Journal of Human Hypertension (2000) 14, 771–772
 2000 Macmillan Publishers Ltd All rights reserved 0950-9240/00 $15.00
COMMENTARY
Blood pressure and aging
DJ Stott and A Bowman
Academic Section of Geriatric Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow G4
0SF, UK
Keywords: aging; blood pressure
It used to be thought that rising blood pressure is an
inevitable consequence of aging. However it is now
recognised that age-related blood pressure changes
are complex and multifactorial in aetiology, and that
aging may merely give increased opportunity for
environmental or lifestyle influences to take effect.
What effects does aging have on blood pressure?
Longitudinal studies in developed or urban popu-
lations have shown systolic blood pressure rises
steadily with increasing age, at least into the ninth
decade. In contrast diastolic pressure increases to a
maximum around the sixth decade, after which it
tends to plateau or even decrease.1–3 Therefore pulse
pressure increases. These changes lead to a greatly
increased incidence of hypertension in the elderly.4
The prevalence varies depending on the diagnostic
criteria used, however in developed countries
between 35 and 50% of the over-65s are thought to
be hypertensive.5,6 Isolated systolic hypertension is
particularly common in the elderly, as would be
expected from the above age-related changes in sys-
tolic and diastolic pressures. The pathophysiolog-
ical basis of these age-related changes in blood
pressure includes arterial and arteriolar stiffening
and increased peripheral resistance. This is due to
a combination of factors including decreased elas-
ticity of connective tissue, atheroma and impaired
smooth muscle relaxation associated with decreased
beta-2 receptor sensitivity.7 What are the underlying
causes of these changes?
Lifestyle and environmental factors appear to be
the most important determinant of age-related blood
pressure change. The rise in systolic blood pressure
is greatly attenuated in secluded communities such
as nuns8 and in rural communities in the developing
world,9 however when subjects from such areas
move to an urban environment blood pressure
rises.10 What are the components of an urban life-
style that lead to this change? Psychological stresses
may play a part. Other more mundane candidates
Correspondence: Professor David J Stott, Academic Section of
Geriatric Medicine, University of Glasgow, Glasgow Royal
Infirmary, Glasgow G4 0SF, UK
E-mail: d.j.stott얀clinmed.gla.ac.uk
Received and accepted 7 June 2000
www.nature.com/jhh
include dietary changes such as increased sodium
intake or chronic excess alcohol consumption, both
of which increase blood pressure.11,12 The pressor
effect of sodium loading is enhanced by aging.13
Aging is associated with several other important
changes that influence blood pressure. The preva-
lence of obesity increases markedly, due largely to
changes in dietary intake and exercise; obesity is an
independent risk factor for hypertension.14 Physical
activity levels decline with increasing age, and a
sedentary lifestyle is another risk factor for hyper-
tension.15
Cross-sectional population studies have found an
inverse relationship between socio-economic status
and blood pressure, ie, subjects from the poorest sec-
tors of society tend to have the highest blood press-
ures. However most of this effect can be explained
by an increased proportion of obese subjects and
higher alcohol intake in the most deprived socio-
economic groups.16 Similar relationships exist for
educational status.17
Environmental influences early in life may affect
blood pressure as an adult and into old age.18 Low
birth weight is associated with raised blood pressure
in middle-age. However the role of foetal develop-
ment and low birth weight in the development of
hypertension in old age remains controversial. Simi-
larly the evidence for a polygenic aetiology of hyper-
tension in old age is not yet strong.19 However it is
possible that foetal development and genetic make-
up are important in determining susceptibility in
later life to environmental stimuli.
Therefore there is good evidence that systolic
blood pressure rises with increasing age in urban
dwellers, and that this is due primarily to a complex
interaction of many different environmental and
lifestyle factors. However in some subjects blood
pressure falls with aging. In particular this occurs in
association with diseases that cause weight loss (eg,
with Alzheimers disease or cancers) and with
impaired left ventricular function (eg, after acute
myocardial infarction). These diseases act as major
confounders in studies of blood pressure and mor-
tality in the elderly. In the current issue of the Jour-
nal of Human Hypertension, Starr et al20 report
results from a prospective longitudinal study of
 Blood pressure and aging
DJ Stott and A Bowman
772
initially healthy older people. Those who developed
disease sustained a fall in blood pressure. There is
an inverse relationship between blood pressure and
mortality in subjects over 85 years of age, with
hypertensive subjects living longer than those with
low blood pressure.21 This paradoxical relationship
is due to a greater prevalence of serious underlying
disease in those elderly patients with low blood
pressure.22
The increasing use of antihypertensive drugs in
the elderly may also influence age-related blood
pressure changes in populations. Up to 25% of eld-
erly people in developed countries are taking anti-
hypertensive drugs.5,23 There is evidence that this
widespread use is impacting on population blood
pressure levels.24 Starr’s article confirms that antihy-
pertensive use is associated with prolonged
reductions in blood pressure in the elderly.20
Therefore there are many different factors that
influence blood pressure changes into old age. A key
message is that the development of hypertension is
not an inevitable consequence of aging. There is a
complex matrix of inter-related environmental and
lifestyle factors, including diet, alcohol, obesity, and
exercise habit, that cause a rise in systolic blood
pressure. Many of these factors are potentially modi-
fiable raising the prospect that hypertension in old
age may be preventable. In addition there are effec-
tive treatments for hypertension in the form of anti-
hypertensive drugs. The more widespread use of
these agents should result in improved control of
blood pressure at a population level, resulting in
major health gains including reductions in disabling
conditions such as stroke and cardiac failure,
increased longevity with reduced cardiovascular
and total mortality25 and possibly prevention of
dementia.26
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