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The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful. Robust evidence is scant, trials of antihypertensive medications have generally excluded those with dementia. Observational data show changes in risk association over the life course, with high BP being a risk factor for cognitive decline in mid-life, while low BP is predictive in later life. It is therefore possible that excessive BP lowering in older people with dementia might harm cognition. From the existing literature, there is no direct evidence of benefit or harm from treating hypertension in people with dementia. So what practical steps can the clinician take? Assess capacity, establish patient preferences when making treatment decisions, use ambulatory monitoring to thoroughly assess BP, individualise and consider deprescribing where side effects (e.g. hypotension) outweigh the benefits. Future research might include pragmatic randomised trials of targeted deprescribing, which include patient-centred outcome measures to help support decision-making and studies to address mechanistic uncertainties., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: ambulatory blood pressure monitoring (ABPM) may be helpful for the management of hypertension, but little is known about its tolerability in people with dementia., Objective: to review the published evidence to determine the tolerability of ABPM in people with dementia., Methods: English language search conducted in MEDLINE and EMBASE, using 'Ambulatory blood pressure' AND 'Dementia' (and associated synonyms) from 1996 to March 2015., Inclusion Criteria: people diagnosed with dementia AND in whom blood pressure was measured using ABPM. The initial search was undertaken using title and abstract reviews, with selected papers being agreed for inclusion by two reviewers. Potentially eligible papers were assessed, and high-quality papers were retained. Two reviewers agreed the abstracted data for analysis. Meta-analysis was used to combine results across studies., Results: of the 221 screened abstracts, 13 studies (6%) met inclusion criteria, 5 had sufficient data and were of sufficient quality, involving 461 participants, most of whom had mild-moderate dementia. 77.7% (95% CI 62.2-93.2%) were able to tolerate ABPM; agreement with office BP was moderate to weak (two studies only-coefficients 0.3-0.38 for systolic blood pressure and 0.11-0.32 for diastolic blood pressure). One study compared home BP monitoring by a relative or ambulatory BP monitoring with office BP measures and found high agreement (κ 0.81). The little available evidence suggested increased levels of dementia being associated with reduced tolerability., Conclusions: ABPM is well tolerated in people with mild-moderate dementia and provides some additional information over and above office BP alone. However, few studies have addressed ABPM in people with more severe dementia., (© The Author 2016. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Hypertension is a common condition in older people, but is often one of many conditions, particularly in frail older people, and so is rarely managed in isolation in the real world--which belies the bulk of the evidence upon which is treatment decisions are often based. In this article, we discuss the issues of ageing, including frailty and dementia, and their impact upon blood pressure management. We examine the evidence base for managing hypertension in older people, and explore some therapeutic ideas that might influence treatment decisions and strategies, including shared decision making. [ABSTRACT FROM AUTHOR]