Chronic Pain & Management (ISSN: 2576-957X)

Article / research article

"The Association of Beta-Blocker Use to Cognitive Impairment among Adults with Hypertension or Cardiovascular Diseases in the United States"

Fnu Safarudin1,2*, Chibuzo O. Iloabuchi1, Amit Ladani3, Usha Sambamoorthi1

1Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, WV, USA

2Department of Pharmacy, School of Mathematics and Natural Sciences, Tadulako University, Central Sulawesi, Indonesia

3Department of Medicine, Section of Rheumatology, School of Medicine, West Virginia University, WV, USA

*Corresponding author: Fnu Safarudin, Department of Pharmaceutical Systems and Policy, West Virginia University School of Pharmacy, Robert C. Byrd Health Sciences Center [North], P.O. Box 9510 Morgantown, WV, 26506-9510, USA

Received Date: 30 April, 2020; Accepted Date: 25 May, 2020; Published Date: 01 June, 2020

Abstract

Background: Some studies have shown that beta-blocker use is associated with better cognitive impairment. However, these studies did not control for pain. The relationship between pain and cognitive impairment has been exhaustively investigated. The association of beta blockers to cognitive impairment in the presence of chronic pain is still unknown.

Objective: To examine the independent association of beta-blocker use to cognitive impairment among adults with hypertension or Cardiovascular Diseases (CVDs).

Methods: We used a cross-sectional study design. We derived data on 8,279 adults from the 2015 Medical Expenditure Panel Survey (MEPS). Study participants were adults (age ≥ 21 years), with hypertension or CVDs and without intracranial injury, Parkinson, Alzheimer’s disease and Related Dementia. Cognitive impairment was measured based on 1) confusion or memory loss; 2) problems making decisions, or 3) supervision for participant’s safety. Anti-hypertensive medications were categorized into 1) beta-blockers; 2) other anti-hypertensives; and 3) no antihypertensive medication. We used multivariable survey logistic regressions to examine the association between beta-blockers and cognitive impairment after controlling for biological factors, pain, chronic conditions, socioeconomic status, access to healthcare services, behavioral, socio-cultural and external environmental factors.

Results: Overall, 24.2%, 41.9%, and 33.9% reported using beta-blockers, other antihypertensives, and no antihypertensive medications, respectively; 18.1% participants reported cognitive impairment. After controlling for pain, beta-blocker use was not significantly associated with cognitive impairment (AOR= 1.22, 95%CI= 1.00-1.49). In fully adjusted models, the AOR for beta-blockers use was 1.05 (95%CI = 0.84-1.31).

Conclusion: In this first large cross-sectional study, we found that the use of beta-blockers was not associated with cognitive impairment. Future prospective studies that include pain management and blood pressure control are needed to confirm the findings.

Keywords

Antihypertensive medicines; Beta-blockers; Cardiovascular diseases; Cognitive impairment; Pain

Introduction

Cognitive impairment, defined as difficulties in learning new things, remembering, concentrating, and making rational decisions affects nearly 16 million adults in the United States (US) [1]. Cognitive impairment has profound negative effects on patients, caregivers, healthcare providers, payers, and society [1-3]. Mild Cognitive Impairment (MCI) is a risk factor for Alzheimer disease and other dementias (ADRD) [4,5] and places excessive humanistic and financial burdens on both adults and their caregivers [6,7].

Many factors have been known to affect cognitive functioning, including age, race, sex, family history,, physical and mental health conditions, head trauma, smoking, physical inactivity, environmental factors, pain [8-14] and pharmacotherapies [15].

There are several plausible explanations of why the use of betablockers may favorably affect cognition. Beta-blockers inhibit the sympathetic nervous system by binding to beta-adrenergic receptors which lowers the hearts’ contractile force, dilates arterial vasculature, and lowers blood pressure [16]. As high blood pressure [17,18] and pathological vascular systems [19] have been shown to have harmful effects on cognitive function, it is plausible that beta-blockers may improve blood pressure and indirectly improve cognitive functioning. Gelber [20] and White [21] reported that beta-blocker use was associated with lower risks of cognitive impairment due to the effect of beta blockers on improved brain tissue functions.

