Archives of Gerontology and Geriatrics 79 (2018) 39–44

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Archives of Gerontology and Geriatrics

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Assessment of risk factors for cerebrovascular disease among the elderly in T

Beijing: A 23-year community-based prospective study in China
Haibin Lia,b, Jin Guoc, Anxin Wanga,b, Deqiang Zhanga,b, Yanxia Luoa,b, Wei Wangd, Xia Lie,
⁎⁎ ⁎
Zhe Tangf, , Xiuhua Guoa,b,
a
Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
b
Beijing Municipal Key Laboratory of Clinical Epidemiology, Capital Medical University, Beijing, China
c
Greenwood Medical Company, 300 Highway Burwood, Melbourne, Victoria, Australia
d
Global Health and Genomics, School of Medical Sciences and Health, Edith Cowan University, Perth, Western Australia, Australia
e
Department of Mathematics and Statistics, La Trobe University, Victoria, Australia
f
Beijing Geriatric Healthcare Center, Xuan Wu Hospital, Capital Medical University, Beijing, China

A R T I C LE I N FO A B S T R A C T

Keywords: Introduction: There are few studies on how lifestyle factors and mental conditions modulate the cerebrovascular
Cerebrovascular diseases diseases (CBVD) mortality risk are rare in the Asian elderly.
Mortality Aim: To comprehensively assess the impact of lifestyle factors and mental conditions on the mortality risk of
Risk factors CBVD among the Chinese older adults.
Survival
Material and methods: This community-based prospective cohort study was based on the Beijing Longitudinal
Study of Aging. We included 2101 participants aged ≥55 years who were interviewed in August 1992 and
followed until December 2015. Baseline sociodemographic variables, lifestyle behaviors, and medical conditions
were collected using a standard questionnaire. In addition, biochemical parameters, the Activities of Daily Living
(ADL) scale, Center for Epidemiological Studies Depression (CES-D) scale, and Mini-Mental State Examination
(MMSE) were performed. Hazard ratio (HR) and 95% confidence intervals (CI) was estimated from the com-
peting risk model.
Results: During the follow-up period, 576 (27.42%) CBVD events were documented. Multivariable analysis
showed that hypertension (HR = 2.331, 95% CI = 1.652–3.288,P < 0.001), depression (HR=2.331, 95%
CI=1.652-3.288, P < 0.001), cognitive impairment (HR=1.382, 95% CI=1.132-1.689, P < 0.001), and
coronary heart diseases (HR=1.360, 95% CI=1.095-1.689, P = 0.005) were independently associated with
CBVD, while body mass index, fasting blood glucose, triglycerides, drinking, and smoking were not associated
with CBVD (all P > 0.05).
Conclusions: Males were at higher risk of CBVD than females. Age, gender, hypertension, cognitive impairment,
and depression were associated with CBVD among the elderly in Beijing, China.

1. Introduction
Cerebrovascular diseases (CBVD) include ischemic and hemorrhagic
stroke and transient ischemic attacks (TIA). CBVD is the second leading
cause of death globally after ischemic coronary heart disease, ac-
counting for a combined 15 million all-cause mortality (World Health
Organization, 2015). The incidence of stroke is similar between high-
and low-income countries (ranging from 217 to 281 per 100,000
person-years), but the mortality is lower in high-income countries
compared with low-income countries (61 vs. 105 per 100,000 person-
years) (Feigin et al., 2014). The incidence of CBVD has increased by
100% in developing countries (Thrift et al., 2017). In China, the stan-
dardized CBVD-related death rate is 124.15 in women and 148.57 in
men per 100,000 people per year (Sun, Zou, & Liu, 2013).
The mortality and disability due to CBVD is expected to increase in
the future because of aging population and change of lifestyles (Feigin,
Norrving, & Mensah, 2017). The risk factors for CBVD include history of
TIA, cardiovascular diseases (hypertension, myocardial infarction, at-
rial fibrillation, atrial tachyarrhythmia, and left atrial enlargement),
smoking, metabolic syndrome, obesity, heavy alcohol use, diabetes

⁎
Corresponding authors at: Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China.
⁎⁎
Corresponding author at: Beijing Geriatric Healthcare Center, Xuan Wu Hospital, Capital Medical University, Beijing, China.
E-mail addresses: tangzhe@medmail.com.cn (Z. Tang), statguo@ccmu.edu.cn (X. Guo).

