The patient initially came to see Mark Supiano in 2017 because her family was concerned about her short-term memory loss.
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. “Clearly that was too high,” he said recently.
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.
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 — still hypertension, according to the guidelines issued 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.)
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. “I was not as aggressive as I should have been,” Supiano recalled. He added a third drug for high blood pressure to the woman’s regimen, and her readings fell to 120 or lower.
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, “How low can you go?”
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 landmark SPRINT trial, which enrolled adults over 50 who were at high cardiovascular risk.
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 stopped the study early.
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.
The most recent revisions, 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 “reasonable” even for those who are not at high risk. Readings considered normal not so long ago are now defined as hypertension.
Blood pressure normally rises with age because “with stiffening of the arteries, the heart has to pump harder,” said Erica Spatz, the director of the preventive cardiovascular health program at the Yale School of Medicine. From 2021 to 2023, about two-thirds of adults over 65 had hypertension, according to the operative definition at the time.
But recent revisions could “define a lot more people as having high blood pressure,” said Rita Redberg, a cardiologist at the University of California-San Francisco.
To Supiano, recent studies in the United States and in China that show cognitive benefit for the lower readings “have tipped the scales” for older adults. “What’s good for the heart is good for the brain,” he said, calling those 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 hold on to their cognition longer.”
Nearly all major medical associations, including the American Geriatrics Society (Supiano is the chair of the organization’s board), have endorsed the latest guidelines.
“I used to be lenient in many of my older patients,” said John Dodson, a cardiologist and researcher at NYU Langone Health. “If I overtreated high blood pressure, bad things were going to happen.”
Blood pressure that drops too low — hypotension — can cause dizziness and fainting or injuries from falls.
Now, Dodson said, “I’m treating my older patients more aggressively.” Studies have shown that treating high blood pressure benefits even frail older adults. And while older adults in the SPRINT trial had more fall injuries, the rate wasn’t higher in those receiving intensive treatment than in those undergoing standard treatment. Among those over 75, it was about 5% for both groups.
Another significant change: The new guidelines recommend at-home monitoring.
“Blood pressure is tricky,” Spatz pointed out. “It varies throughout the day, depending on whether a person is just waking up or just ate or it’s hot outside.” Systolic readings can bounce around by 30 points or more in a single day.
And they’re almost always higher in a doctor’s office. “I don’t want to put much stock in one reading,” Spatz said.
“Maybe the patient has white-coat syndrome,” she added, referring to anxiety about doctors and testing, “or they had a fight with the parking attendant” on the way in.
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.
Will patients adopt home monitoring and more aggressive treatment? Cardiologists argue that high blood pressure, almost always asymptomatic, remains undertreated despite the newer guidelines.
Price is not likely to present an obstacle. Most patients need two or three drugs to lower blood pressure, but as generics they’re “dirt cheap, about $5 a month,” and rarely interact with the other drugs that are often prescribed for older people, Supiano said. A blood pressure monitor for home use runs $35, or more for those that digitally transmit data.
Although some side effects are serious — a fall can be life-altering — most complications “thankfully are transient and reversible and rather mild,” he said.
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.
They already seem overanxious about their blood pressure, she said, adding, “I encourage them to go out and enjoy themselves.”
“Take a class! Go to a museum!” she said. “You can’t do that if you’re at home taking your blood pressure five times a day.”
While trials and guidelines address benefits for the population as a whole — even small reductions in dementia would have an enormous impact — they are not useful for predicting individual outcomes. The PREVENT calculator, 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.
For people with other serious illnesses — cancer patients or frail nursing home residents with dementia, for instance — controlling blood pressure may be far down the list of concerns.
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 take 1.7 years to prevent a single stroke.
Reducing very high blood pressure is simpler and more important than trying to lower a 130 reading to below 120, Lee added. “You’d have to work a lot harder, add a third or fourth medication, and the risk of side effects is higher.”
Supiano’s 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’s diagnosis.
Given what researchers are reporting about the cognitive benefits of treating high blood pressure, “maybe it gave her another couple of good years,” he mused. “Maybe it delayed the progression.” Or maybe, he added, he should have started intensive treatment earlier.
The New Old Age is produced through a partnership with The New York Times.
