LAUSR

Many physicians care for older adults with hypertension and are faced with the question of whether to treat it, and if so, how intensive such therapy should be. My position is pro the treatment of hypertension to preserve cognition in many older adults, but there are areas where I have equipoise as well. In this pair of companion papers, the question posed is whether to treat hypertension specifically to preserve cognition, but this simple question belies the biological complexity. It is accepted that hypertension is an important cause of damage to multiple organs, including kidney, heart, and brain, and that diseases of each of these organs have the potential to affect cognition because of metabolic disarray, hypoxemia and poor cerebral perfusion, and direct brain damage. However, despite the logic of this sequence, the literature has not conclusively shown that treating hypertension preserves cognition, even if such treatment does have other desirable effects, such as lowering the risk of stroke and death. Treating hypertension has the potential to preserve cognition through multiple mechanisms, but which mechanisms are at play in an individual patient is highly variable, complicating clinical decision making. Furthermore, in older adults, questions remain about whether treatment of hypertension at older ages will be helpful or cause harm. Now Joint National Commission (JNC) 8 and American Heart Association guidelines diverge: The JNC 8 states that patients ≥60 years should only be treated for blood pressures >150/90 mm Hg while more recent American College of Cardiology and American Heart Association guidelines that have incorporated the SPRINT (Systolic Blood Pressure Intervention Trial) results now recommend treating older adults for pressures >130/80 mm Hg. There is still debate about aggressive targets, however, and the American Academy of Family Physicians released a statement that the American College of Cardiology and American Heart Association guidelines did …