https://doi.org/10.1016/j.archger.2018.07.017
Received 8 February 2018; Received in revised form 12 July 2018; Accepted 27 July 2018
Available online 29 July 2018
0167-4943/ © 2018 Elsevier B.V. All rights reserved.
H. Li et al.
mellitus type 2, high cholesterol levels, and carotid artery stenosis
(O’Donnell et al., 2016). Fortunately, some risk factors such as dietary
habits (high sodium intake, high intake of processed foods, and low
intake of fruits, vegetables, fish, and whole grains), poor physical
function, and substance abuse are modifiable (Jauch et al., 2013).
However, others factors associated with mortality due to CBVD such as
older age, the number of neurological deficits, being Caucasian are
unmodifiable (Xian, Holloway, Noyes, Shah, & Friedman, 2011).
As reported in previous studies, age, male, stroke severity, hemor-
rhagic stroke, diabetes, ischemic heart disease, and right hemisphere
stroke were independently associated with mortality from CBVD, while
atrial fibrillation, antihypertensive treatment at admission, smoking, or
living alone were also associated with CBVD (Ronning, 2013). In ad-
dition, Guo et al. founded that elderly people (especially women) with
low score mini-mental state examination (MMSE) score were at higher
risk of CBVD (Guo et al., 2017). However, studies on the combined
impact of lifestyle factors and mental conditions (such as depression
and cognitive impairment) on the CBVD mortality risk in the Asian
elderly population are few.
The present study aimed to develop a comprehensive model for
CBVD mortality by incorporating the effects of lifestyle factors and
mental conditions among the older Chinese population in a 23-year
community-based prospective cohort study. We hypothesized that (1)
depression or cognitive impairment were independently associated
with increased risk of CBVD; (2) clustering of CBVD risk factors was
strongly associated with a high risk of CBVD mortality.
2. Methods
2.1. Study design and participants
This study was based on a secondary analysis of the Beijing
Longitudinal Study of Aging (BLSA), a community-based prospective
cohort study (Tang et al., 1999). The procedures for sampling and data
collection were described in details elsewhere (Tang et al., 1999; Tian
et al., 2011). Briefly, a three-stage stratification random clustering
sampling procedure (i.e., urban and rural-level sampling, neighborhood
community-level sampling, and respondent-level sampling) was used to
obtain a representative sample in Beijing in August 1992. Finally, 3257
participants were included from three districts of Beijing: Xuanwu,
Daxing, and Huairou. In this study, 2101 participants aged ≥55 years
were included after agreeing undertake a blood examination test. The
included and the excluded sample were compared to assess enrolment
bias; the differences in baseline characteristics between these two
groups were not statistically significant.
This study was approved by the ethics committee of the Xuanwu
Hospital affiliated to the Capital Medical University (Approval No.:
2015SY52). Written informed consents were originally obtained for
each participant.
2.2. Data collection
A standard questionnaire including demographic characteristics,
socioeconomic status, and health conditions was applied at baseline
data collection. The questionnaire was a modified version of that used
in the English Longitudinal Studies on Aging (ELSA) (Steptoe, Breeze,
Banks, & Nazroo, 2013). The questionnaire was completed at home by
trained interviewers (nurses, doctors, or senior medical students). These
personnel helped the illiterate participants to complete the ques-
tionnaire, where necessary.
2.3. Assessment of risk factors
Demographic characteristics included: age, gender, marital status,
and education level. Smoking and drinking status were ascertained
from self-administered questionnaires. Age was categorized into three
40
Archives of Gerontology and Geriatrics 79 (2018) 39–44
groups: 55–65 years, 66–75 years, and > 75 years. Body mass index
(BMI) was calculated as weight (kg) divided by height squared (m2) and
grouped into four categories: thin (< 18.5 kg/m2), normal (18.5–23 kg/
m2), overweight (23–30 kg/m2), and obesity (> 30 kg/m2) (Chen, Lu,
Department of Disease Control Ministry of Health, & P.R.C, 2004).
Blood pressure (BP) was measured by a trained nurse on the right arm
of participants seated after resting for ≥10 min. Participants were
classified into three groups: high (systolic blood pressure (SBP) ≥140
mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg), critical
(140 > SBP ≥120 mmHg or 90 > DBP ≥80 mmHg), and normal
(SBP < 120 mmHg and DBP > 80 mmHg) (Liu, 2011).
Blood samples were collected after overnight fasting for ≥12 h.
Fasting plasma glucose (FBG), total cholesterol (TC), high-density li-
poprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol
(LDL-C), and triglycerides (TG) were measured using standardized en-
zymatic methods. Participants who had TC ≥ 200 mg/dL (5.18 mmol/
L), or TG ≥ 150 mg/dL (1.70 mmol/L), or HDL-C ≥ 40 mg/dL
(1.03 mmol/L) for men and ≥50 mg/dL (1.29 mmol/L) for women, or
LDL-C ≥ 130 mg/dL (3.37 mmol/L) were considered to be dyslipidemic
(Wu, 2007). Diabetes mellitus was defined as self-reported history of
diabetes diagnosis or using the antidiabetic medicine after the baseline
examination, or FBG ≥ 126 mg/dL (7.0 mmol/L) (Alberti & Zimmet,
1998). Impaired fasting glucose was identified having a FPG level of
109.8–125.9 mg/dL (6.1–6.9 mmol/L) (Alberti & Zimmet, 1998).
The questionnaire also included the frequency of doing exercise: if
the participant exercised regularly (almost every day), then this was
defined as exercising frequently. Participants were asked, “Do you eat
fresh fruit almost every day? and “Do you eat fresh vegetables almost
every day?”. A possible answer was “yes” or “no”.
Physical function was assessed using the Instrumental Activities of
Daily Living (ADL) scale (Jefferson et al., 2008). ADL scale included 6
items of daily activities (walking, getting out of bed, feeding, dressing,
bathing, and toileting). A participant was categorized as disabled if he/
she was unable to complete at least one of the above activities alone.
Depression was assessed using a 20-item measure of the Center for
Epidemiological Studies Depressive symptoms scale (CES-D) (Radloff,
1977). The CES-D has a high sensitivity and specificity for major de-
pressive symptoms among the elderly. The total scores ranged from 0 to
30, and a cut-off value ≥16 was used to identify depression (Radloff,
1977).
The Mini-Mental State Examination (MMSE) was used to measure
the global cognitive function (Li et al., 2012). The MMSE scale included
five domains: orientation, attention, calculation, recall, and language.
The total score ranged from 0 to 30, with higher scores representing
good cognitive ability. Cognitive impairment was defined based on the
education level and MMSE score. The cutoff values were as follows:
illiterate < 17, primary school education < 20, and secondary or
higher education < 24.
2.4. Outcome assessment
CBVD incidence and/or mortality was defined as the primary cause
of death as indicated by the International Classification of Disease
(ICD)-10 (I60-169). Deaths from cardiovascular diseases, cancers, and
other causes were considered as competing events.
2.5. Statistical analysis
Since a few serum biochemical values were missing, multiple im-
putation (MI) was performed to impute the missing information.
According to data distribution, the Markov Chain Monte Carlo (MCMC)
method was used to avoid the loss of generality. The “PROC MI” pro-
cedure in the SAS software package (Version 9.2; SAS Institute,
Chicago, IL, USA) was used. Follow-up time was calculated from the
initial date of the 1992 questionnaire to CBVD incidence, mortality, loss
to follow-up, or end of follow-up (December 31, 2015), whichever came
H. Li et al. Archives of Gerontology and Geriatrics 79 (2018) 39–44

