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Blood pressure in advanced age: with focus on epidemiology, cognitive impairment and mortality
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Geriatric Medicine.
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general conception is that blood pressure increases with age, but that diastolic blood pressure (DBP) starts decreasing in the elderly. There are, however, indications that systolic blood pressure (SBP) might also decline in advanced age, but further studies are needed to establish whether this is true. Midlife hypertension is an acknowledged risk factor for mortality and dementia. Some research has, however, suggested more complicated associations between blood pressure and these outcomes in old age, as low blood pressure has been linked to both increased mortality and increased risk of dementia. Research on this subject, especially in very old people (≥85 years of age), is still limited. The purpose of the present thesis was to investigate blood pressure epidemiology in old age and associations between blood pressure and mortality and cognition in very old people.

Subjects were mainly derived from the Umeå 85+/GERDA (GErontological Regional DAtabase) study, a study on individuals aged 85 years, 90 years or ≥95 years carried out in northern Sweden and Finland in 2000-2007. For analysis of blood pressure change with age, data from this study were combined with data from the U70 study that was carried out in the city of Umeå, Sweden between 1981-1990 and included individuals aged 70-88 years. Investigations were performed during a home visit in the Umeå 85+/GERDA study and at a geriatric centre in the U70 study. SBP and DBP were measured in the supine position in both studies and pulse pressure (PP) was calculated as SBP-DBP.  Main outcome variables were 4-year mortality, Mini-Mental State Examination (MMSE) scores, dementia and blood pressure change with age and over the years. Treatment with antihypertensive drugs was also considered.

Blood pressure changes with age and time were investigated using 1133 blood pressure measurements from 705 individuals aged ≥70 years performed between 1981 and 2005. DBP continually decreased with increasing age, whereas SBP and PP increased up to age 74.5 and 80.6 years, respectively, to then start decreasing. Mean SBP and DBP also decreased over the years. The prevalence of treatment with antihypertensive drugs increased during the same period and is probably one explanation for the decrease in blood pressure with time. Blood pressure also decreased in longitudinal analyses of those individuals who participated in more than one data collection. Women had higher SBP and PP than men.

The association between blood pressure and 4-year mortality was investigated in a sample of 348 individuals aged ≥85 years. Results indicated a non-linear association between SBP and mortality, i.e. both lower and higher SBP were associated with increased mortality. The lowest mortality risk was associated with an SBP of 164 mmHg (95% confidence interval 154-184 mmHg). The analyses were adjusted for a number of diseases and health factors and thus suggest a negative effect of low SBP on survival, independent of health status. There was no association between DBP or PP and 4-year mortality.

The impact of blood pressure on MMSE scores and dementia was investigated both in a cross-section of 575 individuals and longitudinally in two samples including 102 and 205 individuals, respectively, all ≥85 years old. Cross-sectional analysis demonstrated nonlinear associations between SBP and PP and MMSE scores, indicating poorer cognitive function with both low and high blood pressure. The association between DBP and MMSE scores was linear, higher DBP being associated with higher scores. Individuals with dementia had lower blood pressure than those without dementia. Longitudinally, over five years, no association between baseline blood pressure and incident dementia or change in MMSE scores could be demonstrated. Mean blood pressure declined over this time period, and this decline was greater in individuals who developed dementia than in those who remained dementia free. A greater decline in blood pressure was associated with a greater decline in MMSE scores.