Other studies have hypothesized that the use of adrenergic receptor antagonists may affect cognitive function through the pain pathway [15,22]. It is important to note that the association between pain and cognitive impairment is complex and involves changes to brain morphology, electrophysiology, neurotransmitters and receptors, glial cells, cytokines, enzymes, and neurotrophic factors [15]. Several pre-clinical and clinical studies have documented the association of chronic pain to cognitive impairment [14,15,23]. Whitlock and colleagues reported that respondents with persistent pain had 15% higher rates of memory decline compared to participants without pain [24]. In addition, higher levels of pain have been correlated with increased depressive symptoms and reduced neuropsychological test scores [25].

Recent observational studies have found that beta-blockers may reduce pain. For example, Valdes et al, used data from the Genetics of Osteoarthritis and Lifestyle study and found that among adults with osteoarthritis, those who used beta‐blockers reported less joint pain and were less likely to use opioids and other analgesics compared to those who did not use beta-blockers [22].

To date, no study has evaluated the association of beta-blockers to cognitive impairment after controlling for chronic pain. Therefore, the primary objective of the current study is to explore the association of beta-blocker medication use to cognitive impairment after controlling for pain among adults with cardiovascular diseases (CVDs) or hypertension using a nationally representative sample of adults in the United States. Adults with hypertension or CVDs were chosen because they are more likely to receive betablockers for treatment of these conditions [16].

Methods

Study design

This study adopted a cross-sectional design.

Data source

We used data from the 2015 Medical Expenditure Panel Survey (MEPS), a household survey of non-institutionalized adults in the US [26]. The survey collects a variety of health-related information including individual socio-demographic characteristics, health conditions, healthcare use and expenditures, sources of payment and health insurance coverage. We combined data from MEPS Household Survey, Prescribed Medicines, and Medical Condition Files to create our analytical dataset.

Sample

Study participants were adults (21 years or older) with CVDs or hypertension. The cardiovascular conditions included were pulmonary heart disease, acute myocardial infarction, cardiomyopathy, coronary atherosclerosis, conduction disorders, cardiac dysrhythmias, congestive heart failure, cardiac arrest, ventricular fibrillation, and other ill-defined heart diseases. These conditions were measured based on Clinical Classification Code, International Classification of Diseases, Ninth Revision (ICD-9), and self-reported data (especially for hypertension) on MEPS. We excluded adults with missing information on cognitive impairment, (n = 158) individuals with intracranial injury, (n = 59) Parkinson’s disease or ADRD (n = 199) and individuals who died during the calendar year. The final sample size consisted of 8,279 adults with CVDs or hypertension.

Measures

Dependent variable: Cognitive Impairment

We identified the presence or absence of cognitive impairment from the household (full year consolidated) file based on the questions asking if the person (1) experienced confusion or memory loss, (2) had problems making decisions, or (3) required supervision for their own safety. We used codes COGLIM31, COGLIM53 – representing cognitive limitations (round 3/1 and 5/3), and Code DFCOG42 – representing serious cognitive difficulties (round 4/2). We categorized this into a binary variable Yes (cognitive limitation) and No (no cognitive limitation).

Key Independent Variables

Use of Beta-Blockers

We identified Beta-blockers and other antihypertensive medications using the prescribed medicines file. This file contains information on drug names, national drug code, drug-supplied and other medication related information. Prescription drugs were classified into various therapeutic classes based on the proprietary “Multum Lexicon” files. Multum Lexicon provides a 3-level nested category system for each drug based on the ingredients [27]. Therapeutic classification code 47 represented beta-blockers and codes 42, 43, 48, 49, 53, 55, 56 represented other antihypertensives (ACE-inhibitor, alpha-adrenergic blockers, calcium channel blockers, diuretics, vasodilators, angiotensin receptor blockers, antihypertensive combinations, and angiotensin II inhibitors). This variable was categorized into three groups: (1.) Beta-Blockers (2.) other antihypertensives (3.) No antihypertensive medication.

