Cognitive difficulties and malnutrition can be common with scleroderma

Cognition is a problem for 50% of patients in study, while 29% were malnourished by Patricia Inácio, PhD | March 5, 2024

Cognitive difficulties affected half of all scleroderma patients in a recent study in Italy, while malnutrition was found in more than one quarter.

While no correlation was seen between cognitive impairment and malnutrition in the 100 patients involved, the presence of these complications associated with greater functional disability and a poorer quality of life.
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Identifying them early is “pivotal to better address the chronic needs of patients affected by this disease,” researchers wrote in the study, “Role of cognitive impairment and malnutrition as determinants of quality of life in patients with systemic sclerosis,” published in the Journal of Scleroderma and Related Disorders.

​Cognitive impairment could affect majority of people with scleroderma
Evidence suggests that cognitive impairment can affect up to 87% of all with scleroderma — also known as systemic sclerosis or SSc — but factors contributing to this high prevalence remain largely unknown.

Scleroderma, caused by a buildup of collagen, leads to scarred tissue and inflammation most often affecting the skin, but also organs that can include the gastrointestinal (digestive) system, potentially putting patients at risk of malnutrition.

Recent studies suggest that malnutrition may be involved in the onset and progression of cognitive decline. With this in mind, researchers at Marche Polytechnic University in Ancona assessed the degree to which malnutrition and cognitive impairment are evident in people with scleroderma.

They analyzed data covering 100 SSc patients (88% women, median age of 62) being followed at their university’s scleroderma unit between February and December 2021.

A majority of these people (72%) had limited cutaneous SSc (lcSSc), and a majority (53%) were being treated with iloprost, marketed under the brand name Ventavis, given to relax and widen blood vessels.

Most patients, 67%, also were using a proton pump inhibitor therapy, approved to help manage gastroesophageal reflux disease in people whose scleroderma affects the digestive system.

Nutritional status was assessed by body mass index (BMI, a measure of body fat) and the Global Leadership Initiative on Malnutrition criteria, using the Malnutrition Universal Screening Tool (MUST). Specifically, MUST includes BMI, weight loss, and the presence of acute illness or no nutrition intake for more than five days, irrespective of the underlying disease.

Cognitive abilities were evaluated using the Montreal Cognitive Assessment, where scores below 26 points indicate impairments, and depression with the Patient Health Questionnaire-9 (PHQ-9) and the Beck Depression Inventory II (BDI-II). Digestive involvement and quality of life also were assessed.

Half of the patients (50%) had cognitive impairment, with overall test scores ranging from 23 to 27. Clinically significant dysphagia, or swallowing difficulties, was reported in 37% of patients and gastrointestinal symptoms in 20%.

Clinically significant depression was found in 22% according to the PHQ-9 and in 26% according to the BDI-II.

Cognitive difficulties more common in older than younger study patients
Patients with cognitive difficulties were significantly older than those with normal cognition (mean of 68 vs. 56 years), and they had a significantly higher number of co-existing disorders (a mean four vs. two). Their health-related quality of life also was poorer, as assessed by the Short Form 36 questionnaire and the Scleroderma Health Assessment Questionnaire, with worse scores in domains that included physical function, bodily pain, general health, and mental health.

Malnutrition was found in 29 of the 100 patients (29%). These people also were older (mean age, 67 vs. 60) and they had significantly higher (worse) modified Rodnan Skin Scores, a measure of skin thickness. In fact, a higher percentage of malnourished patients had diffuse scleroderma, a more severe disease form (48.2%), than did those showing adequate nutrition (19.7%).

Lung involvement also was more common in malnourished patients than other patients (82.7% vs. 59.1%), as was the prevalence of disease involvement affecting the esophagus, the muscular tube that connects the throat to the stomach (86.2% vs. 53.5%).

A greater need for therapies that prevent blood clotting, also known as antiplatelet therapy, was evident in malnourished patients (44.8% vs. 19.7%), and their dysphagia and gastrointestinal symptoms were significantly worse.
Statistical analysis showed that age was the only significant predictor of cognitive impairment. Higher skin scores, dysphagia, and age all significantly associated with malnutrition. However, no correlation was seen between malnutrition and cognitive impairment.

“As expected, the main determinant of cognitive impairment was found to be the age of patients, followed by the number of comorbidities,” the researchers wrote. “In contrast, we did not observe associations with disease duration, disease subset (diffuse or limited) … different disease localizations (including gastrointestinal), and current therapy.”
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Overall, study findings indicate that “both cognitive impairment and malnutrition occur frequently in patients with SSc,” the researchers concluded. Their early recognition “could help initiate a pathway to meet all the patient’s needs, expectations, and preferences, both in terms of diagnostic and therapeutic aspects.”