Cardiovascular Disease and Cognitive Impairment in Older Greek Adults

This research proposal investigates the relationship between cardiovascular disease (CVD) and cognitive impairment in older Greek adults. The study aims to compare the cognitive performance of elderly individuals with a history of CVD to a control group of healthy elderly individuals, matched for age and education. The methodology involves administering a battery of cognitive tests, including the Mini-Mental State Examination and tests assessing memory, attention, and executive function. The research hypothesizes that older adults with chronic CVD will exhibit poorer cognitive performance compared to their healthy counterparts. The study seeks to identify specific cognitive tests sensitive to CVD-related cognitive decline. Findings will be analyzed using multiple independent t-tests and linear regression to determine the association between CVD and cognitive deficits, contributing to the understanding of cognitive impairment in this population and informing future research and clinical practices.

RESEARCH PROPOSAL
Topic: Cardiovascular Disease in Older Greek Adults and Cognitive Impairment
PS14021
International Faculty of the University of Sheffield, CITY College
BSc Psychology
CPY3330: Research Project in Psychology
Supervisor: Dr. Anna Emmanouel

07/12/2018
ABSTRACT
The objective of this study is to determine the impact of cardiovascular disease no cognitive
functions such memory or visual abilities of Greek patients who are 65 years both male and
female, both matched in educational level in years. The sample size is thirty (30) Greek elderly
adults. Fifteen(15) are unhealthy that is they have had the previous history of cardiac surgery,
myocardial infarction or any other heart disease while the other fifteen (15) are healthy elderly
patients with no history of cardiovascular disease. The exclusion criteria are those elderly
patients who have a history of mental disease. The tools for this study are ten (10) cognitive test
but first, mini-mental state examination, screening, and measuring of blood pressure was done
before the cognitive test. Cognitive tests include Montreal cognitive assessment, California
verbal learning test, digit span test which has forward and backward option, digit symbol
modalities test, Trail making test, letter-number sequencing test, Rey-osterrieth complex figure

test, semantic and phonetic test. Multiple independent was used to compare the results between
the two groups. This will help in assessing any abnormality or normalit
The findings of this study will be used as the primary source of data that will indicate the
connection between cognitive variable to cognitive dysfunction which is related to
cardiovascular disease in elderly patients. Comparison of samples will be done using the
multiple independent t-tests to get the similarities and differences of performances of the elderly
with chronic CVD and those of healthy older adults. For cognitive measures, to predict
deficiencies related to CVD linear regression method will be used. And therefore I would
recommend that same investigations should be carried out regularly in future for confirmation
and to also expand the results of this research.
Introduction
Literature Review
According to WHO cardiovascular disease is a variety of heart and blood vessel disorders for
example heart failure and myocardial infarction. CVD is the number one cause of death
worldwide, many people die from CVD than from another cause annually and especially among
the old patients, by 2012 CVDs were among the leading causes of non-communicable diseases
and are mainly prevalent in underdeveloped and developing countries because many people are
not accessible to effective and equitable health care services. WHO recommended that most of
the cardiovascular disease can be addressed by emphasizing on avoidance of behavioral risk
factors for example use of tobacco, physical inactivity, obesity and diet which is not good to
health and harmful consumption of excess alcohol and stimulants such as caffeine. Risk factors
stated by WHO include: hypertension, diabetes, and hyperlipidemia which need early diagnosis