Pain

A self-administered questionnaire was used to collect information on pain and other domains of health-related quality of life. Pain was measured using one item from the Short Form (SF)-12, asking how much pain “interfered with normal work (including both work outside the home and housework)” during the past 4 weeks prior to the interview. Responses were recorded using a 5-item Likert scale: 1) ‘Not at all’; 2) ‘A little bit’; 3) ‘Moderate’; 4) ‘Severe’; and 5) ‘Extreme’. We used this pain interference with activities as a proxy for chronic pain [28,29].

Other Independent Variables

Other variables that may influence cognitive impairment were selected based on the determinants of health model initially proposed by Park in the Textbook of Preventive and Social Medicine (2015) and published studies that examined factors associated with cognitive impairment. These included: biological characteristics like sex (female vs. male), age, categorized into 4 groups (21-44, 45-54, 5564, 65 and older) and race (White, African American, Latino, and other), socio-economic factors like education (Less than high school, high school, and above high school) and poverty status (poor, near poor, middle income, and high income measured in terms of percentages of federal poverty line), socio-cultural factors like marital status (married, widowed, divorced/separated, and not married)], and behavioral factors like body mass index (underweight, normal, overweight, obese), physical activity (exercising five times/week and others), and smoking status (yes/ no). We also included variables of access to healthcare services, measured by health insurance (public, private, and uninsured) and prescription coverage (yes/no), medical condition including the presence of asthma, chronic obstructive pulmonary disease (COPD), cancer, diabetes mellitus, mental health conditions (depression and anxiety), hypercholesterolemia, and arthritis (yes/no), and region of residence (Northeast, Midwest, South and West).

Statistical analysis

Statistically significant differences in cognitive impairment by type of antihypertensive medications were determined by Rao-Scott chi-square tests. Multivariable logistic regression models were used to assess the relationship between type of antihypertensive medications and cognitive impairment after controlling for sex, age, race, pain, education, poverty status, marital status, body mass index, physical activity, smoking status, health insurance, prescription coverage, asthma, Chronic Obstructive Pulmonary Disease (COPD), cancer, diabetes mellitus, mental health conditions (depression and anxiety), hypercholesterolemia, arthritis, region of residence. Since MEPS uses as complex survey design with clustering, stratification, and weights, we conducted all the analyses using the survey procedure in SAS version 9.4. Because pain information was assessed from selfadministered questionnaires, we applied appropriate weights for the responses derived from those self-administered questionnaires.

Results

Our study participants consisted of 8,279 adults (Wt. N= 94,815,011) with hypertension or cardiovascular disease. Majority of the respondents were female (50.8%), white (67.6%) and married (58.8%). Thirty-seven percent of the participants were 65 years or older and 54.3% had greater than high school education. About 52.9% of the sample had prescription medicine coverage and only 5.9% were uninsured (Table 1).

Overall, 24.2% of the participants reported using beta-blockers and 41.9% used other antihypertensives (Appendix 1). A higher percentage of elderly participants (65 years or older) used betablockers compared to adults aged 21-44 years (36.3% vs 9.2%). A similar trend was also observed among individuals with chronic conditions. Compared to individuals without chronic conditions, respondents with chronic conditions such as COPD (31.9% vs 23.3%), cancer (32.8% vs 22.9%), diabetes mellitus (32.7% vs 21.4%), hypercholesterolemia (30.1% vs 16.0%), and arthritis (28.8% vs 17.6%) were more likely to use beta blockers. We found statistically significant differences in reported pain and cognitive impairment between groups of individuals who used beta-blockers, other antihypertensive medications, compared to those who did not use antihypertensive medications.

