Sex Differences in the Association of Simultaneous Decline in Blood Pressure and Decline in Cognition during Aging

Both high and declining blood pressure (BP) are associated with risk of cognitive decline in older adults, and women have higher rates of hypertension and faster cognitive decline in late-life. In old age, the relationship between changes in BP and changes in cognition is complex, and although sex differences in cognitive function and decline are recognized, little is known about the relationship of longitudinally collected BP and cognition, simultaneous changes in BP and cognition, or whether they differ by sex. We investigated the association of simultaneous change in BP and cognition in older adults followed annually for an average of 9 years.

A total of 4,719 older adults without baseline dementia (mean age = 76.7 [standard deviation = 7.7] years; 74% women) from 5 prospective community-based cohort studies completed annual assessments of BP and cognition, yielding composite global and 5 domain-specific scores. BP and cognition were modeled simultaneously using joint bivariate linear mixed-effects models.

Among 3,502 women and 1,217 men, faster decline in systolic BP was associated with faster decline in global cognition (r = 0.20, p < 0.01). Stratified models revealed a stronger relationship in women (r = 0.26, 95% confidence interval [CI]: 0.17-0.37) than men (men: r = 0.01, 95% CI: -0.13 to 0.11). In secondary analyses, decline in systolic BP was related to decline in 5 cognitive domains in women but none in men.

This large longitudinal study reports evidence of a relationship between simultaneous decline in systolic BP and cognition in women, but not men. As women experience a disproportionate burden of both hypertension and cognitive decline in late-life, declining systolic BP, a routine clinical measure, may serve as an important indicator of concurrent cognitive decline in older women. Understanding these sex-specific associations may help advance the understanding of drivers behind sex differences in cognitive decline. ANN NEUROL 2026;100:572-583.