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A study published in Nature Medicine looks at blood pressure control for dementia.
Prof David Attwell, Director, BHF/UKDRI Centre for Vascular Dementia Research, said:
“In this paper He et al. carry out a randomized controlled trial investigating the effect on dementia risk of intensively lowering blood pressure in (mean age) 63 year old people with uncontrolled hypertension (high blood pressure). They found that patients in an intensive treatment group (taking 3 anti-hypertensive agents, which reduced their systolic blood pressure from 157 to 128 mm Hg) showed a 15% smaller chance of developing dementia after 4 years than patients in the normal treatment group (on average taking 1.2 antihypertensive drugs, which reduced systolic blood pressure from 155 to 148 mmHg). This statistically significant reduction of the risk of developing dementia by intensive blood pressure reduction is in line with earlier work such as the SPRINT MIND study (Williamson et al., 2019, JAMA, https://pmc.ncbi.nlm.nih.gov/articles/PMC6439590/), which used a similar protocol to show a reduction in the development of mild cognitive impairment but, however, failed to show a statistically significant reduction in the development of dementia.
“There are several likely reasons for the better outcome of this study. Importantly, it included 3.6-fold more participants, which would improve the statistical significance. The rural Chinese population studied may have differed importantly in terms of genetics, diet, alcohol consumption and exercise from the USA and Puerto Rico subjects in SPRINT MIND. It was biased more towards female patients (61%) than the SPRINT MIND trial (36%), although interestingly in both studies males responded somewhat better. There may have been different proportions of different classes of antihypertensive drugs used, with perhaps more ACE (angiotensin converting enzyme) inhibitors and calcium channel blockers used in this study.
“Although a 15% reduction in dementia development is far from perfect prophylaxis, if uniformly implemented in people with high blood pressure in the population it would greatly reduce both human suffering and the costs of health care systems, making it important to understand the mechanism(s) by which the improvement is generated. High blood pressure can evoke a reduction of brain blood flow, so reducing blood pressure may tend to maintain the energy supplied to the brain’s nerve cells (as oxygen and glucose in the blood) which is needed for normal cognition. High blood pressure is also correlated with more transmission of heart-generated blood pressure pulse waves into the small blood vessels within the brain, which may lead to vessel damage. Interestingly, a clinical trial of two drugs that are also thought to maintain brain blood flow and healthy blood vessel function has also shown promising results in reducing the cognitive decline that can follow strokes occurring deep in the brain (Wardlaw et al., 2023, JAMA Neurol, https://pubmed.ncbi.nlm.nih.gov/37222252/). Together these studies reinforce the notion that prophylaxis for dementia by targeting vascular dysfunction is possible.”
Prof Joanna Wardlaw, Professor of Applied Neuroimaging, University of Edinburgh, said:
“The study is large and rigorous and important.
“However, the press emphasise the blood pressure (BP) reduction – this is not just about blood pressure control – the intensive BP control was alongside strong lifestyle advice including on smoking, weight loss, exercise and better diet including reducing salt. The control group received usual BP management and did not receive the lifestyle advice.
“The findings add weight to the results of the FINGER trials which have so far conducted mainly in Europe and which also showed that intensive vascular risk factor management along with lifestyle interventions helped delay cognitive decline in older individuals.
“There is no doubt that BP reduction is not only important for vascular health (preventing heart attacks and strokes) but also, partly by reducing stroke and partly by reducing diffuse vascular damage from small vessel disease and retaining cerebrovascular health, can help reduce all cause dementia and cognitive decline.
“No one, anywhere in the world, should be living with less than optimal blood pressure control, for a whole bunch of reasons, and we have to pay more attention to smoking cessation, exercise, salt reduction, a healthy diet and good sleep hygiene.”
Dr Julia Dudley, Head of Research at Alzheimer’s Research UK, said:
“This large trial of over 33,000 people in rural China provides further evidence that addressing high blood pressure could be one way to reduce dementia risk. This is consistent with a landmark report published in The Lancet last year, which highlighted untreated high blood pressure as one of 14 risk factors that account for almost half of global dementia cases. Existing medicines and lifestyle changes to reduce blood pressure could present a more accessible way to lower dementia risk for those with high blood pressure.
“While the results from this trial are reassuring, further studies are needed to understand how other risk factors like genetics interact with factors like high blood pressure to influence dementia risk. It will also be interesting to see whether interventions trialed in this study can work in other populations across the world.
