includes 20 male patients (50%) and 20 female patients (50%).Gender-related trends in stroke occurrence are still being debated in the existing literature. 26,27Some studies suggest a higher incidence of strokes in women, while others report a greater tendency for strokes in men. 28,29he mean systolic blood pressure in this study was 150.95 ± 3.27 mmHg.Elevated or decreased systolic blood pressure values in ischemic stroke patients may indicate the potential for unfavourable outcomes, as shown by the U or J graphs. 30,31,32In contrast to ischemic stroke, no association was found between systolic pressure and the clinical status of patients with hemorrhagic stroke. 30Other studies have suggested that maintaining systolic blood pressure below 140 mmHg in hemorrhagic stroke can lead to more favourable outcomes. 33,34n this study, the mean diastolic blood pressure was 89.28 ± 2.68 mmHg.It is important to note that low diastolic blood pressure (less than 70 mmHg) has been associated to a higher occurrence of heart disease and less favourable stroke outcomes, as assessed by the NIHSS. 20Other studies, however, have found that diastolic blood pressure more than 80 mmHg is associated with poor outcomes in cases of ischemic stroke. 35,36he majority of the study subjects (n = 32, n% = 80%) had systolic blood pressure > 140 mmHg or diastolic blood pressure > 90 mmHg when they arrived at the hospital.With these values, blood pressure can be categorized as stage 2 hypertension. 23High blood pressure, especially above 115/75 mmHg, increases the risk of stroke. 37Other studies mention that those aged ≥ 65 years have a higher risk of stroke if their blood pressure is ≥ 160/90 mmHg and ≥ 130/80 mmHg for those under 65 years old. 38n addition to its association with the occurrence of stroke, several studies endeavours have sought to establish a connection between blood pressure and the prognosis of stroke patients.Reduced blood pressure within the initial 24 hours following acute ischemic stroke has been found to correlate with more favourable outcomes, as measured through disability measurements using the Rankin Scale. 39In contrast, in cases of hemorrhagic stroke, achieving lower blood pressure by implementing blood pressure-lowering therapy has been associated to improved disability outcomes as evaluated by the Rankin Scale. 40side from disability, cognitive function is also a concern in stroke cases.Cognitive function is divided into several domains.These cognitive domains serve as the criteria for diagnosing various cognitive function disorders.According to the study, there are four domains: memory, attention, language, and orientation. 41However, the American Psychiatrist Association's DSM-5 defines six domains of cognitive function: complex attention, executive function, learning and memory, language, motor perception, and social cognition. 42he association between blood pressure and cognitive function in stroke patients is still debated. 43n this study, there was no significant difference in cognitive function among stroke patients based on their hospital blood pressure status, whether they were hypertensive or not (U = 93, p > 0.05).These findings are consistent with previous studies showing that blood pressure levels, particularly systolic blood pressure, do not associate with cognitive performance in stroke survivors. 44There is no clear evidence that hypertension lowers cognitive function in middle-aged subjects. 45Another study also found no differences in cognitive function between older adults with and without self-reported hypertension. 46everal factors can make the difference between high and low blood pressure on cognitive function insignificant.The location and severity of the stroke are two factors that can influence cognitive function in post-stroke patients. 47Apart from that, nutritional supplementation influences stroke patient recovery, including cognitive function. 48ge and gender are known to influence the relationship between blood pressure and cognitive function.Higher systolic and diastolic blood pressure was associated to lower cognitive function in men 45 to 55 years old, but not as strongly as it was in men 65 to 74 years old.The same study also found that systolic and diastolic blood pressure were not associated with cognitive function in women aged 45 to 55.However, higher systolic blood pressure was associated to lower cognitive function in women aged 65 to 74. 49 Hormones have a significant impact on cognitive function.Exogenous sex hormones have been shown to improve certain cognitive abilities and may be used as cognitive enhancers.Exogenous estrogen can improve verbal abilities, while exogenous androgen enhances mathematical, visual and spatial abilities. 50here are some significant concerns for future studies into the correlation between blood pressure and cognitive function in stroke patients.During the conduct of comparative statistical tests in this study, subjects were not specifically differentiated or divided into age categories or educational backgrounds.However, the MMSE's assessment of the relationship between blood pressure and cognitive function in older people did not show a significant relation. 51Other studies have found that the length of education can have a positive impact on cognitive function and vice versa, indicating a reciprocal relationship between the two. 52Furthermore, there is a need for cognitive function assessment tools that offer heightened sensitivity and specificity, especially for stroke patients, as well as the ability to account for educational background and age when determining cognitive function outcomes.The MMSE has shown lower sensitivity and specificity compared to memory and executive screening (MES) in detecting subtle cognitive decline. 53

CONCLUSION
There was no difference in the measured cognitive function category on the MMSE (Mini-Mental State Examination) between hypertensive and non-hypertensive hospital admission blood pressure stroke patients.In this research, cognitive function via MMSE scores in stroke patients could not be predicted via hospital admission blood pressure.

Table 1 .
Demographic and clinical information

Table 2 .
Mann-Whitney test between hypertension and non-hypertension with cognitive function