Division of Clinical Geriatrics, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden (M.K., K.P.).
Medical Unit Aging, Karolinska University Hospital (M.K.).
Stroke. 2022 Feb;53(2):444-456. doi: 10.1161/STROKEAHA.121.032614. Epub 2022 Jan 10.
There is robust evidence linking vascular health to brain health, cognition, and dementia. In this article, we present evidence from trials of vascular risk factor treatment on cognitive outcomes. We summarize findings from randomized controlled trials of antihypertensives, lipid-lowering medications, diabetes treatments (including antidiabetic drugs versus placebo, and intensive versus standard glycemic control), and multidomain interventions (that target several domains simultaneously such as control of vascular and metabolic factors, nutrition, physical activity, and cognitive stimulation etc). We report that evidence on the efficacy of vascular risk reduction interventions is promising, but not yet conclusive, and several methodological limitations hamper interpretation. Evidence mainly comes from high-income countries and, as cognition and dementia have not been the primary outcomes of many trials, evaluation of cognitive changes have often been limited. As the cognitive aging process occurs over decades, it is unclear whether treatment during the late-life window is optimal for dementia prevention, yet older individuals have been the target of most trials thus far. Further, many trials have not been powered to explore interactions with modifiers such as age, race, and apolipoprotein E, even though sub-analyses from some trials indicate that the success of interventions differs depending on patient characteristics. Due to the complex multifactorial etiology of dementia, and variations in risk factors between individuals, multidomain interventions targeting several risk factors and mechanisms are likely to be needed and the long-term sustainability of preventive interventions will require personalized approaches that could be facilitated by digital health tools. This is especially relevant during the COVID-19 pandemic, where intervention strategies will need to be adapted to the new normal, when face-to-face engagement with participants is limited and public health measures may create changes in lifestyle that affect individuals' vascular risk profiles and subsequent risk of cognitive decline.
有大量证据表明血管健康与大脑健康、认知功能和痴呆有关。本文介绍了血管危险因素治疗对认知结果影响的临床试验证据。我们总结了抗高血压药物、降脂药物、糖尿病治疗（包括降糖药物与安慰剂比较，强化血糖控制与标准血糖控制比较）和多领域干预（同时针对多个领域，如血管和代谢因素控制、营养、身体活动和认知刺激等）的随机对照试验结果。我们报告称，血管风险降低干预措施的疗效证据有希望，但还没有定论，并且有几个方法学限制妨碍了结果的解释。证据主要来自高收入国家，由于认知和痴呆不是许多试验的主要终点，因此对认知变化的评估通常受到限制。由于认知衰老过程需要数十年的时间，因此尚不清楚在生命晚期进行治疗是否最有利于预防痴呆，但迄今为止，大多数试验的目标人群都是老年人。此外，许多试验没有足够的能力来探索年龄、种族和载脂蛋白 E 等修饰剂的相互作用，尽管一些试验的亚组分析表明，干预措施的成功与否取决于患者的特征。由于痴呆的病因复杂多样，个体之间的危险因素也存在差异，因此可能需要针对多个危险因素和机制的多领域干预措施，预防干预的长期可持续性将需要个性化方法，这可以通过数字健康工具来实现。在 COVID-19 大流行期间，这一点尤其重要，届时需要调整干预策略以适应新的常态，此时与参与者的面对面接触受到限制，公共卫生措施可能会导致生活方式发生变化，从而影响个人的血管风险状况和随后的认知能力下降风险。