In conclusion, this study has shown a decrease in both SBP and DBP in advanced age and also that low blood pressure is associated with both increased mortality and poor cognitive function in very old people. These associations might not be fully explained by underlying disease or poor health status; the underlying mechanisms are so far mostly speculative. Very high blood pressure might also remain a risk factor for the mentioned outcomes even in very old age, at least in some people. No association between baseline blood pressure and cognitive decline or incident dementia could be demonstrated, but blood pressure decline was associated with cognitive decline and incident dementia. The direction of this association remains to be determined. Blood pressure also decreased over the years from 1981 to 2005, probably partly due to an increasing prevalence of treatment with antihypertensive drugs.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2010. , 99 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1372
Keyword [en]
Blood pressure, hypertension, very old, mortality, epidemiology, cognitive impairment, dementia
Keyword [sv]
Blodtryck, hypertoni, mycket gamla, dödlighet, epidemiologi, demens
National Category
Geriatrics
Research subject
Geriatrics; Epidemiology
Identifiers
URN: urn:nbn:se:umu:diva-37153ISBN: 978-91-7459-077-7 (print)OAI: oai:DiVA.org:umu-37153DiVA: diva2:358105
Public defence
2010-11-13, Aulan, Vårdvetarhuset, Umeå Universitet, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Projects
Umeå 85+/GERDA
Available from: 2010-10-23 Created: 2010-10-20 Last updated: 2010-10-23Bibliographically approved
List of papers
1. Lower systolic blood pressure is associated with greater mortality in people aged 85 and older
Open this publication in new window or tab >>Lower systolic blood pressure is associated with greater mortality in people aged 85 and older
Show others...
2008 (English)In: Journal of The American Geriatrics Society, ISSN 0002-8614, E-ISSN 1532-5415, Vol. 56, no 10, 1853-1859 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To investigate the association between blood pressure and mortality in very old people. DESIGN: Population-based cohort study.

SETTING: County of Västerbotten, Sweden.

PARTICIPANTS: Half of all subjects aged 85 and all of those aged 90 and 95 and older (N=348) in one urban and five rural municipalities in the north of Sweden.

MEASUREMENTS: Among others, supine blood pressure, Mini-Mental State Examination, Barthel Index of activities of daily living, Mini Nutritional Assessment, and body mass index. Information on diagnoses, medications, and 4-year mortality was collected. Associations between blood pressure and mortality were investigated using Cox regression analyses, controlling for a number of diagnoses and health factors.

RESULTS: Baseline systolic blood pressure (SBP), diastolic blood pressure, and pulse pressure were all inversely associated with mortality within 4 years according to univariate analysis. SBP was the strongest predictor. In Cox regression analyses, low SBP (≤120 mmHg) correlated with greater 4-year all-cause mortality alone and when controlling for health status. This connection persisted after exclusion of deaths within the first year. There was a tendency toward a U-shaped mortality curve for the adjusted model, with SBP of 164.2 mmHg (95% confidence interval=154.1–183.8 mmHg) being associated with the lowest mortality.

CONCLUSION: Lower SBP seems to be associated with greater mortality in people aged 85 and older, irrespective of health status. There are indications of a U-shaped correlation between SBP and mortality, and the optimal SBP for this age group could be above 140 mmHg.

Keyword
blood pressure;hypertension;mortality;oldest-old;Cox models
Identifiers
urn:nbn:se:umu:diva-37128 (URN)10.1111/j.1532-5415.2008.01948.x (DOI)18811610 (PubMedID)
Available from: 2010-10-20 Created: 2010-10-20 Last updated: 2017-12-12Bibliographically approved
2. Low blood pressure is associated with cognitive impairment in very old people
Open this publication in new window or tab >>Low blood pressure is associated with cognitive impairment in very old people
2010 (English)In: Dementia and Geriatric Cognitive Disorders, ISSN 1420-8008, E-ISSN 1421-9824, Vol. 29, no 4, 335-341 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND/AIMS: Hypertension is an established risk factor for dementia. However, the association between blood pressure and cognition in the very old is not fully determined and important to study considering the ageing population and the morbidity associated with cognitive impairment. METHODS: This cross-sectional study included 575 individuals aged 85, 90 or 95 years and above and living in northern Sweden or Finland. Participants were interviewed and assessed using a structured protocol. Systolic (SBP) and diastolic blood pressures (DBP) were measured and pulse pressure (PP) calculated. Cognitive function was evaluated using the Mini-Mental State Examination (MMSE). Data were also collected from medical charts and caregivers. RESULTS: After adjustment for several demographic variables and diagnoses, SBP was significantly associated with MMSE in a nonlinear fashion; both high and low pressures were associated with poorer results. There was also a linear and positive association between PP and MMSE scores, but no association with DBP was found. Participants with dementia had lower blood pressure. CONCLUSION: After adjustment for a number of health factors, there was an association between low blood pressure and cognitive impairment. The direction of any causal relationship between blood pressure and cognition remains to be determined.

