Diverse cognitive impairment after spinal cord injury is associated with orthostatic hypotension symptom burden

•Spinal cord injury impairs cognitive function.•We evaluated the associations between blood pressure instability and cognition.•Impaired cognition is associated with symptoms of low blood pressure. This study: 1) compared cognitive functioning between individuals with chronic (>1 year) spinal cord injury (SCI) and non-injured controls and, 2) assessed associations between symptoms of autonomic dysreflexia and orthostatic hypotension with cognitive functioning in SCI participants with a history of unstable blood pressure (BP). Thirty-two individuals with SCI (C4–L2, American Spinal Injury Association Impairment Scale A-D) and thirty age, sex-matched non-injured controls participated in this study. Participants completed a motor-free neuropsychological test battery assessing 1) memory, 2) attention/concentration/psychomotor speed and, 3) executive function. Nineteen participants with SCI who had injuries ≥T6 and a history of unstable BP also completed the Autonomic Dysfunction Following Spinal Cord Injury (ADFSCI) questionnaire. Cognitive function was significantly lower in people with SCI across measures of memory and executive function compared to non-injured controls. Significant, moderate-to-large associations were observed between cumulative (frequency x severity) orthostatic hypotension and total BP instability symptoms scores, with measures of attention/concentration/psychomotor speed and executive function. These data demonstrate a 10 – 65% reduced performance across specific realms of cognitive functioning in individuals with SCI relative to non-injured controls. Furthermore, cumulative subjective scores for symptoms of unstable BP were associated with diverse cognitive deficits. These findings, in individuals without co-occurring traumatic brain injury, imply cardiovascular dysregulation plays a role in cognitive deficits observed in this population.