As many as 18.1% of the participants reported having cognitive impairment. Individuals who reported cognitive impairment differed significantly from those who did not with respect to all the independent variables included in the study except race/ethnicity, cancer, and region (Table 2). For example, compared to adults with no antihypertensive medications, a higher percentage of those with beta-blocker use had cognitive impairment (13.2% vs 20.2%). The Unadjusted Odds Ratios (UOR) indicated that adults who used beta-blockers had significantly higher odds of cognitive impairment (OR = 1.67; 95%CI= 1.39, 2.01, p <.0001) compared to individuals who did not use any anti-hypertensive medication. We did not find significantly higher odds of cognitive impairment among individuals who used other antihypertensive medications (OR=1.17; 95%CI= 0.97, 1.41, p = 0.0920). Pain was significantly associated with cognitive impairment; adults who reported extreme pain (UOR = 13.52; 95%CI = 9.99, 18.30, p= <0.001), severe pain (UOR = 8.70; 95%CI = 6.85, 11.06, p= <0.001), and moderate pain (UOR = 4.47; 95%CI = 3.49, 5.73, p= <0.001) all had higher odds of having cognitive impairment compared to those with no pain.

After controlling for pain in our model, beta-blocker use was not significantly associated with cognitive impairment (AOR= 1.22, 95%CI= 1.00-1.49). Adults who reported extreme pain were 13.2 times more likely to report impaired cognition (95%CI= 9.71, 17.92, p <.001) compared to those with no pain. In the fully adjusted model, the use of beta-blockers was not associated with cognitive impairment. (OR=1.05, 95% CI = 0.84-1.31, p=0.6901) (Table 3).

Discussion

This paper examined the association of beta-blockers with cognitive impairment among adults with hypertension or CVDs. In this study, 18.1% of all participants and 19.0% of the elderly reported cognitive impairment. This finding is broadly consistent with previous studies in adults over 65 years that report rates of cognitive impairment between 5% and 36.7% [30].

After controlling for pain, the association between beta blocker use and cognitive impairment was not statistically significant. In the fully adjusted model, individuals with extreme pain were 5.4 times more likely to have cognitive impairment compared to those without pain. The prevalence of moderate and extreme pain was comparable within the anti-hypertensive medication categories (Appendix 1) Taken together, these findings suggest that pain rather than antihypertensive medication use may account for the observed association to cognitive impairment.

Our study findings are not consistent with previous studies by Gelber, et al. and White, et al. which reported that individuals who used beta blockers had lower risks of developing cognitive impairment compared to those who did not use antihypertensive medications [20,21,31]. Differences in study design, study population, cognitive impairment scales, and controlling for pain may partly explain the inconsistent findings. Gelber, et al. used a prospective cohort of Japanese American men living in Hawaii and measured cognitive impairment using a combination of the Hasegawa Dementia Screening Scale, the Folstein Mini-Mental State Examination, and the Modified Mini-Mental State Examination but did not control for pain. Several reports postulated that the mechanism behind this protective effect of beta-blocker on cognition involved the action of beta-blockers on vasculature to improve and maintain the ability of the heart and blood vessels to adjust to systemic or local physiological disturbances in the cardiovascular system [16,17]. Conversely, Gliebus and Lippa posited that beta-blockers could potentially block the activation of norepinephrine, the neurotransmitter which plays an essential role in the retrieval of memories from the hippocampus [32]. On the other hand, our main study finding that there is no significant association between beta blocker use and cognitive impairment is consistent with an analysis of published clinical trial data from 19 trials on beta-blockers [33] and a randomized, double-blind, controlled crossover trial [34].

Several factors that may account for the different findings in this study include extent of blood pressure control, which has been shown to be correlated with medication adherence [35,36], and other residual factors which were not measured in this study [37]. The cognitive impairment scale used in MEPS was relatively crude and we expect that more specific measures of cognition (such as attention, learning and memory, speed of processing, psychomotor ability and executive function) could improve the robustness the study design.

Our study findings are consistent with previous reports on the association of pain to cognitive impairment which has been exhaustively investigated [14,15]. Almost all pain categories were associated with cognitive impairment with adjusted odds ratios ranging from 1.28 for mild pain, 2.51 for moderate pain, 3.68 for severe pain, and 5.41 for extreme pain. This is consistent with a review of pre-clinical and clinical studies by Moriarty and colleagues [15].

