Cumulative blood pressure and risk of dementia and cognitive decline: a systematic review and meta-analysis

Cumulative blood pressure (cBP), reflecting long-term BP exposure, is increasingly used to examine risk associations with dementia and cognitive function, but findings to date are inconsistent. This systematic review aimed to synthesize existing evidence to clarify risk associations in adults.

We searched for articles in Medline, Embase (Ovid), Web of Science, Cochrane Library, and China National Knowledge Infrastructure from inception to January 2025 in any language. Longitudinal, observational studies involving participants aged over 18 years at the time of initial BP assessment were eligible for inclusion. cBP was defined as the area under the curve of BP values over time or an equivalent method, expressed in units of mmHg × time. Study outcomes were dementia, cognitive function assessments, and neuroimaging markers. This review is registered in PROSPERO (CRD42025640637).

From 6334 records identified, 10 independent prospective cohort studies from 9 publications were included in the review, of which four cohort studies were eligible for meta-analysis. Meta-analysis showed that higher cumulative systolic BP (cSBP) was associated with an increased risk of incident dementia (odds ratio [OR] 1.21, 95% CI 1.00-1.45; I² = 92.4%, P for heterogeneity<0.001), while cumulative diastolic BP (cDBP) was not associated with dementia risk (OR 0.97, 95% CI 0.72-1.32; I²=97.3%, P for heterogeneity<0.001). Among eight studies on cognitive function, five reported that higher cSBP was associated with poorer cognitive performance, while three reported non-significant results. In contrast, findings for higher cDBP were mixed, with two studies reporting adverse associations, two reporting protective associations, and three reporting null associations. Two studies linked higher cSBP and cDBP to greater white matter hyperintensity burden. Sensitivity and subgroup analyses suggested that the positive association between cSBP and dementia-related outcomes were more pronounced among middle-aged adults, whereas inverse or null associations for higher cDBP was observed in some cohorts among individuals aged ≥60 years.

Higher cSBP is associated with increased risk of incident dementia and cognitive decline, whereas associations for cDBP are mixed. Given the limited evidence, future studies should incorporate age-stratified analyses and consider including cumulative pulse pressure and mean arterial pressure to further clarify the relationship between cBP and cognition.