Hypertension
by Women’s Brain Health Initiative:
HIGH BLOOD PRESSURE IN YOUNG ADULTS HEIGHTENS FUTURE DEMENTIA RISK.
Anthony Sherwood* was going through member orientation at his new gym in Toronto when a staff member took his blood pressure.
The reading stopped the staffer cold.
Sherwood’s blood pressure was 146/90, above Canada’s threshold for hypertension diagnosis of 140/90.
“I was 23 years old with the blood pressure of a stressed out 50-year-old man,” Sherwood said. “I had no symptoms and felt fine like I always felt. It was quite the wake-up call.”
Sherwood is part of a relatively small group – according to Statistics Canada 3% of people aged 20-39 have high blood hypertension, with the majority of those diagnosed over the age of 60, according to Hypertension Canada, a national non-profit organization.
Typical risks that come with untreated high blood pressure include heart attack or stroke, kidney failure, aneurysms, and loss of vision. But Statistics Canada estimates 74% of people who had stage 1 hypertension are unaware they even had it, since it is a silent disease that produces few if any symptoms.
And several recent studies have now linked a hypertension diagnosis in early adulthood with an increased risk of dementia.
FINDINGS SHOULD PROMPT EARLIER INTERVENTION
One study, entitled “The Association of Age at Diagnosis of Hypertension with Brain Structure and Incident Dementia in the UK Biobank” and published in Hypertension in October 2021, looked at data collected from the UK Biobank between 2006 and 2010.
Research, led by Dr. Xianwen Shang and colleagues, concluded there were different levels of cognitive risk depending on the age of the patient at the time of diagnosis.
PATIENTS DIAGNOSED WITH HIGH BLOOD PRESSURE BETWEEN THE AGES OF 35 AND 44 FACED A HIGHER RISK OF DEVELOPING DEMENTIA, WHILE THERE WAS AN ASSOCIATION WITH SMALLER BRAIN VOLUME FOR THOSE DIAGNOSED AT THE AGE OF 54 OR YOUNGER. THOSE WHO DEVELOPED HYPERTENSION LATER IN LIFE DID NOT FACE INCREASED ASSOCIATIONS WITH SMALLER BRAIN VOLUME OR DEMENTIA.
A second study, entitled “Association of Early Adulthood 25-Year Blood Pressure Trajectories with Cerebral Lesions and Brain Structure in Midlife,” published in March 2022 in JAMA Network Open, made a similar conclusion.
Researchers followed 853 adults with hypertension who were between the ages of 18 and 30 years old for 30 years. The research, led by Dr. Yi-Han Hu and colleagues, found high blood pressure in early adulthood was associated with a decline in brain health in midlife after adjusting for sociodemographic and cardiovascular risk factors.
HYPERTENSION IN YOUNGER ADULTS
Dr. Ernesto Schiffrin, Professor and Vice-Chair of the Department of Medicine at McGill University, who was named the American Heart Association’s 2021 Distinguished Scientist, was not involved in the aforementioned studies but said when it comes to hypertension, it’s hard to pinpoint the difference in risk or consequences between men and women.
Dr. Schiffrin said while there is a risk of a dementia diagnosis for both sexes, there is no evidence to suggest women suffer more or less cognitive decline than men. Furthermore, he said women are more likely to identify high blood pressure earlier on as they tend to be more proactive with their health from a younger age and can therefore work to get it under control earlier.
In Sherwood’s case, before that high blood pressure reading he hadn’t had a physical in nearly 10 years.
However, he visited a walk-in clinic just hours after learning how high his blood pressure was. He also booked a full physical and has already started making significant changes to his diet.
“A stressful job, poor diet, non-existent sleep, and partying with friends was catching up to me a lot sooner than I thought it would,” he said.
Dr. Schiffrin said while all of those things certainly contribute to high blood pressure, it’s always a good idea to look for secondary reasons, like a condition connected to an adrenal abnormality, which he noted is a relatively rare cause, especially when dealing with hypertension as a young adult.
Once any underlying conditions are ruled out, Dr. Schiffrin said treatments revolve around a healthy lifestyle that includes regular sleep, minimal alcohol, consistent fitness routines, eating foods that are rich in nutrients, and very importantly, lowering salt intake.
EARLY INTERVENTION IS KEY BECAUSE WHILE A HEALTHY LIFESTYLE AND MEDICATION CAN CERTAINLY SLOW DOWN OR PREVENT FURTHER DETERIORATION, IT CAN’T REVERSE THE DAMAGE THAT HAS ALREADY BEEN DONE.
PATIENTS OFTEN IGNORE PREVENTATIVE MEASURES
The real problem occurs when people don’t take their diagnosis seriously and fail to monitor their blood pressure on a regular basis, Dr. Schiffrin said.
He explained all the research he has come across suggests that controlling blood pressure is likely the only intervention that can help reduce cognitive decline.
GETTING PATIENTS TO ADHERE TO A LIFESTYLE AND TREATMENT PLAN TO HELP REGULATE THEIR BLOOD PRESSURE IS ONE OF THE BIGGEST CHALLENGES DOCTORS FACE ON A REGULAR BASIS.
“I’ve studied small vessels all my life and I know that they’re very affected by high blood pressure, both from a point of view of function and structure. If blood pressure is elevated then the same thing occurs in the brain,” he said. “If you intervene very late, you may slow down things a little bit but you won’t go back, especially if dementia has already developed.”
