The patient first came to see Mark Spiano in 2017 because her family was concerned about her short-term memory loss.
While reviewing her medical history and vital signs, Spiano, a geriatrician at the University of Utah, noticed a disturbing signal. Her blood pressure was above normal at 148/86, despite taking two medications to lower it. “It was clearly too expensive,” he said recently.
Several factors may have contributed to the high numbers, including anti-inflammatory drugs the 78-year-old woman took for arthritis pain, a high-sodium diet, and lack of regular exercise. She also told Spiano that she usually drinks two glasses of wine every night.
The woman and her husband joined the gym after Spiano discussed ways to lower their risk. She stopped taking her anti-inflammatory medications and reduced her salt and alcohol intake, resulting in her systolic blood pressure readings in the 130-140 range. It’s still high blood pressure, but it’s now in a more tolerable range, according to guidelines issued later that year by the American Heart Association and American College of Cardiology. (Systolic blood pressure is the highest value of the blood pressure ratio and is the most clinically important value.)
However, by 2019, the patient was diagnosed with mild cognitive impairment, and medical evidence emerged of a link between hypertension (the medical term for high blood pressure) and dementia. “I wasn’t as aggressive as I should have been,” Spiano recalls. He added a third hypertension drug to the woman’s treatment plan, and her readings dropped below 120.
Changes in blood pressure management guidelines may remind older adults of a dance fad from their youth: limbo. Chubby Checker once said, “How low can you go?”
For more than 25 years, a reading of 140/90 or lower has been considered normal, according to AHA/ACC guidelines. However, the 2017 update introduced major changes supported by results from the landmark SPRINT trial, which enrolled adults aged 50 and older at high cardiovascular risk.
In the SPRINT trial, researchers stopped the study early after finding that intensive treatment aimed at bringing systolic numbers below 120 significantly reduced the risk of heart attacks, strokes, and other cardiovascular diseases, as well as overall mortality.
They decided it would be unethical to deny the benefit of intensive care to half the trial participants. Therefore, the 2017 guidelines recommend drug therapy for people with a systolic blood pressure above 130.
The latest revision, published last year, encourages even stricter controls. They urge patients at risk for cardiovascular disease to strive for a systolic reading of less than 120, and say the goal is “reasonable” even for patients who are not at high risk. Measurements that were considered normal not too long ago are now defined as high blood pressure.
“Blood pressure typically increases with age because when the arteries harden, the heart has to pump harder,” said Erica Spatz, director of the Preventive Cardiovascular Health Program at Yale School of Medicine. From 2021 to 2023, about two-thirds of adults 65 and older had high blood pressure, according to doctors’ definitions at the time.
But recent changes “may mean more people will be defined as having high blood pressure,” said Rita Redberg, a cardiologist at the University of California, San Francisco.
Recent studies in the U.S. and China have shown that lower readings are beneficial for cognitive function, and “tipped the scales” for older adults, Spiano said. “What’s good for your heart is good for your brain,” he said, calling these findings “a lever to get people to pay more attention to their blood pressure. They may not want to live longer, but they want to preserve their cognitive abilities longer.”
Nearly every major medical association, including the American Geriatrics Society (of which Spiano is president), supports the latest guidelines.
“I was generous to many of my older patients,” says John Dodson, a cardiologist and researcher at New York University Langone Health. “If you overtreat high blood pressure, bad things will happen.”
If your blood pressure drops too low (hypotension), it can cause dizziness, fainting, or injury from falls.
Now, Dodson said, “we’re treating older patients more aggressively.” Research shows that treating high blood pressure can also be beneficial for frail older people. Also, although fall-related injuries were more common among older adults in the SPRINT trial, the rate was not higher among those receiving intensive care than among those receiving standard care. For people over 75, the numbers were about 5% in both groups.
Another important change: new guidelines recommend home monitoring.
“Blood pressure is tricky,” Spatz points out. “It changes throughout the day, depending on whether you just woke up, if you just ate, or if it’s hot outside.” Systolic readings can fluctuate by more than 30 points in a day.
And in the clinic it is almost always higher. “I don’t want to put too much value on one reading,” Spatz says.
“Maybe the patient has white coat syndrome,” he said, referring to anxiety about doctors and tests, adding, “Or maybe he got into a fight with a parking lot attendant on the way to the hospital.”
She asks patients to record their blood pressure twice a day for one to two weeks before their appointment. Some doctors prescribe 24-hour home monitoring.
Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that hypertension remains undertreated despite new guidelines because it is mostly asymptomatic.
Price is unlikely to be a barrier. Most patients need two or three drugs to lower their blood pressure, but as a generic version it’s “very cheap, about $5 a month,” and it’s rarely used in conjunction with other drugs often prescribed to older adults, Spiano said. Home blood pressure monitors that transmit data digitally can cost upwards of $35.
While some side effects are serious and falls can be life-altering, most complications are “thankfully temporary, reversible and fairly mild,” he says.
However, there are also skeptics of this guideline. For example, Dr. Redberg advises older patients about diet, exercise, and weight loss, but he does not recommend starting medications to lower a systolic blood pressure reading of 135 to below 120.
They may already be overly concerned about their blood pressure, she said, adding: “We encourage people to go out and have fun.”
“Let’s take a class! Let’s go to an art museum!” she said. “You can’t do that if you’re checking your blood pressure five times a day at home.”
Trials and guidelines address population-wide benefits, and while even small reductions in dementia have a significant impact, they are not useful in predicting individual outcomes. The PREVENT calculator, which is used to assess whether hypertension treatments provide cardiovascular benefits, has not been validated in people over 79 years of age and does not take into account cognitive effects, Spiano noted.
For people with other serious illnesses, such as cancer patients or frail nursing home residents with dementia, controlling blood pressure may be far below the list of concerns.
Time is also a factor when weighing risks and benefits. A meta-analysis of elderly patients by UCSF geriatrician Sei Lee and colleagues found that for 200 patients receiving intensive treatment for high blood pressure, it would take 1.7 years to prevent a single stroke.
Lee added that lowering very high blood pressure is easier and more important than trying to lower a reading of 130 to below 120. “You have to work harder, you have to add a third or fourth drug, and the risk of side effects is higher.”
Spiano’s 78-year-old patient certainly achieved that goal and did well for six or seven years. Then, as happens with many patients with mild cognitive impairment, she began to decline and was eventually diagnosed with Alzheimer’s disease.
Given what researchers have reported about the cognitive benefits of high blood pressure treatment, he thought, “Maybe she could have had a few more years of good time.” “Maybe that slowed the progression,” he added, or maybe he should have started intensive treatment earlier.
New Old Age is produced in partnership with The New York Times.
