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Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia.
JAMA 2019; 322(6):535-545JAMA

Abstract

Importance

The association between late-life blood pressure (BP) and cognition may depend on the presence and chronicity of past hypertension. Late-life declines in blood pressure following prolonged hypertension may be associated with poor cognitive outcomes.

Objective

To examine the association of midlife to late-life BP patterns with subsequent dementia, mild cognitive impairment, and cognitive decline.

Design, Setting, and Participants

The Atherosclerosis Risk in Communities prospective population-based cohort study enrolled 4761 participants during midlife (visit 1, 1987-1989) and followed-up over 6 visits through 2016-2017 (visit 6). BP was examined over 24 years at 5 in-person visits between visits 1 and 5 (2011-2013). During visits 5 and 6, participants underwent detailed neurocognitive evaluation. The setting was 4 US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Follow-up ended on December 31, 2017.

Exposures

Five groups based on longitudinal patterns of normotension, hypertension (>140/90 mm Hg), and hypotension (<90/60 mm Hg) at visits 1 to 5.

Main Outcomes and Measures

Primary outcome was dementia onset after visit 5, based on Ascertain Dementia-8 informant questionnaires, Six-Item Screener telephone assessments, hospital discharge and death certificate codes, and the visit 6 neurocognitive evaluation. Secondary outcome was mild cognitive impairment at visit 6, based on the neurocognitive evaluation.

Results

Among 4761 participants (2821 [59%] women; 979 [21%] black race; visit 5 mean [SD] age, 75 [5] years; visit 1 mean age range, 44-66 years; visit 5 mean age range, 66-90 years), there were 516 (11%) incident dementia cases between visits 5 and 6. The dementia incidence rate for participants with normotension in midlife (n = 833) and late life was 1.31 (95% CI, 1.00-1.72 per 100 person-years); for midlife normotension and late-life hypertension (n = 1559), 1.99 (95% CI, 1.69-2.32 per 100 person-years); for midlife and late-life hypertension (n = 1030), 2.83 (95% CI, 2.40-3.35 per 100 person-years); for midlife normotension and late-life hypotension (n = 927), 2.07 (95% CI, 1.68-2.54 per 100 person-years); and for midlife hypertension and late-life hypotension (n = 389), 4.26 (95% CI, 3.40-5.32 per 100 person-years). Participants in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) and in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly increased risk of subsequent dementia compared with those who remained normotensive. Irrespective of late-life BP, sustained hypertension in midlife was associated with dementia risk (HR, 1.41 [95% CI, 1.17-1.71]). Compared with those who were normotensive in midlife and late life, only participants with midlife hypertension and late-life hypotension had higher risk of mild cognitive impairment (37 affected individuals (odds ratio, 1.65 [95% CI, 1.01-2.69]). There was no significant association of BP patterns with late-life cognitive change.

Conclusions and Relevance

In this community-based cohort with long-term follow-up, sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal BP, were associated with increased risk for subsequent dementia.

Authors+Show Affiliations

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland.School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis.Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Johns Hopkins Center on Aging and Health, Baltimore, Maryland.Division of Geriatrics, Department of Medicine, University of Mississippi Medical Center, Jackson.Department of Neurology, Mayo Clinic, Rochester, Minnesota.Department of Epidemiology and Biostatistics, George Washington University Milken Institute School of Public Health, Washington, DC.Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.Division of Geriatrics, Department of Medicine, University of Mississippi Medical Center, Jackson.Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland. Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