Our study has many strengths such as the use of a representative sample of adults in the US, availability of prescription drug information, and adjustment for a comprehensive list of variables, especially pain, which could confound the relationship between antihypertensive medications and cognitive impairment. However, our study has some limitations including the use of cross-sectional data, which precludes the assumption of any causal relationship. We did not adjust for blood pressure control due to the fact that MEPS does not include clinical parameters. Other limitations are that this study utilized self-reported overall cognitive impairment as a crude measure of cognitive function and did not include data on duration of beta-blockers use. Future studies that employ a prospective study design, with robust measures of cognitive impairment and duration of beta-blocker use and medication adherence measures are needed to confirm our study findings.

Acknowledgement

Research reported in this publication was supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number 5U54GM104942-03. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


N

Wt. %

ALL

8,279

100.0

Anti-Hypertensive Medications

Beta-blockers

1,917

24.2

Other Antihypertensives

3,451

41.9

No Antihypertensives

2,911

33.9

Cognitive Impairment

Yes

1,496

18.1

No

6,783

81.9

Pain

No Pain

3,290

40.8

A Little bit

2,116

26.8

Moderate

1,164

14.2

Severe

1,141

12.7

Extreme

457

4.5

Biological Factors

Sex

Female

4,489

50.8

Male

3,790

49.2

Race/Ethnicity

White

3,855

67.6

African American

1,950

13.6

Latino

1,728

11.6

Other

746

7.3

Age

21-44 years

1,778

20.3

45-54 years

1,615

18.8

55-64 years

2,042

24.0

65 years and older

2,844

37.0

Socio-economic Factors

Poverty Status

Poor

1,526

11.3

Near Poor

1,877

18.7

Middle Income

2,404

28.2

High Income

2,472

41.8

Education

Less than High School

1,673

13.3

High School

2,673

31.8

Greater than High School

3,869

54.3

Socio-cultural Factors

Marital Status

Married

4,234

58.8

Widowed

982

11.0

Divorced/Separated

1,625

16.4

Not Married

1,438

13.8

Behavioral Factors

Body Mass Index

Underweight

82

1.0

Normal

1,761

22.3

Over

2,673

33.0

Obese

3,642

42.4

Current Smoking Status

Current Smoker

1,311

15.1

Other

6,768

82.7

Exercise

5/week

3,548

44.9

No exercise

4,688

54.6

Access to Healthcare

Insurance Coverage

Public

4,639

65.6

Private

2,952

28.6

Uninsured

688

5.9

Prescription Coverage

Yes

3,739

52.9

No

4,540

47.1

Health Status (Chronic Conditions)

Asthma

Yes

1,141

12.9

No

7,137

87.1

COPD

Yes

732

9.8

No

7,547

90.2

Cancer

Yes

861

12.9

No

7,418

87.1

Diabetes Mellitus

Yes

2,212

24.2

No

6,066

75.8

Mental Health Condition

Yes

2,094

26.9

No

6,185

73.1

Hypercholesterolemia

Yes

4,674

58.1

No

3,601

41.9

Arthritis

Yes

4,771

58.6

No

3,507

41.4

External Environment

Region

Northeast

1,258

17.0

Midwest

1,670

22.1

South

3,443

39.7

West

1,908

21.2

Notes: Based on 8,279 adults age 18 years or older, who participated in the survey in 2015, observed during the entire calendar year and reported having hypertension or cardiovascular diseases.

COPD: Chronic Obstructive Pulmonary Disease; Wt. %: Weighted Percentage.


Table 1: Description of Sample Characteristics Adults with hypertension or Cardiovascular diseases Medical Expenditure Panel Survey, 2015.

Cognitive Impairment

No Cognitive Impairment

Sig.

N

Wt%

N

Wt%

 

ALL

1,496

18.1

6,783

81.9

 

Anti-hypertensive medications

***

Beta-blockers

457

20.2

1,460

79.8

 

Other antihypertensives

612

15.1

2,839

84.9

 

No antihypertensives

427

13.2

2,484

86.8

 

Pain

***

No pain

211

6.2

3,079

93.8

 

A little bit

277

10.7

1,839

89.3

 

Moderate

295

23.0

869

77.0

 

Severe

458

36.6

683

63.4

 

Extreme

226

47.3

231

52.7

 

Biological Factors

Sex

***

Female

905

17.2

3,584

82.8

 

Male

591

14.1

3,199

85.9

 