Table 1 pressure were significantly different between men and women

Characteristics of the study population. (P < 0.05) (Table 1).
Variables Male Female P-value
N = 1037 N = 1064 3.2. Risk factors for cerebrovascular diseases

Age, mean (SD), y 69.9 (8.5) 68.7 (8.7) 0.002

During follow-up, 576 (27.42%) CBVD events were documented.
BMI, mean (SD), kg/m2 22.8 (3.9) 23.7 (4.2) < 0.001
SBP, mean (SD), mmHg 140.0 (25.2) 142.7 (25.0) 0.012
Fig. 1 presents the Kaplan-Meier survival curves according to age
DBP, mean (SD), mmHg 81.7 (13.0) 80.2 (12.1) 0.008 groups, gender, BMI groups, BP groups, cognitive impairment, and
FBG, mean (SD), mg% 102.1 (31.6) 104.3 (33.4) 0.132 smoking status.
TC, mean (SD), mg/dl 160.5 (33.0) 175.8 (36.8) < 0.001 As shown in Table 2, the competing risk model showed that hy-
TG, mean (SD), mg/dl 126.5 (60.0) 143.4 (67.0) < 0.001
pertension (HR = 2.331, 95% CI = 1.652–3.288, P < 0.001), depres-
HDL, mean (SD), %, 56.9 (19.9) 58.8 (20.2) 0.022
LDL, mean (SD), % 110.3 (32.2) 121.6 (37.0) < 0.001 sion (HR=2.331, 95% CI=1.652-3.288, P < 0.001), cognitive im-
MMSE-score, mean (SD) 24.5 (3.5) 21.8 (4.4) < 0.001 pairment (HR=1.382, 95% CI=1.132-1.689, P < 0.001), and
Cognitive impairment, n (%) 101(9.7) 194 (18.2) < 0.001 coronary heart diseases (HR=1.360, 95% CI=1.095-1.689, P = 0.005)
Depression (CES-D score ≥16), n (%) 138 (13.3) 232 (21.8) < 0.001
were independently associated with CBVD incidence or mortality, while
Educational level, n (%) < 0.001
≥Junior college 106 (10.2) 34 (3.2)
body mass index, fasting blood glucose, triglycerides, drinking, and
High school 59 (5.7) 38 (3.6) smoking were not linked to CBVD (P > 0.05).
Junior high school 123 (11.9) 45 (4.2) In men, hypertension (HR = 2.727, 95% CI = 1.730–4.2999,
Primary school 425 (41.0) 176 (16.5) P < 0.001), depression (HR=2.331, 95% CI=1.132–2.047,
Illiteracy 324 (31.2) 771 (72.5)
P = 0.005), cognitive impairment (HR=1.337, 95% CI=1.012–1.766,
Marital status, n (%) < 0.001
Unmarried 8 (0.8) 5 (0.5) P = 0.041), and coronary heart diseases (HR=1.397, 95%
Married 786 (75.8) 611 (57.4) CI=1.028–1.900, P = 0.033) were independently associated with
Separated 3 (0.3) 9 (0.8) CBVD incidence or mortality, while BMI, FBG, TG, drinking, and
Divorced 4 (0.4) 3 (0.3) smoking was not (Supplemental Table 1). In women, hypertension
Widowed 236 (22.8) 436 (41.0)
Daily vegetables intake, n (%) 1009 (97.3) 1035 (97.3) 0.971
(HR = 1.895, 95% CI = 1.119–3.207, P = 0.017), depression
Daily fruits intake, n (%) 494 (47.6) 512 (48.1) 0.825 (HR=1.466, 95% CI=1.107–1.942, P = 0.008), cognitive impairment
Current smoker, n (%) 471 (45.4) 151 (14.2) < 0.001 (HR=1.471, 95% CI=1.099–1.967, P = 0.009) were independently
Current drinker, n (%) 391 (37.7) 69 (6.5) < 0.001 associated with CBVD incidence and mortality, while the BMI, FBG, TG,
Physical activity, n (%) < 0.001
drinking, smoking, and coronary heart diseases were not (Supplemental
Never 339 (32.7) 423 (39.8)
< 1 time/ week 8 (0.8) 18 (1.7) Table 1).
1–3 times/ week 48 (4.6) 72 (6.8)
Every day 642 (61.9) 551 (51.8) 3.3. Risk assessment
Disabled in ADL 32 (3.1) 51 (4.8) 0.045
Hypertension, n (%) 190 (18.3) 237 (22.3) 0.024
Coronary heart disease, n (%) 151 (14.6) 175 (16.4) 0.233
Participants were divided into: low-risk, moderate-risk, and high-
Arrhythmia, n (%) 2 (0.2) 5 (0.5) 0.271 risk groups based on the tertiles of total score presented in
