Case Report

By Dr. Jurgen Claassen
Corresponding Author Dr. Jurgen Claassen
Geriatric Medicine, Radboud University Nijmegen Medical Center, 925 department of geriatric medicine, PObox 9101 - Netherlands 6500 HB
Submitting Author Dr. Jurgen A Claassen

white matter lesions, brain perfusion, cerebral autoregulation, antihypertensive treatment, cognition, aging

Claassen J. Safe Treatment of Hypertension to Guideline Targets in Nonagenarian Vascular Dementia. WebmedCentral NEURORADIOLOGY 2010;1(10):WMC00890
doi: 10.9754/journal.wmc.2010.00890
Submitted on: 04 Oct 2010 01:29:21 PM GMT
Published on: 04 Oct 2010 07:23:55 PM GMT


More than 60 % of those over the age of 70 have hypertension, yet two-third receive no treatment or are not treated to meet current hypertension guideline criteria (≤ 140/90 mm Hg), even in case of secondary prevention [1]. Although there is evidence that blood pressure lowering in older adults effectively reduces cardiovascular risk [2], there remains concern that treatment may not confer any mortality benefit [3], whilst it could have unfavorable side-effects, including cerebral hypoperfusion. Recently, data from the HYVET study indicated that treatment of hypertension in patients aged 80 and over reduces stroke, heart failure and mortality [4]. However, trial participants were relatively healthy, and blood pressure was not rigorously lowered to meet guideline criteria.

            This case study reports on the outcome of hypertensive treatment in a very old subject with cerebrovascular co-morbidity.

Case Report(s)

A 94- year old woman was diagnosed in our memory clinic with mild vascular dementia (CDR 1, NINCDS-AIREN: probable VaD). She had a history of hypertension, for which she received hydrochlorothiazide 12.5 mg/day, and a possible TIA that had not been further evaluated. She had played tennis into her late eighties, and had moved to an elderly home, requiring little formal care, after a hip fracture in 2004. In the past year, she had developed impairments in memory and executive functioning. Her MMSE score was 19, her CAMCOG (Cognitive part of the Cambridge Examination for Mental Disorders of the Elderly) score was 72 out of a maximum score of 104; memory: 19 of 37 points, executive function: 14 of 28 points, with a Geriatric Depression Scale score of 2 of 30. The Barthel index for ADL was 80 of 100. Carotid ultrasound evaluation showed plaques, but no significant stenosis. Her MRI displayed diffuse white matter disease, with a lacunar infarction, as well as central and cortical atrophy (fig 1). Blood pressure was 210/100 mmHg sitting 190/100 mm Hg standing on both sides on first measurement, and 190/90 mm Hg sitting and standing with repeated measurements after 4, 8 and 12 weeks, during which time medication compliance was ascertained.

There were no clear indicators for a very limited life expectancy, and this patient experienced  a good quality of life and had a reasonably good functional ability. Because of the high risk of stroke with resulting disability, her blood pressure was reduced to 140/80 mmHg within a period of 3 months, by adding perindopril (starting dose 2 mg, final dose 4 mg per day). During follow-up, there was no orthostatic hypotension, and there were no falls or dizziness. 12 months after initiation of therapy, she was cognitively and functionally stable, showing no decline in test scores, although her caregiver noted some further impairment in memory in her everyday contact. Repeated MRI (fig 1) showed no progression of white-matter disease, and no new lacunar or cortical infarction. Renal function was stable.


Regarding prevention of stroke, old patients with cerebrovascular disease have most to gain from antihypertensive treatment. However, they are also perceived as having most to loose from such therapy, because of the widespread believe that the aged brain, due to stiffened and stenotic arteries, needs elevated blood pressure to maintain adequate perfusion. This perception is not, however, substantiated by our physiological knowledge of cerebral autoregulation [5], nor by the available evidence in patients up to 75 years old showing normal autoregulation in hypertension [6].


This case-report in a very old patient with known cerebrovascular disease suggests stable cerebral perfusion despite rigorous blood pressure lowering, as evidenced by stable vascular lesions on MRI, stable cognitive function, and absence of dizziness or falls. Awaiting further trials, we may be able to prevent disabling comorbidity by critically asking ourselves in each individual patient: which arguments do I have not to aim for blood pressure values within guideline targets?


HYVET: Hypertyension in the very elderly trial
CDR: clinical dementia rating scale
NINCDS-AIREN: National Institute of Neurological Disorders and Stroke (NINDS) Association Internationale pour la Recherche et l’Enseignement en Neurosciences
VaD: vascular dementia
MMSE: mini mental state examination


1. Wong ND, Lopez VA, L'Italien G, Chen R, Kline SE, Franklin SS. Inadequate control of hypertension in US adults with cardiovascular disease comorbidities in 2003-2004. Arch Intern Med 2007; 167:2431-2436.
2. Zhang H, Thijs L, Staessen JA. Blood pressure lowering for primary and secondary prevention of stroke. Hypertension 2006; 48:187-195.
3. Oates DJ, Berlowitz DR, Glickman ME, Silliman RA, Borzecki AM. Blood pressure and survival in the oldest old. J Am Geriatr Soc 2007; 55:383-388.
4.Beckett NS, Peters R, Fletcher AE et al. Treatment of Hypertension in Patients 80 Years of Age or Older. N Engl J Med 2008; 358(18):1887-98.
5.Zhang R, Witkowski S, Fu Q, Claassen JA, Levine BD. Cerebral hemodynamics after short and long-term reduction in blood pressure in mild and moderate hypertension. Hypertension 2007; 49(5):1149-1155.
6. van Beek AH, Claassen JA, Rikkert MG, Jansen RW. Cerebral autoregulation: an overview of current concepts and methodology with special focus on the elderly. J Cereb Blood Flow Metab 2008; 28(6):1071-85.

Source(s) of Funding

No funding

Competing Interests



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