“Looking after our heart and blood vessel health is something we can all do to improve our overall wellbeing and reduce our risk of dementia. With no current treatments available on the NHS to slow or stop the diseases that cause dementia, there has never been a more pressing need to promote good brain health and to gain a deeper understanding of how we can reduce our risk of developing dementia.
“The government also has a vital role to play in tackling the health and lifestyle factors that influence dementia risk – including cardiovascular health. This could mean introducing policies to reduce salt, sugar, and calories in processed foods, and lowering the NHS Health Check eligibility age in England from 40 to 30, so more people can start managing their blood pressure earlier in life.
“If you’re worried about your blood pressure, or haven’t had it checked for a while, speak to your GP or your local pharmacy may offer this service. If you’re over 40, you should ideally have your blood pressure checked at least every five years.”
Prof James Leiper, Director of Research, British Heart Foundation, said:
“There has been evidence for a long time that people who have high blood pressure have a higher risk of developing dementia, especially vascular dementia. The findings of this large trial, involving high blood pressure treatments that are already widespread, offer strong evidence that enhanced treatment of high blood pressure could in turn reduce the heightened dementia risk that comes with it.
“It will be important to see whether this reduced risk continues for longer than the four-year follow up period in the study, and whether similar effects are seen in other populations that receive the same treatment. If so, wider use of high blood pressure treatment in people with the condition could be recommended to fight the growing impact of dementia.”
Dr Richard Oakley, Associate Director of Research and Innovation at Alzheimer’s Society, said:
“Dementia is the UK’s biggest killer. The condition is progressive and although no single behaviour is guaranteed to prevent dementia, we know that what’s good for your heart is often also good for your head.
“This study is one of the first big trials to test whether treating high blood pressure, supported by health coaching can reduce dementia risk, and the results appear to be promising.
“It is encouraging that the intervention worked in real-world, rural settings using non-physician healthcare workers, which may have implications for delivering care in areas with limited resources in the future. However, this four-year study cannot tell us whether the benefits will last in the long-term so we will continue to follow this trial.
“Research will one day beat dementia. This study takes another step forwards and we will be keen to see further studies provide more information about the impact of blood pressure control over the longer term and in other populations.”
Prof Sir Mark Caulfield, Vice Principal for Health for Queen Mary’s Faculty of Medicine and Dentistry, Queen Mary, said:
“the findings reported in Nature Medicine show that optimizing blood pressure control convincingly reduces risk of dementia. There have been prior studies suggesting correlation of blood pressure level and dementia risk -especially vascular dementia – but this is a very emphatic outcome of a trial. The trial is in a Chinese population so some people might say it isn’t generalisable, but we know from other research that the correlation of blood pressure level with adverse outcomes is consistent across populations. This is a really major advance in dementia prevention and will transform global blood pressure guidance and prevention strategies.”
Prof Ian Maidment, Professor of Clinical Pharmacy, Aston University, said:
“There is already good evidence that we should control hypertension to reduce the potential risk of dementia.
“The study here showed that the intervention reduced the risk of dementia (as expected). However, the intervention would require significant modification. It was delivered by “village doctors” in rural villages in China. It would require significant changes for the UK and other similar healthcare systems; although potentially community pharmacists could deliver a similar programme.
“There are also a number of further limitations to consider before we should consider changing UK practice. The cohort were relatively young at baseline (62/ 63 years old) and only followed up for 48 months. In part due to these two factors, very few dementia cases actually arose during the trial: 4.59% (n=668) intervention vs 5.40% (n=734) in control. This represents 66 excess cases (734 minus 668; although the denominator is different. There were 17,407 people in the intervention group vs 16,588 in the control group). There was also no health economic data for the intervention delivered across 163 villages for 48 months.”
Prof Masud Husain, Professor of Neurology, University of Oxford, said:
“This is a landmark study with a very large sample size and a robust effect. It’s a wake-up call to treat high blood pressure intensively, not just to protect the heart but also the brain.”
“Remarkably, within just four years, there was a significant reduction in the incidence of dementia by aggressively treating raised blood pressure. Although many patients and their GPs understand how important it is to treat blood pressure, they might not appreciate what a risk it poses for developing dementia. In my clinic, I recommend keeping BP consistently below 140/80.”