Diabetes mellitus, n (%) 32 (3.1) 49 (4.7) 0.071 Supplementary Table 2. Fig. 2 presents the Kaplan-Meier survival
Stroke, n (%) 60 (5.8) 31 (2.9) 0.001 curves according to risk groups. The high-risk groups were at high risk
Minor stroke, n (%) 18 (1.7) 12 (1.1) 0.240
of CBVD compared with the low-risk groups (P < 0.0001). As shown in
BMI: body mass index; SBP: systolic blood pressure; DBP: diastolic blood the Supplementary Table 3, the 10-year risk of CBVD risk increased
pressure; FBG: fasting blood glucose; TC: total cholesterol; TG: triglyceride; with the risk scores.
HDL: high-density lipoprotein; LDL: low-density lipoprotein.
4. Discussion
first. We fitted a competing risk model to compute hazard ratios (HR)
and 95% confidence intervals (95% CI) for the association between Based on the Beijing Longitudinal Study of Aging, we conducted a
each risk factor and CBVD mortality. When the multivariate model was multivariate competing risk model to identify the risk factors of cere-
conducted, variables with a P-value of < 0.30 in univariate analyses brovascular disease. In addition, we developed a compressive algorithm
were included as risk factors in the final multivariate model. The integrating the major risk factors to identify the high risks population
competing risk model was performed in the R software version 3.3 for cerebrovascular disease among adults aged ≥55 years.
(https://www.r-project.org/) using “cmprsk” package. Two-sided P- Many epidemiological surveys have shown that obesity is a risk
value < 0.05 were considered statistically significant. factor for CBVD when combined with other risk factors such as hy-
pertension and hyperlipidemia (Overvad et al., 2013). Studies on Chi-
nese adults have also confirmed that elevated BMI increases the in-
3. Results cidence and mortality risk of ischemic and hemorrhagic stroke, which
supports this study (Bazzano et al., 2010). But, high BMI was not
3.1. Characteristics of the participants identified as an independent risk factor of CBVD mortality in this study.
In this study, mental health status increased the risk of vascular
Among the 2101 participants, 6 were excluded because of missing events and mortality related to CBVD, which is in line with a previous
data and 374 participants had some biochemical missing data which study in the Netherlands (Grool et al., 2012). A population-re-
were imputed using MI. At the end of the follow-up period, 211parti- presentative cohort from the United Kingdom (Scotland and London,
cipants were alive, 763 participants were lost, and 1121 participants respectively) confirmed that psychological distress is associated with
died. Among the 1121 deaths, 273 were caused by cardiovascular dis- increased risk of death due to CBVDs (Murray et al., 2013). In the
eases (25.5%), 375 by CBVD (33.4%), 140 by cancer (13.1%), and 333 Chicago Health and Aging Project, Henderson et al. reported that high
were from other causes (29.7%). levels of psychosocial distress increases the risk of both fatal and non-
Table 1 shows age, BMI, systolic pressure, diastolic blood pressure, fatal stroke in older adults (Henderson et al., 2013). On the contrary, a
TC, TG, HDL-C, LDL-C, MMSE scale, CES-D, education level, marital study founded that no clear evidence that depression is a risk factor for
status, smoking, alcohol consumption, physical activity, and high blood CBVD (Nabi et al., 2010). Recently, a study conducted based on BLSA