and management using appropriate drugs and counseling therapy. WHO was able to put the
mechanism in place to reduce the avoidable disease burdens by implementing a global action
plan for prevention and control of NCDs 2013-2020 and the sixth target is reduction of blood
pressure which the main contributing factor to cardiovascular disease and the eighth target is to
implement the use of drugs and guiding counseling on stress to prevent attacks and strokes
In Greece, 38% of the mortality rate has been due to CVD mainly caused by ischemic attacks,
more than17.5 million deaths are from CVD and are associated with risk factors which are
modifiable and can be controlled such as hypertension, diabetes, and obesity, increasing rate of
depression has made it even worse (Lim et al., 2012). Hazzouri et al. (2014) found an important
connection between cognitive impairment and CVD risk factors in elderly people, incidences of
CVD risk factors increase with age and they are considered the source of cognitive changes that
are thought to be part of the aging process which is actually not but rather cognitive impairment
due to cardiovascular disease, it is important to consider these factors and to recommend them
more routine cognitive screening because this will lead to early diagnosis and management of
risk for example hypertension.
Loss of memory and dementia are among the disorders that old people suffer from and CVD is a
secondary cause of these disorders. Gikas et al. (2016) also show a strong relationship between
severe cognitive decline and CVD in the elderly that it is the most frequent as aging causes the
heart and its blood vessels to stiffen which can lead to cardiovascular disease. CVD functions
and noted the association between high obesity, diabetes, and blood pressure with cognition of
human's brain (Leritz et al, 2011). These three conditions have been associated with both
cardiovascular disease and dementia and a decrease in cognit ive function. Diabetes particularly

those patients who are insulin depended, high glucose level causes damage to vessels and nerves
that control the heart and its blood vessels which increases chances of having heart pressure or
stroke (Salina et al, 2016) as high blood pressure even when glucose level is under control it still
increases chances of heart disease and stroke, diabetes has an unhealthy cholesterol level
including high-density lipoprotein which causes coronary disease. According to Etterhad et al,
2016, High blood pressure causes strain on heart vessels causing damage which will, in turn,
causes ischemic heart attacks, stroke and even eye damage. On the other hand, health behaviors
such as engaging in moderate but intensive exercise, nonsmoking and adopting diet which has a
lot of fruits, vegetables and fish leads to a lowered risk of dementia (Steinberger et al,2016).
According to the American Heart Association which mostly emphasized on prevention against
cardiovascular disease. It developed a 7-item tool which included mainly 4 health behaviors such
as nonsmoking, physical activity, dietary management and three biological measures which
included treating high blood cholesterol, regulating blood glucose and regulating blood pressure.
This effort by the American heart association tool has helped prevent cardiovascular disease
which is a secondary benefit of preventing dementia and cognitive impairment.
Embolic stroke or chronic cerebral hypoperfusion has a connection between CVD and cognitive
impairment (Abete et al, 2014) and they out that found out that embolic stroke and
hypoperfusion increases the risk of causing cognitive impairment by inducing neuronal energy
crisis which causes degeneration of brain nerves and vessels which causes damage of brain tissue
which eventually leads to no or less blood flow to brain because of reduced metabolic demand
which then causes impaired cognitive function in brain for example impaired memory, attention,

learning, calculation, visual perception and impairment in skilled movement because there will
be a lack of muscle coordination and weakness.
Cognitive development of a cardiovascular incident was introduced (Schievink et al., 2017) this
study was done in Maastricht among the old. This cognitive impairment includes troubles in
remembering new things or old things and making daily life decisions which affect their living.
This incidence ranges from mild to severe. In mild cognitive deficiency, people begin to notice
changes in cognitive function but they are able to perform their daily activities while Severe one
causes the loss of ability to understand meaning or importance of simple things, they are unable
to write or talk making them very hard to live independently as they will require a full-time
caregiver.
Research Gap
Many people fear to lose cognitive function. We fear to lose our mental capacity than physical
ability and therefore adults are worried about memory loss. Taking a step to address this issue
will eventually have a positive impact on the entire community and state that's why am carrying
out this study to address this issue. A lot of research on cardiovascular diseases has been
conducted among older Greek adults but there has been an increasing prevalence of CVD with
age, there has not been any improvement on morbidity and mortality among the older people
with CVD. Risk factors of cardiovascular disease have always been underrepresented especially
on the knowledge about risk factors among this population that contribute to cardiovascular
disease which eventually cause cognitive impairment and dementia, improved understanding of

this risks factors is necessary because they are always under-treated and under-diagnosed in
older patients. Moreover, the main research problem of this study is the ability to recruit Greek
participants from the question "whether there is a cognitive impairment related to cardiovascular
diseases both for clinical and research purposes?”. This study is therefore set to analyze the
relationship between cardiovascular disease in elderly patients and their impact on cognitive
function.
Research Question
How do older people with cardiovascular disease perform on the cognitive test compared to old
patients who are healthy, matched for age and educational background and which cognitive test
can show cognitive impairment to chronic cardiovascular disease?
Research Hypothesis
On cognitive test older adults with chronic CVD will perform worse compared to healthy
elderly.
Null Hypothesis: Between older adults with CVD and older adults who are healthy who act as
control experiment there is no difference in cognitive performance.

