A recent study suggests blood pressure patterns later in life may be linked to dementia risk. Which patient cohort is at an increased risk?
People who experience sustained hypertension in midlife to late life and those who experience midlife hypertension followed by late-life hypotension are at increased risk for dementia vs people who maintain normal blood pressure (BP).
The findings, reported in the August edition of JAMA, “are consistent with previous work that has demonstrated a relationship between chronic hypertension and reduced cognition in older adults,” stated researchers led by Keenan A. Walker, PhD, assistant professor of neurology at Johns Hopkins University School of Medicine.
It is known that hypertension and hypotension can both lead to cognitive decline and dementia. There is a gap in understanding, however, about the effect of BP patterns in the later decades of life on cognitive function and subsequent dementia.
The authors sought to determine if community dwelling adults with extended duration of midlife hypertension followed by hypotension later in life are at higher risk for dementia at an older age.
This community-based cohort study used data from the ongoing Atherosclerosis Risk in Communities study, which has recorded BP information for its cohort over 24 years, including midlife to late life.
The current analysis included all participants who received a baseline cognitive battery and functional assessment at visit 5 (2011-2013). A total of 4761 participants were included in the analytic sample (59% women, 21% black race).
The mean age at visit 5 was 75 years; mean age range at visit 1 was 44-66 years; and mean age range at visit 5 was 66-90 years.
Patients in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) as well as subjects in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly higher risk of subsequent dementia vs control subjects who remained normotensive.
Sustained hypertension in midlife was associated with higher dementia risk (HR, 1.41 [95% CI, 1.17-1.71]) regardless of BP later in life, suggesting a critical period for initiating therapy.
Subjects with midlife hypertension and subsequent late-life hypotension had the highest odds of developing mild cognitive impairment.
“The finding that a pattern of midlife hypertension and late-life hypotension showed a stronger relationship with incident dementia in the younger group of older adults supports studies suggesting that hypertension at a younger age (and closer to midlife) is especially deleterious, and further suggests that significant blood pressure declines following hypertension may be more pathogenic at a younger age,” the authors added.
The results underscore the need for clinicians to closely monitor antihypertensive drug therapy in elderly hypertensive patients as inappropriate dosing may lead to periods of hypotension which may lead to cognitive decline and possibly dementia.
In conclusion, patterns of sustained hypertension, particularly through midlife, should be avoided through close monitoring and management with treatment tailored to each patient.
As our hypertensive patients age, they must be closely watched with medication and dosage changes being geared toward preventing hypotension while continuing to maintain BP in a normal range.
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Walker KA, Sharrett AR, Wu A, et al. Association of midlife to late-life blood pressure patterns with incident dementia. JAMA. 2019;322:535-545.