41
H. Li et al. Archives of Gerontology and Geriatrics 79 (2018) 39–44

Fig. 1. Survival curves for cerebrovascular incidence or mortality (a) comparison among age groups; (b) comparison between gender; (c) comparison among BMI
groups; (d) comparison among blood pressure groups; (e) comparison among cognitive function groups (MMSE score); (f) comparison among smoking habits.

reported that depressive symptoms increased the risk of cardiovascular
diseases mortality by 1.48-fold (Li et al., 2018). Similarly, we found
that males who suffered from depression, as assessed by the CES-D
scale, were at a higher risk than those who did not. Yet, the biological
mechanisms by which depression increases CBVD risk are not fully
understood. Depression has neuroendocrine and inflammatory effects
and increases platelet activity, which may promote the development of
CBVD (Kwan et al., 2013).
Cognitive impairment is common in older adults. A previous report
based on the BLSA showed that elderly people (especially women) with
lower MMSE score are at higher risk of CBVD (Guo et al., 2017). Many
CBVDs such as cerebral subcortical small vessel disease, acute stroke,
and Alzheimer disease are related to poorer cognition in elderly
(Smallwood et al., 2012). In addition, the MMSE score has a high dis-
criminative power to predict the onset stroke of compared to the
Framingham stroke risk score (Sabayan, Gussekloo, de Ruijter,
Westendorp, & de Craen, 2013). Therefore, the MMSE scale can be
applied in clinical assessment of cognitive function as a simple
screening tool to identify older adults at high risk of stroke.
The mechanism of the association between BP and CBVD may in-
volve psychological distress, which is often associated with increased
BP and sleep disturbance (Ojike et al., 2016). Indeed, both critical BP
values and hypertension were associated with CBVD mortality, al-
though the correlation between psychological distress and BP was not
established, because many factors influence BP. Additionally, the effect
of psychological distress on BP may be minor compared with other
factors. Accordingly, a previous study showed that psychological dis-
tress was caused by patients knowing that they had hypertension, but
was not associated with elevated BP values in patients without a di-
agnosis (Hamer, Batty, Stamatakis, & Kivimaki, 2010). Nevertheless,