Age

***

21-44 years

221

11.1

1,557

88.9

 

45-54 years

255

12.6

1,360

87.4

 

55-64 years

405

16.8

1,637

83.2

 

65 years and older

615

19.0

2,229

81.0

 

Race/Ethnicity

White

672

15.2

3,183

84.8

 

African American

389

16.6

1,561

83.4

 

Latino

308

16.9

1,420

83.1

 

Other race

127

16.6

619

83.4

 

Socio-economic Factors

Poverty Status

***

Poor

524

35.3

1,002

64.7

 

Near Poor

441

24.4

1,436

75.6

 

Middle Income

319

13.8

2,085

86.2

 

High Income

212

7.7

2,260

92.3

 

Education

***

Less than High School

420

24.5

1,253

75.5

 

High School

527

18.0

2,146

82.0

 

Greater than High School

529

12.0

3,340

88.0

 

Socio-cultural Factors

Marital Status

***

Married

466

10.0

3,768

90.0

 

Widowed

269

26.9

713

73.1

 

Divorced/Separated

443

25.2

1,182

74.8

 

Not Married

318

19.7

1,120

80.3

 

Behavioral Factors

Body Mass Index

*

Underweight

20

23.5

62

76.5

 

Normal

350

18.2

1,411

81.8

 

Over

452

14.5

2,221

85.5

 

Obese

658

15.3

2,984

84.7

 

Current Smoking

***

Current Smoker

331

22.8

980

77.2

 

Other

1,120

14.1

5,648

85.9

 

Exercise

***

5 times /week

445

10.1

3,103

89.9

 

No exercise

1,047

20.3

3,641

79.7

 

Access to Healthcare

Insurance Coverage

***

Public

493

9.8

4,146

90.2

 

Private

925

29.5

2,027

70.5

 

Uninsured

78

13.6

610

86.4

 

Prescription Coverage

***

Yes

348

8.8

3,391

91.2

 

No

1,148

23.4

3,392

76.6

 

Health Status (Chronic Conditions)

Asthma

***

Yes

327

25.3

814

74.7

 

No

1,169

14.2

5,968

85.8

 

COPD

 

 

 

 

***

Yes

259

32.2

473

67.8

 

No

1,237

13.9

6,310

86.1

 

Cancer

Yes

190

17.8

671

82.2

 

No

1,306

15.4

6,112

84.6

 

Diabetes Mellitus

***

Yes

557

22.4

1,655

77.6

 

No

939

13.5

5,127

86.5

 

Mental Health Condition

***

Yes

798

32.0

1,296

68.0

 

No

698

9.7

5,487

90.3

 

Hypercholesterolemia

***

Yes

1,005

18.5

3,669

81.5

 

No

490

11.7

3,111

88.3

 

Arthritis

***

Yes

1,219

21.8

3,552

78.2

 

No

277

7.0

3,230

93.0

 

External Environment

Region

Northeast

222

12.9

1,036

87.1

 

Midwest

308

15.5

1,362

84.5

 

South

637

16.7

2,806

83.3

 

West

329

16.2

1,579

83.8

 

Notes: Based on 8,279 adults age 21 years or older, who participated in the survey in 2015, observed during the entire calendar year and reported having hypertension or cardiovascular diseases. Asterisks represent significant group differences by cognitive impairment based on Rao-Scott Chi square tests.

***p< .001; **.001 ≤ p < .01; *.01 ≤ p <.05

Unweighted N may not add to total due to missing data in pain, body mass index, exercise, smoking, asthma, diabetes mellitus, hypercholesterolemia, and arthritis.

COPD: Chronic Obstructive Pulmonary Disease; Sig: Significance, wt. %: Weighted Percentage.


Table 2: Unweighted N and Weighted Percentages of Adults with Hypertension or Cardiovascular Diseases by Cognitive Impairment status Medical Expenditure Panel Survey, 2015.

