Biomed & Pharmacother 1997;51:208-212 0 Elsevier, Paris Dossier “Aging part II” The treatment of hypertension in older people and its effect on cognitive function MJ Prince Epidemiology Unit, London School of Hygiene and Tropical Medicine. Keppel St, London WCIE 7Hr UK Summary - The benefits of antihypertensive drug therapy for older people have been clearly established, Meta-analysis suggests a 12% reduction in all-cause mortality, a 20% reduction in coronary heart disease and a 36% reduction in stroke. The absolute benefits of treatment are great due to the high incidence of vascular disease among older people. Clinicians may nevertheless have been deterred from initiating treatment because of concerns regarding adverse effects on cognition, mood, functional ability and quality of life. Recent evidence from randomised controlled trials suggests that these concerns are groundless. In the light of this evidence it is therefore disturbing that up to 50% of all older people with hypertension may remain untreated; and in over 50% of those who are treated, blood pressure may be inadequately controlled. hypertension / vascular disease / drug therapy INTRODUCTION Hypertension is recognised as an important inde- pendent risk factor for cardiovascular and cere- brovascular disease. In principle, the absolute benefits associated with antihypertensive treat- ment should be greatest in the older population, as the vascular diseases associated with hyperten- sion are much more common among the aged. The absolute risk of experiencing a major car- diovascular event over ten years amounts to only 1% for hypertensives aged 25-34 years, but rises to 30% for those aged 65-74 years. However, until relatively recently the ratio of risks to bene- fits for the elderly had not been investigated, and without clear treatment guidelines many older people with moderate hypertension either escaped detection; or, if detected, were not treated. Two attitudes seemed to underpin this reluctance to treat: first, that high blood pressure constituted a healthy adaptation to arteriosclerotic rigidity; and second, that lowering the blood pressure in the elderly was fraught with danger. In 1989 [16], a textbook of family medicine commented on high blood pressure in older people as having “a differ- ent significance from high blood pressure in the young... a high blood pressure in the aged might actually have survival value,” and warned that hy- potensive drugs were “more likely to produce postural hypotension and confusion in the aged.” In 1994, Materson [ 151 identified four criteria which should be met to justify therapy for older patients with hypertension, ie, that: 1) untreated hypertension is associated with increased morbid- ity and mortality; 2) blood pressure levels are re- duced by antihypertensive drug therapy; 3) ther- apy reduces morbidity and mortality associated with hypertension; 4) therapy does not cause sig- nificant adverse effects on intellectual function, affect, motor skills and activities of daily living. Evidence in support of the first two criteria was already available when Materson wrote his edi- torial, and need not be re-examined here; that re- lating to the third and fourth criteria forms the basis of this review. EFFECT OF ANTIHYPERTENSIVE DRUG THERAPY ON MORBIDITY AND MORTALITY Three large prospective placebo-controlled trials reported on in 1991 and 1992 provided the first unequivocal indication of the benefits associated