42
H. Li et al. Archives of Gerontology and Geriatrics 79 (2018) 39–44

Table 2
Competing risk model analysis for risk factors of CBVD.
HR (95% CI)

β*
P-value *
Model 1 Model 2

Blood pressure <0.001

Normal 1.00 1.00
Critical 0.373 0.043 1.436 (1.004-2.053) 1.452 (1.012-2.084)
Hypertension 0.846 < 0.001 2.355 (1.684-3.293) 2.331 (1.652-3.288)
BMI 0.201
Thin 0.025 0.886 0.920 (0.660-1.283) 1.025 (0.732-1.435)
Normal 1.00 1.00
Overweight −0.140 0.164 0.958 (0.792-1.160) 0.870 (0.715-1.059)
Obesity 0.137 0.302 1.371 (1.065-1.764) 1.147 (0.884-1.489)
FBG 0.170
Normal 1.00 1.00
Impaired 0.070 0.571 1.139 (0.897-1.447) 1.073 (0.841-1.370)
Hyperglycemia 0.255 0.062 1.409 (1.086-1.827) 1.290 (0.960-1.569)
High TG (≥150 mg/dl) 0.205 0.102 1.379 (1.089-1.747) 1.227 (0.960-1.569)
Depression 0.401 < 0.001 1.484 (1.213-1.816) 1.494 (1.219-1.832)
Cognitive impairment 0.324 < 0.001 1.405 (1.151-1.715) 1.382 (1.132-1.689)
Drinking −0.029 0.791 0.991 (0.807-1.218) 0.972 (0.785-1.202)
Smoking 0.148 0.132 0.942 (0.782-1.135) 1.160 (0.956-1.407)
Coronary heart disease 0.308 0.005 1.434 (1.160-1.771) 1.360 (1.095-1.689)

*
β and P-value was estimated from Model 2.
Model 1: adjusted for gender and age.
Model 2: full adjusted model.
HR: hazard ratio; CI: confidence interval; BMI: body mass index; FBG: fasting blood glucose; TG: triglycerides; CES-D: Center for Epidemiological Studies Depression;
MMSE: mini-mental state examination.

high BP is a well-recognized risk factor for CBVD (Jauch et al., 2013;
Ronning, 2013).
The present study has several limitations. Despite the large sample
size, the 95% CI value was wide suggesting a high variability among the
participants. In addition, several other confounding factors such as at-
rial fibrillation were not be collected, yet it was identified as risk factors
for CBVD mortality in previous studies. However, we note that cardiac
conditions were not assessed in the present study. Finally, despite the
random sampling in the entire Beijing area, these results may not be
applicable to all people in the Beijing area. Additionally, large-scale
prospective cohort studies are still needed to identify the full-range of
risk factors for CBVD in the broader Chinese population.

Fig. 2. Survival curves for cerebrovascular cumulative survival rate according to different levels of risk groups in 1992.

43
H. Li et al.
5. Conclusion
Based on the results of this study, we confirmed that advanced age,
male gender, hypertension, cognitive impairment, and depression were
associated with higher risk of CBVD among the elderly in Beijing,
China. Individuals with clustering of multiple risk factors were at a
higher risk of CBVD mortality. Departments of public health manage-
ment and clinicians should pay more attention to the management of
blood pressure and mental conditions to reduce the risk of CBVD among
the elderly individuals. Future studies are warranted to explore the
impact of longitudinal changes in blood pressure, cognition function
and depression on the risk of CBVD.
Conflict of interest statement
There are no potential conflicts of interest include employment,
consultancies, stock ownership, honoraria, paid expert testimony, pa-
tent applications/registrations, and grants or other funding.
Funding
This study was funded by the National Natural Science Foundation
of China (No.: 81502885, 81530087, 81703317).
Acknowledgment
We thank the staff in Xuanwu hospital for collecting the epide-
miological data and maintaining the database.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.archger.2018.07.017.
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