The patient initially came to see Mark Supiano in 2017 because her family was concerned about her short-term memory loss.<\/p>\n
While taking her history and vital signs, Supiano, a geriatrician at the University of Utah, saw one disturbing signal: Her blood pressure was 148\/86, above normal despite her taking two medications intended to lower it. \u201cClearly that was too high,\u201d he said recently.<\/p>\n
Several factors could have contributed to the high reading, including the anti-inflammatory drug the 78-year-old woman took for arthritis pain, a high-sodium diet, and a lack of regular exercise. She had also told Supiano that she typically drank a couple of glasses of wine each evening.<\/p>\n
After Supiano discussed ways to lower her risk, the woman and her husband joined a gym. She stopped taking the anti-inflammatory and cut back on salt and alcohol, bringing her systolic blood pressure readings into the 130-to-140 range \u2014 still hypertension, according to the guidelines<\/a>\u00a0issued by the American Heart Association and the American College of Cardiology later that year, but more acceptable. (Systolic is the top number in the blood pressure ratio and the more clinically important number.)<\/p>\n By 2019, though, the patient had a diagnosis of mild cognitive impairment, and medical evidence was emerging about a connection between hypertension (the medical term for high blood pressure) and dementia. \u201cI was not as aggressive as I should have been,\u201d Supiano recalled. He added a third drug for high blood pressure to the woman\u2019s regimen, and her readings fell to 120 or lower.<\/p>\n The shifting guidelines for blood pressure control may remind those at advanced ages of a dance fad from their youth, the limbo. As Chubby Checker once intoned, \u201cHow low can you go?\u201d<\/p>\n For more than 25 years, a reading of 140\/90 or below was considered normal, according to the AHA\/ACC guidelines. But the 2017 update introduced major changes, backed by results from the\u00a0landmark SPRINT trial<\/a>, which enrolled adults over 50 who were at high cardiovascular risk.<\/p>\n The SPRINT trial found that intensive treatment aimed at bringing the systolic number below 120 reduced the risk of heart attacks, strokes, other cardiovascular illnesses, and overall mortality so substantially that the investigators\u00a0stopped the study early<\/a>.<\/p>\n It was unethical, they decided, to deny half the trial participants the benefits of intensive treatment. The 2017 guidelines, therefore, recommended medication for those with a systolic blood pressure over 130.<\/p>\n The\u00a0most recent revisions<\/a>, issued last year, encourage still tighter control. They call for patients at cardiovascular risk to strive for systolic readings below 120, and they also call that target \u201creasonable\u201d even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.<\/p>\n Blood pressure normally rises with age because \u201cwith stiffening of the arteries, the heart has to pump harder,\u201d said Erica Spatz, the director of the preventive cardiovascular health program at the Yale School of Medicine. From 2021 to 2023, about\u00a0two-thirds of adults over 65<\/a> had hypertension, according to the operative definition at the time.<\/p>\n But recent revisions could \u201cdefine a lot more people as having high blood pressure,\u201d said Rita Redberg, a cardiologist at the University of California-San Francisco.<\/p>\n To Supiano, recent\u00a0studies in the United States<\/a>\u00a0and\u00a0in China<\/a>\u00a0that show cognitive benefit for the lower readings \u201chave tipped the scales\u201d for older adults. \u201cWhat\u2019s good for the heart is good for the brain,\u201d he said, calling those findings \u201ca lever to get people to pay more attention to their blood pressure. They may not want to live longer, but they want to hold on to their cognition longer.\u201d<\/p>\n Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization\u2019s board), have endorsed the latest guidelines.<\/p>\n \u201cI used to be lenient in many of my older patients,\u201d said John Dodson, a cardiologist and researcher at NYU Langone Health. \u201cIf I overtreated high blood pressure, bad things were going to happen.\u201d<\/p>\n Blood pressure that drops too low \u2014 hypotension \u2014 can cause dizziness and fainting or injuries from falls.<\/p>\n Now, Dodson said, \u201cI\u2019m treating my older patients more aggressively.\u201d Studies have shown that treating high blood pressure\u00a0benefits even frail older adults<\/a>. And while older adults in the SPRINT trial had more fall injuries, the rate wasn\u2019t higher\u00a0in those receiving intensive treatment<\/a>\u00a0than in those undergoing standard treatment. Among those over 75, it was\u00a0about 5%<\/a>\u00a0for both groups.<\/p>\n Another significant change: The new guidelines recommend at-home monitoring.<\/p>\n \u201cBlood pressure is tricky,\u201d Spatz pointed out. \u201cIt varies throughout the day, depending on whether a person is just waking up or just ate or it\u2019s hot outside.\u201d Systolic readings can bounce around by 30 points or more in a single day.<\/p>\n And they\u2019re almost always higher in a doctor\u2019s office. \u201cI don\u2019t want to put much stock in one reading,\u201d Spatz said.<\/p>\n \u201cMaybe the patient has white-coat syndrome,\u201d she added, referring to anxiety about doctors and testing, \u201cor they had a fight with the parking attendant\u201d on the way in.<\/p>\n She asks patients to record their blood pressure twice a day for a week or two before their appointments. Some doctors prescribe a 24-hour home monitor.<\/p>\n Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.<\/p>\n Price is not likely to present an obstacle. Most patients need two or three drugs to lower blood pressure, but as generics they\u2019re \u201cdirt cheap, about $5 a month,\u201d and rarely interact with the other drugs that are often prescribed for older people, Supiano said. A blood pressure monitor for home use\u00a0runs $35<\/a>, or more for those that digitally transmit data.<\/p>\n Although some side effects are serious \u2014 a fall can be life-altering \u2014 most complications \u201cthankfully are transient and reversible and rather mild,\u201d he said.<\/p>\n Yet the guidelines have skeptics, too. Redberg, for example, counsels older patients about diet, exercise, and weight loss but does not urge them to start medication to reduce a 135 systolic reading to below 120.<\/p>\n They already seem overanxious about their blood pressure, she said, adding, \u201cI encourage them to go out and enjoy themselves.\u201d<\/p>\n \u201cTake a class! Go to a museum!\u201d she said. \u201cYou can\u2019t do that if you\u2019re at home taking your blood pressure five times a day.\u201d<\/p>\n While trials and guidelines address benefits for the population as a whole \u2014 even small reductions in dementia would have an enormous impact \u2014 they are not useful for predicting individual outcomes. The\u00a0PREVENT calculator<\/a>, used to gauge whether someone would see cardiovascular benefit from hypertension treatment, has not been validated for people over 79 and does not factor in cognitive benefits, Supiano noted.<\/p>\n For people with other serious illnesses \u2014 cancer patients or frail nursing home residents with dementia, for instance \u2014 controlling blood pressure may be far down the list of concerns.<\/p>\n Time is also a factor in weighing risks versus benefits. A meta-analysis of older patients by Sei Lee, a geriatrician at UCSF, and colleagues found that for 200 patients in intensive treatment for hypertension, it would\u00a0take 1.7 years to prevent a single stroke<\/a>.<\/p>\n Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. \u201cYou\u2019d have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher.\u201d<\/p>\n Supiano\u2019s 78-year-old patient did hit that target and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and eventually received an Alzheimer\u2019s diagnosis.<\/p>\n Given what researchers are reporting about the cognitive benefits of treating high blood pressure, \u201cmaybe it gave her another couple of good years,\u201d he mused. \u201cMaybe it delayed the progression.\u201d Or maybe, he added, he should have started intensive treatment earlier.<\/p>\n The New Old Age is produced through a partnership with The New York Times<\/a>.<\/em><\/p>\n\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n