Methodology
Participants
Eligible participants for this study will be 30 individuals in total. They should be of both sexes
matched with educational level in years and of 65years and above. They will be grouped into two
groups according to the status of their health. The first group consists of fifteen (15) with CVD
and the other fifteen (15) are healthy. According to (Bastien et al. (2014) he suggested that
participants will be included in the study if they have had one or more of heart conditions such as
cardiac surgery or myocardial infarction. individuals with a psychiatric disease such as
schizophrenia, dementia or neurodegenerative disorders and they are using psychoactive drugs
will be excluded from the study.
All participants are required to provide their consent so that they will be allowed to participate in
this study. Before distributing the questionnaires, participants will be given enough time to read
the consent form and informed sheet and allowed to decide whether they will participate in the
study or not. They are given room for any clarification or questions concerning the study. The
participant has the right to withdraw from carrying out this study at any time if they wish without
giving any explanation to the researcher why they don’t want to take part in the study.
Participants who participate voluntarily are to sign the written consent form and will be included
in the study. In the consent form, they ensure their acknowledgment of the important process and
the objective as well as their voluntary, anonymous participation and the collection of the data
for research purposes. Confidential information such as Personal information, medical records
should not be disclosed. Results of the participants will also remain confidential since their

participation will be anonymous and coded names will be only used. In addition to this, study
participants have the right to quit from their involvement in the study at any point during the
process as it is voluntary as their nature of participation state. The aim of the study is that
participants should give honest answers. Upon completion of this study, all data regarding the
participant's personal information and phone numbers will be deleted. International Faculty of
the University of Sheffield in Thessaloniki, Greece will be the place that data will be stored and
will only be accessible by the researcher and the supervisor. The researcher will also state to
participants that information that would make it possible to give the participant's identity or
someone else identity will not be included in any type of report.
The order of administration should be as follows with the first one being the information sheet,
secondly the consent form, thirdly a demographic form which includes information about age,
sex, educational level and if they have a history of cardiovascular disease and finally, they will
be given with a set of 10 cognitive tests. The first test is the Montreal cognitive test that will last
approximately 8 minutes, the second will be the California Verbal Learning Test (CVLT) which
as different learning trials that is: 5 learning trials, trial 6, trials 7 and 8 and will last
approximately 25 minutes, then the Rey Osterrieth Complex Figure Test (ROCFT) that test for
Copying and Immediate Recall that will last approximately 8 minutes, then the Trail Making
Test which has part A and B and it will last a period of 5 minutes at the same time participants
will be given with the Digit Span Test with forwarding and Backward method that will take a
period of 2-5 minutes, followed by Digit Symbol Modalities Test that will last 1,5 minute, then
the Letter-Number Sequencing Test (WAIS-III) that will take a period of 5-8 minutes, then
again California verbal learning test (CVLT) that will test delayed recall and recognition that will
take a period of 3 minutes, then again ROCFT for delayed Recall and Recognition that will take