Model 1: Unadjusted Model

 

UOR

95% CI

Significance

Anti-Hypertensive Medication

Beta-blockers

1.67

[1.39,2.01]

<0.001***

Other Anti-hypertensive (s)

1.17

[0.97,1.41]

0.0920

 No Anti-hypertensive (s)

 

 

 

Model 2: Adjusted for Pain

 

AOR

95% CI

Significance

Anti-Hypertensive Medication

Beta-blockers

1.22

[1.00, 1.49]

0.0544

Other Anti-hypertensive (s)

0.94

[0.77, 1.15]

0.5674

No Anti-hypertensive (s)

 

 

 

Pain

None

 

 

 

Little

1.78

[1.41, 2.25]

<0.001***

Moderate

4.38

[3.42, 5.60]

<0.001***

Severe

8.57

[6.76, 10.86]

<0.001***

Extreme

13.19

[9.71, 17.92]

<0.001***

Model 3: Fully Adjusted Model

Anti-Hypertensive Medication

Beta-blockers

1.05

[0.84, 1.31]

0.6901

Other Anti-hypertensive (s)

0.84

[0.67, 1.05]

0.1335

No Anti-hypertensive (s)

 

 

 

Pain

None

 

 

 

Little

1.28

[1.01, 1.63]

  0.0409*

Moderate

2.51

[1.89, 3.34]

<0.001***

Severe

3.68

[2.85, 4.74]

<0.001***

Extreme

5.41

[3.90, 7.50]

<0.001***

Note: Based on 8,279 adults age 21 years or older, who participated in the survey in 2015, observed during the entire calendar year and reported having hypertension or cardiovascular diseases. : Reference Group.

Fully adjusted model controlled for pain, sex, age, race, education, poverty status, marital status, body mass index, physical activity, smoking status, health insurance, prescription coverage, asthma, chronic obstructive pulmonary disease (COPD), cancer, diabetes mellitus, mental health conditions (depression and anxiety), hypercholesterolemia, arthritis, region of residence.  Pain included a missing category as well (not presented).

***p< .001; **.001 ≤ p < .01; *.01 ≤ p <.05


Table 3: Unadjusted Odds Ratios (UOR) and Adjusted Odds Ratios (AOR) and 95% Confidence Intervals (CI) of The Use of Anti-hypertensive Medication and Pain Categories from Logistic Regression on Cognitive Impairment Among adults, Medical Expenditures Panel Survey, 2015.

 

Beta-blocker

Other Anti-HTN Rx

No Anti-HTN Rx

Sig.

N

Wt%

N

Wt%

N

Wt%

 

ALL

1,917

24.2

3,451

41.9

2,911

33.9

 

Cognitive Impairment

***

Yes

457

20.2

612

15.1

427

13.2

 

No

1,460

79.8

2,839

84.9

2,484

86.8

 

Pain Interference with Normal Activities

***

No pain

572

18.7

1,306

40.6

1,412

40.8

 

A little bit

512

24.8

898

41.7

706

33.5

 

Moderate

332

30.4

493

41.8

339

27.8

 

Severe

337

30.1

528

48.3

276

21.6

 

Extreme

137

33.0

188

39.9

132

27.1

 

Biological Factors

Sex

*

Female

1,045

23.8

1,943

43.5

1,501

32.7

 

Male

872

24.5

1,508

40.3

1,410

35.2

 

Age

***

21-44 years

150

9.2

423

22.8

1,205

68.0

 

45-54 years

253

16.8

698

42.4

664

40.8

 

55-64 years

481

23.8

985

48.2

576

28.0

 

65 years and older

1,033

36.3

1,345

48.1

466

15.6

 

Race/Ethnicity

***

White

1,031

26.3

1,580

42.2

1,244

31.5

 

African American

432

21.6

908

45.3

610

33.1

 

Latino

286

16.4

653

36.6

789

47.0

 

Other race

168

21.7

310

41.2

268

37.1

 

Socio-Economic Factors

Poverty Status

***

Poor

336

20.6

601

39.4

589

39.9

 

Near Poor

465

27.0

743

39.6

669

33.5

 

Middle Income

564

25.4

1,001

40.2

839

34.4

 

High Income

552

23.1

1,106

44.8

814

32.2

 

Education

*

Less than High School

392

25.2

719

42.9

562

31.9

 