31408138

Citation

Walker, Keenan A., et al. "Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia." JAMA, vol. 322, no. 6, 2019, pp. 535-545.
Walker KA, Sharrett AR, Wu A, et al. Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia. JAMA. 2019;322(6):535-545.
Walker, K. A., Sharrett, A. R., Wu, A., Schneider, A. L. C., Albert, M., Lutsey, P. L., ... Gottesman, R. F. (2019). Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia. JAMA, 322(6), pp. 535-545. doi:10.1001/jama.2019.10575.
Walker KA, et al. Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia. JAMA. 2019 08 13;322(6):535-545. PubMed PMID: 31408138.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Association of Midlife to Late-Life Blood Pressure Patterns With Incident Dementia. AU - Walker,Keenan A, AU - Sharrett,A Richey, AU - Wu,Aozhou, AU - Schneider,Andrea L C, AU - Albert,Marilyn, AU - Lutsey,Pamela L, AU - Bandeen-Roche,Karen, AU - Coresh,Josef, AU - Gross,Alden L, AU - Windham,B Gwen, AU - Knopman,David S, AU - Power,Melinda C, AU - Rawlings,Andreea M, AU - Mosley,Thomas H, AU - Gottesman,Rebecca F, PY - 2020/02/13/pmc-release PY - 2019/8/14/entrez PY - 2019/8/14/pubmed PY - 2019/8/31/medline SP - 535 EP - 545 JF - JAMA JO - JAMA VL - 322 IS - 6 N2 - Importance: The association between late-life blood pressure (BP) and cognition may depend on the presence and chronicity of past hypertension. Late-life declines in blood pressure following prolonged hypertension may be associated with poor cognitive outcomes. Objective: To examine the association of midlife to late-life BP patterns with subsequent dementia, mild cognitive impairment, and cognitive decline. Design, Setting, and Participants: The Atherosclerosis Risk in Communities prospective population-based cohort study enrolled 4761 participants during midlife (visit 1, 1987-1989) and followed-up over 6 visits through 2016-2017 (visit 6). BP was examined over 24 years at 5 in-person visits between visits 1 and 5 (2011-2013). During visits 5 and 6, participants underwent detailed neurocognitive evaluation. The setting was 4 US communities: Washington County, Maryland; Forsyth County, North Carolina; Jackson, Mississippi; and Minneapolis, Minnesota. Follow-up ended on December 31, 2017. Exposures: Five groups based on longitudinal patterns of normotension, hypertension (>140/90 mm Hg), and hypotension (<90/60 mm Hg) at visits 1 to 5. Main Outcomes and Measures: Primary outcome was dementia onset after visit 5, based on Ascertain Dementia-8 informant questionnaires, Six-Item Screener telephone assessments, hospital discharge and death certificate codes, and the visit 6 neurocognitive evaluation. Secondary outcome was mild cognitive impairment at visit 6, based on the neurocognitive evaluation. Results: Among 4761 participants (2821 [59%] women; 979 [21%] black race; visit 5 mean [SD] age, 75 [5] years; visit 1 mean age range, 44-66 years; visit 5 mean age range, 66-90 years), there were 516 (11%) incident dementia cases between visits 5 and 6. The dementia incidence rate for participants with normotension in midlife (n = 833) and late life was 1.31 (95% CI, 1.00-1.72 per 100 person-years); for midlife normotension and late-life hypertension (n = 1559), 1.99 (95% CI, 1.69-2.32 per 100 person-years); for midlife and late-life hypertension (n = 1030), 2.83 (95% CI, 2.40-3.35 per 100 person-years); for midlife normotension and late-life hypotension (n = 927), 2.07 (95% CI, 1.68-2.54 per 100 person-years); and for midlife hypertension and late-life hypotension (n = 389), 4.26 (95% CI, 3.40-5.32 per 100 person-years). Participants in the midlife and late-life hypertension group (hazard ratio [HR], 1.49 [95% CI, 1.06-2.08]) and in the midlife hypertension and late-life hypotension group (HR, 1.62 [95% CI, 1.11-2.37]) had significantly increased risk of subsequent dementia compared with those who remained normotensive. Irrespective of late-life BP, sustained hypertension in midlife was associated with dementia risk (HR, 1.41 [95% CI, 1.17-1.71]). Compared with those who were normotensive in midlife and late life, only participants with midlife hypertension and late-life hypotension had higher risk of mild cognitive impairment (37 affected individuals (odds ratio, 1.65 [95% CI, 1.01-2.69]). There was no significant association of BP patterns with late-life cognitive change. Conclusions and Relevance: In this community-based cohort with long-term follow-up, sustained hypertension in midlife to late life and a pattern of midlife hypertension and late-life hypotension, compared with midlife and late-life normal BP, were associated with increased risk for subsequent dementia. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/31408138/Association_of_Midlife_to_Late_Life_Blood_Pressure_Patterns_With_Incident_Dementia_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2019.10575 DB - PRIME DP - Unbound Medicine ER -