25 Aug Discontinuing Blood Pressure Medication In Older Adults Did Not Improve Cognition
MedicalResearch.com Interview with:
Justine Moonen and Jessica Foster-Dingley
On behalf of the principal investigators:
Roos van der Mast, Ton de Craen, Wouter de Ruijter and Jeroen van der Grond
Department of Psychiatry, Leiden University Medical Center
Leiden, the Netherlands
Medical Research: What is the background for this study? What are the main findings?
Response: Mid-life high blood pressure is a well-known risk factor for cerebrovascular pathology and, consequently, cognitive decline in old age. However, the effect of late-life blood pressure on cognition is less clear. It has been suggested that at old age not a higher, but a lower blood pressure increases the risk of cognitive decline as well as neuropsychiatric symptoms. Older persons are at risk for impaired regulation of their cerebral blood flow, and stringently lowering their blood pressure may compromise cerebral blood flow, and thereby cognitive function. Therefore, we hypothesized that increasing blood pressure by discontinuation of antihypertensive treatment would improve cognitive and psychological functioning. We performed a community-based randomized controlled trial in a total of 385 participants aged ≥75 years with mild cognitive deficits and without serious cardiovascular disease, and who were all receiving antihypertensive treatment. Persons were randomized to continuation or discontinuation of antihypertensive treatment. Contradictory to our expectation, we found that discontinuation of antihypertensive treatment in older persons did not improve cognitive functioning at 16-week follow-up.
Medical Research: What should clinicians and patients take away from your report?
Response: This trial addressed a narrowly defined research question. We can only conclude that discontinuation of antihypertensive treatment in older persons with mild cognitive deficits and without serious cardiovascular disease has no short-term cognitive or psychological benefit. We cannot exclude that older persons with overt cardiovascular disease, in whom regulation of cerebral blood flow is more likely to be impaired, do benefit of an increase in blood pressure to improve cognitive and psychological function. Moreover, a sustained increase in blood pressure during a longer period than 16 weeks may be needed to prevent long-term structural cerebral damage, such as lacunar infarcts or white matter lesions, and thereby prevent cognitive deterioration. For the present, trials in older persons, generally including higher functioning older persons, indicate no increased or decreased risk of cognitive decline of antihypertensive treatment. Observational studies performed in lower functioning older persons indicate that a lower blood pressure is associated with increased risk of cognitive decline and total mortality. The newest recommendations from the Eighth Joint National Committee allow blood pressures to be as high as 150/90 mm Hg for persons aged 60 years and above.
Medical Research: What recommendations do you have for future research as a result of this study?
Response: Future randomized clinical trials with longer follow-up periods should determine whether older persons with an impaired regulation of cerebral blood flow might benefit from less stringent blood pressure targets. Nursing home residents would form a study population of interest, as they often have more serious cerebrovascular disease, and are thus prone to have an impaired regulation of cerebral blood flow.
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Justine Moonen and Jessica Foster-Dingley (2015). Discontinuing Blood Pressure Medication In Older Adults Did Not Improve Cognition