a period of 3 minutes and lastly the speech Fluency Test (Semantic and Phonemic Parts) that will
last 6 minutes.
Measures
Participants will be administered cognitive tests that are ten (10) in total that asses variety of
cognitive functions such as information processing, attention, visual and verbal, working
memory, executive functions, mental flexibility, and visual-constructional capabilities. Montreal
Cognitive Assessment (MoCA) is the first test to be used and will last approximately 8 minutes.
MoCa test is a 30-point screening task. If one of the health participants scored less than or equal
24 points, they will not take part in the study but they will be referred to a neurologist,
(Cummings‐Vaughn et al, 2014). The second will be the California Verbal Learning Test
(CVLT) which has several learning trials that is: trial5, trial 6, trials 7 and 8 and recognition and
will last approximately 25 minutes. Short-term and long-term verbal, verbal material, recall
encoding, and recognition will be examined through MOCA. Participants are requested to learn
and retrieve a list of words (List A), consisting of 16 words and repeat it 5 times. Each time list
A will be repeated by the researcher. After trial 5 researcher will read a new list to the
participants (List B) and then in trial 7 researcher will ask from participants to group the items
from list A in fruits, clothes, tools, and spices respectively.
In addition, the Rey Osterrieth Complex Figure Test (ROCFT) that test for copying and
Immediate Recall will be administered, it will last approximately 8 minutes. Subjects will be

requested to redraw a complicated shape drawing by copying it freehand (recognition).
Trail Making Test which as part A and B will follow which will take a period of 5 minutes. It
consists of 25 circles distributed over a sheet of paper where the circles are numbered 1 – 25, and
the patient should connect the numbers in ascending order by drawing lines as quickly as
possible while still maintaining accuracy, time used taken to complete the test will be used as the
performance metric (Iuliano et al, 2015). In Part B, both numbers will be included in the circles
(1 – 13) and letters (A – L) and participants will be requested to interchange between the
numbers and letters (i.e., 1-A-2-B-3-C, etc. A stopwatch is necessary for this task; the higher the
time, the slower the reaction time. At the same time participants will be given the Digit Span
Test which has Forward and Backward method that will take a period of 2-5 minutes, then
followed by Digit Symbol Modalities Test will be administered and it will take a period of last
1.5 minutes and it examines the visual-motor, speed, and muscle coordination. In addition,
Letter-Number Sequencing Test WAIS-III will be administered and it will take a period of 5-8
minutes. The study subjects will be requested to remember the first numbers correctly and in
order and letters in alphabetic order.
CVLT will be given again for the test of Delayed Recall trials and Recognition and it will take a
period of 3 minutes. Participants will be required to recall many items as possible from the
previously given to the list A and then again try to categorize the items into clothes, tools, fruits,
and spices (trial 9, 10). Lastly, the researcher would read to the participants several items and
they have to recognize which items belong to list A.
ROCFT will be given again for the test of Delayed Recall and Recognition, it will be
administered to participants for them to remember again the previously given shape from short
term memory that will take a period of 3 minutes.

And lastly, a shorter version of the Verbal Fluency Test (Semantic and Phonemic Parts) will be
given and it will take a period of 2 minutes. This test is specifically used to assess study subjects’
verbal abilities. Study subjects are required to produce as many words as possible firstly from
animal category (semantic) and secondly from letter x (phonemic), with 1-minute countdown.
Before this test diastolic blood pressure (DBP), systolic blood pressure (SBP) will be taken to
rule out any danger of hypertension. The Mini-Mental State Examination which includes:
appearance, attitude, behavior, affect, speech, thought process, thought content, perception,
cognition, and insight. A screening test will also be done. This baseline test helps the research to
identify the cognitive impairment which will enable the researcher to differentiate between
healthy from unhealthy individuals. In addition, Verbal Fluency Task (Lezak, 2004) will be done
to test language range capabilities. To assess for the attention of the study subjects the following
test will be used, they are Trail Making Test, Digit Span Forward Condition and the Digit
symbol modalities test (Kostaridou, 2018). Working memory will be assessed by the Letter-
Number sequencing will examine working memory, the Trail Making Test the second part that is
part B and the Digit Span Backward Condition will test for working memory. California Verbal
Learning Test (CVLT) will assess the verbal memory as well and visual memory. Visual-
constructional abilities will be calculated by the use of Rey-Osterrieth Complex Figure Test
(ROCFT).
Design
The study design used was cross-sectional, quantitative, experimental, which will compare
between two different subjects that are health individual who is over 65 of age for both sexes and