High School

652

25.6

1,097

41.9

924

32.6

 

Greater than High School

860

23.2

1,604

41.5

1,405

35.3

 

Socio-cultural Factors

Marital Status

***

Married

950

24.0

1,828

43.3

1,456

32.7

 

Widowed

318

32.3

474

50.1

190

17.6

 

Divorced/Separated

419

26.1

673

40.9

533

33.0

 

Not Married

230

16.2

476

30.6

732

53.1

 

Behavioral Factors

Body Mass Index

***

Underweight

21

24.5

21

26.5

40

49.0

 

Normal

358

20.0

648

36.0

755

44.1

 

Over

607

23.4

1,122

42.9

944

33.6

 

Obese

910

27.1

1,611

44.7

1,121

28.3

 

Current Smoking

***

Current Smoker

251

19.6

478

36.1

582

44.3

 

Other

1614

24.9

2,887

43.0

2,267

32.2

 

Exercise

***

5 times /week

710

20.0

1,509

43.3

1,329

36.7

 

No exercise

1,200

27.7

1,928

40.8

1,560

31.5

 

Access to Healthcare

Insurance Coverage

***

Public

979

22.2

1,979

42.8

1,681

34.9

 

Private

867

31.0

1,265

42.6

820

26.4

 

Uninsured

71

12.4

207

28.3

410

59.3

 

Prescription Coverage

***

Yes

753

21.5

1,609

42.5

1,377

36.0

 

No

1,164

27.1

1,842

41.3

1,534

31.6

 

Health Status (Chronic Conditions)

Asthma

 

Yes

283

25.1

488

43.1

370

31.8

 

No

1634

24.0

2,962

41.7

2,541

34.2

 

COPD

***

Yes

224

31.9

320

43.5

188

24.6

 

No

1,693

23.3

3,131

41.7

2,723

34.9

 

Cancer

***

Yes

297

32.8

401

48.5

163

18.7

 

No

1,620

22.9

3,050

40.9

2,748

36.2

 

Diabetes Mellitus

***

Yes

695

32.7

1,128

51.0

389

16.3

 

No

1,222

21.4

2,322

39.0

2,522

39.6

 

Mental Health Condition

 

Yes

539

25.2

881

43.0

674

31.7

 

No

1,378

23.8

2,570

41.5

2,237

34.7

 

Hypercholesterolemia

***

Yes

1,369

30.1

2,151

46.2

1,154

23.7

 

No

547

16.0

1,298

35.9

1,756

48.1

 

Arthritis

***

Yes

1,340

28.8

2,145

44.5

1,286

26.7

 

No

577

17.6

1,306

38.3

1,624

44.1

 

External Environment

Region

 

Northeast

327

26.9

499

38.8

432

34.3

 

Midwest

419

25.1

700

42.6

551

32.4

 

South

805

24.3

1,475

43.2

1,163

32.6

 

West

366

20.8

777

41.4

765

37.8

 

Notes: Based on 8,279 adults age 21 years or older, who participated in the survey in 2015, observed during the entire calendar year and reported having hypertension or cardiovascular diseases. Asterisks represent significant group differences by cognitive impairment based on Rao-Scott Chi square tests.

***p< .001; **.001 ≤ p < .01; *.01 ≤ p <.05

Unweighted N may not add to total due to missing data in pain, body mass index, exercise, smoking, asthma, diabetes mellitus, hypercholesterolemia, and arthritis.

AntiHTN-Rx: Antihypertensive Medications, COPD: Chronic Obstructive Pulmonary Disease; Sig: Significance, Wt. %: Weighted Percentage.


Appendix 1: Unweighted N and Weighted Percentages of Adults with Hypertension or Cardiovascular Diseases by Antihypertensive Categories Medical Expenditure Panel Survey, 2015.

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Citation: Safarudin F, Iloabuchi CO, Ladani A, Sambamoorthi U (2020) The Association of Beta-Blocker Use to Cognitive Impairment among Adults with Hypertension or Cardiovascular Diseases in the United States. Chron Pain Manag 4: 125. DOI: 10.29011/2576-957X.100025

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