But dementia is far from being the only thing a younger patient with hypertension needs to think about.
“If somebody has elevated blood pressure from a young age, they have more of a chance of having target organ damage, of having a stroke, of having a heart attack. They have more of a chance of developing chronic kidney disease and developing peripheral vascular disease. And then eventually, cognitive decline,” said Dr. Schiffrin.
HOW TRUST CAN HELP
There are many reasons why patients don’t always stick to a treatment plan. In some studies, the pandemic and the level of misinformation circulating on social media seemingly made things worse as people began to increasingly question doctors and their ties to pharmaceutical companies.
“COVID has had terrible consequences on the population on so many levels – anxiety, solitude, long COVID – and that has impacted the trust that people have in authorities making mandates, public health, and physicians,” said Dr. Schiffrin.
He said the most important part of a doctor-patient relationship is building up a trusting relationship.
THERAPEUTIC DECISIONS ARE SHARED DECISIONS BUT THE PATIENT NEEDS TO BE INFORMED. THEY HAVE TO KNOW WHAT THEY ARE DEALING WITH AND THE CONSEQUENCES OF DISEASE. THERE’S A TRUST THAT NEEDS TO BE BUILT BETWEEN DOCTOR AND PATIENT.
For his part, Sherwood is determined to get his blood pressure under control, listen to his doctor’s advice, and find a healthier balance between life and work. His motivation? Now that he has landed a job in his field, he worries having high blood pressure will cost him an opportunity.
“(Having high blood pressure) is not something I want tied to my name. I haven’t been at the company that long, and I don’t want anyone wondering, ‘Is the stress too much? Should he be doing this job?’” But, overall, he’s cautiously optimistic. “I’m lucky I live in Canada where we have access to great doctors and great medicine. It’s been a hell of an adjustment period trying to find a healthy balance, but I’m getting there.”
*Name has been changed to protect his privacy
ARE WOMEN WHO ARE DIAGNOSED WITH HYPERTENSION MORE AT RISK
OF DEVELOPING DEMENTIA?
The difference between men and women when it comes to early-onset hypertension and the impact on cognitive function is still being carefully studied, but one study published in Neurology in October 2017 found evidence that being diagnosed with this condition in midlife is a risk factor for dementia, but only for women.
The study, conducted by Dr. Paola Gilsanz and colleagues and entitled “Female Sex, Early-onset Hypertension, and Risk of Dementia,” found that although it is more common for men to be diagnosed with high blood pressure in midlife, only women with hypertension in mid-adulthood appeared to have an elevated risk (65%) of developing dementia.
Researchers identified midlife as being around 43.3 years old. They did not find that dementia was associated with hypertension in early adulthood (a mean age of 32.7 years old) although again, they found effect estimates were elevated in women.
While the study noted that links between early adulthood hypertension and dementia are unclear, its findings about women in their 40s pointed to “growing evidence” that high blood pressure carries more of a harmful effect for women in terms of some outcomes.
TIPS TO KEEP YOUR BLOOD PRESSURE UNDER CONTROL
There are several steps you can take to ensure you maintain a healthy blood pressure.
Dr. Ernesto Schiffrin, Director, Hypertension and Vascular Research Unit, Lady Davis Institute for Medical Research and Editor-in-Chief of the American Journal of Hypertension, said regardless of age, a balanced lifestyle is critical to living a healthy life.
1. MAINTAIN A HEALTHY WEIGHT
“Blood pressure rises proportionally to weight,” said Dr. Schiffrin. “People who suffer from obesity very often have elevated blood pressure levels or, if their blood pressure is at the higher end of normal, will develop it within five years, some studies have shown.” He said to a large extent, maintaining a healthy weight helps keep fluctuations in blood pressure under control.
2. KEEP A REGULAR FITNESS ROUTINE
Aside from helping patients keep the weight off, cardiovascular activity is essential to keep the heart strong and healthy. According to the Mayo Clinic’s “Strategies to Prevent Heart Disease,” people should aim for 150 minutes a week of exercise or 30 to 60 minutes of activity daily.
3. MINIMIZE SALT INTAKE
According to Dr. Schiffrin, ideally, people should stick to less than five grams of table salt a day, particularly as it contributes to elevated blood pressure and cardiovascular disease. However, the reality is that most people in developed countries actually consume 10-15 grams of salt a day, he said.
4. EAT A CONSISTENTLY HEALTHY DIET
Nothing is perhaps more critical to our health than diet, said Dr. Schiffrin. So stock your diet with plenty of fish, fruit, poultry, whole grains, and nuts, and eat very little red meat. Avoid refined carbohydrates, drinks with added sugar, and meals with added sugar, sodium, and trans fats. A study published in The Journal of Nutrition in 2012 by Dr. Stephanie Chiuve and colleagues, found that people with diets that consistently included the foods recommended by Dr. Schiffrin had a 31% lower risk of heart disease and a 33% lower risk of diabetes.
5. LIMIT ALCOHOL INTAKE
Canadian guidelines suggest that consuming more than two drinks a week increases health risks. Dr. Schiffrin said recent studies back that up. “Data from the UK Biobank suggests that anything above that certainly increases blood pressure and increases mortality significantly,” he said.