Keyword
Blood pressure, Cognitive impairment, Mini Mental State Examination, Oldest-old population, Dementia
Identifiers
urn:nbn:se:umu:diva-37127 (URN)10.1159/000289821 (DOI)000278130700007 ()20389075 (PubMedID)
Available from: 2010-10-20 Created: 2010-10-20 Last updated: 2017-12-12Bibliographically approved
3. Longitudinal associations between blood pressure and dementia in the very old
Open this publication in new window or tab >>Longitudinal associations between blood pressure and dementia in the very old
2010 (English)In: Dementia and Geriatric Cognitive Disorders, ISSN 1420-8008, E-ISSN 1421-9824, Vol. 30, no 3, 269-276 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND/AIMS: Midlife hypertension is associated with an increased risk for dementia, but the association between blood pressure and dementia in very old age is unclear.

METHODS: In a population-based cohort study, a total of 102 individuals aged 85, 90 or ≥ 95 years participated in 2 examinations with a 5-year interval. The investigations consisted of a structured interview, blood pressure measurement, rating scales such as the Mini-Mental State Examination (MMSE) and an investigation of medical charts.

RESULTS: The majority of participants exhibited a decline in blood pressure. Baseline systolic blood pressure (SBP), diastolic blood pressure or pulse pressure (PP) were not associated with incident dementia or with decline in MMSE scores in multiple regression analyses adjusted for age and sex. However, incident dementia cases exhibited a greater decline in SBP (p = 0.02) and PP (p = 0.04), and decline in SBP was associated with a decline in MMSE score (p = 0.008).

CONCLUSION: In this small longitudinal study on the very old, no association between baseline blood pressure and incident dementia was found, but individuals who developed dementia exhibited a greater blood pressure decline. Low blood pressure could be an effect of dementia in the very old.

Keyword
Blood pressure, dementia, very old
National Category
Geriatrics
Research subject
Geriatrics
Identifiers
urn:nbn:se:umu:diva-37126 (URN)10.1159/000320252 (DOI)000281965800011 ()20847558 (PubMedID)
Available from: 2010-10-20 Created: 2010-10-20 Last updated: 2017-12-12Bibliographically approved
4. Blood pressure change and antihypertensive treatment in old and very old people: evidence of age and cohort effects
Open this publication in new window or tab >>Blood pressure change and antihypertensive treatment in old and very old people: evidence of age and cohort effects
2013 (English)In: Journal of Human Hypertension, ISSN 0950-9240, E-ISSN 1476-5527, Vol. 27, no 3, 197-203 p.Article in journal (Other academic) Published
Abstract [en]

The epidemiology of blood pressure in very old age has not been thoroughly studied. The objective of this study was to study blood pressure changes throughout old age and changes in blood pressure and antihypertensive drug use from 1981 to 2005. The study includes 1133 blood pressure measurements from two studies carried out in Umea, Sweden. The U70 study (1981-1990) included individuals aged 70-88 and the Umea 85+/GERDA study (2000-2005) covered people aged 85, 90 or >= 95 years. The impact of age, sex and year of investigation on blood pressure was investigated using linear regression. Mean diastolic blood pressure (DBP) decreased by 0.35mmHg (P<0.001) for each year of age. An inverted U-shaped relation was found between age and systolic blood pressure (SBP), with SBP reaching its maximum at 74.5 years. Mean SBP and DBP also decreased over time (SBP by 0.44mmHg per year, P<0.001 and DBP by 0.34mmHg per year, P<0.001). The proportion of participants on antihypertensive drugs increased from 39.0% in 1981 to 69.4% in 2005. In this study of people aged >= 70 years, mean SBP and DBP decreased with higher age and later investigation year. Antihypertensive drug use increased with time, which might partly explain the observed cohort effect.

Place, publisher, year, edition, pages
Nature Publishing Group, 2013
Keyword
blood pressure, epidemiology, very old, cohort effect
National Category
Geriatrics
Identifiers
urn:nbn:se:umu:diva-37152 (URN)10.1038/jhh.2012.14 (DOI)
Available from: 2010-10-20 Created: 2010-10-20 Last updated: 2017-12-12Bibliographically approved

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