Prof Tara Spires-Jones, Director of the Centre for Discovery Brain Sciences at the University of Edinburgh, Group Leader in the UK Dementia Research Institute, and President of the British Neuroscience Association said:
“This paper by He and team based at the University of Texas Southwestern Medical Center tested whether treatment for high blood pressure was associated with a reduction in risk of developing dementia. The team randomly assigned 163 villages in rural China to treat people with high blood pressure with medication and coaching to help them manage blood pressure and in 163 similar villages, people received standard care. The team observed that the people in the group receiving treatment for four years had a 15% reduced risk of developing dementia to the control group. This randomized, controlled trial provides further strong evidence supporting the importance of managing blood pressure and other cardiovascular risks to protect the brain during ageing. It is important to note that treating high blood pressure was not a fool-proof guarantee as some people receiving treatment still developed dementia. Although lifestyle modification is not a guarantee of avoiding dementia, strong evidence suggests there are things we can all do to keep our brains healthy and reduce dementia risk as we age including keeping mentally, physically, and socially active, treating conditions like hearing loss and high blood pressure, and avoiding things like head injury, too much alcohol, and smoking.”
Prof Atticus Hainsworth, Professor of Cerebrovascular Disease, St George’s, University of London (SGUL), said:
“It is encouraging to see further support for the concept that intensive blood pressure control reduces dementia risk. Jiang He and colleagues report a large clinical study, sampling older people from over 300 Chinese villages (almost 34,000 participants). Blood pressure was treated with cheap, readily-available drugs, managed by community healthcare workers who were not specialist doctors. They found a significant reduction in dementia risk among those villages where blood pressure was treated intensively. The implication is clear. We have an intervention that moves the needle on dementia risk, that can be delivered to large numbers of people in their communities, at modest cost.
“There are parallels with a previous large clinical trial of intensive blood pressure lowering in older North Americans (the SPRINT-MIND study). The reduction in risk was similar – about 15%. In both studies, the beneficial effect did not depend on using specific drug type to lower blood pressure. And in both, an effect of treatment was apparent after 12-18 months (though both studies continued for a longer duration).
“Replicating experimental findings doesn’t always happen. Here we are looking at similar findings from two big trials in different settings – rural China and (largely urban, primarily white) North America. These concordant findings may prompt changes in healthcare policy guidelines.”
Prof Toby Richards, Department of Allied and Public Health, School Of Health, Sport And Bioscience at the University of East London, said:
“Dementia is a rising problem in society today.
“In this large community based clinical trial in 34,000 people, the authors have shown two important findings. Firstly, that non-medical staff can provide medical information and deliver primary care protocols effectively in a community setting. And secondly that effectively lowering blood pressure to < 130/80 reduced the risk of developing dementia by about 15 %.
“The data reinforce recent European Society of Cardiology 2024 guidelines aiming for a lower blood pressure and a structured algorithm of treatment.
“This has important ramifications for individuals. Blood Pressure can be relatively easy to measure at home enabling individuals to take control and autonomy for their health and these data show benefit in reducing the risk for developing dementia.
“In a resource strapped NHS these data also show that an algorithm of Treatment based on the European Society guidelines can be implemented by non-health care professionals, potentially at pharmacy level.
“In summary these data support treating blood pressure to <130/80, something that could be achieved by following a protocol of treatment, reducing the workload and wait for GPs. The outcome would have a directed benefit to individuals and the NHS.”
‘Blood pressure reduction and all-cause dementia in people with uncontrolled hypertension: an open-label, blinded-endpoint, cluster-randomized trial’ by Jiang He et al. was published in Nature Medicine at 16:00 UK time on Monday 21st Monday.
DOI: https://doi.org/10.1038/s41591-025-03616-8
Declared interests
Prof David Attwell: I have no conflicts of interest
Prof James Leiper: No conflicts of interest to declare.
Prof Sir Mark Caulfield: Mark Caulfield was President of the British and Irish Hypertension Society between 2009-11 and served on the European Society of Hypertension Council.
Between 2013-21 he was Chief Scientist for Genomics England, a Department of Health and Social Care Company
Prof Ian Maidment: No declarations of interest.
Prof Masud Husain: I don’t have any conflicts of interest.
Prof Tara Spires-Jones: I have no conflicts with this study but have received payments for consulting, scientific talks, or collaborative research over the past 10 years from AbbVie, Sanofi, Merck, Scottish Brain Sciences, Jay Therapeutics, Cognition Therapeutics, Ono, and Eisai. I am also Charity trustee for the British Neuroscience Association and the Guarantors of Brain and serve as scientific advisor to several other charities and non-profit institutions.
Prof Atticus Hainsworth: I have co-authored a publication with one of the authors, Dr Jeff Williamson, on a related topic. I lead the Vascular Experimental Medicine group in DementiasPlatformUK. I serve on a scientific panel for AriBio Ltd.
Prof Toby Richards: Professor Richards has declared no conflicts of interest.
For all other experts, no reply to our request for DOIs was received.