Internal Medicine Section DOI : 10.7860/JCDR/2018/32597.11971
Year : 2018 | Month : Sep | Volume : 12 | Issue : 09 Page : OC05 - OC08

Effect of Age and Hypertension on Cognition: A Cross-sectional Study

Deepalakshmi Kaliyaperumal1, Vijayabas Karan Shanmuga Varadharajan2, Varsha Viswanathan3, Murali Alagesan4

1 Associate Professor, Physiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
2 Assistant Professor, Physiology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
3 Intern, Internal Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.
4 Professor, Internal Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India.

NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Murali Alagesan, Department of Medicine, PSG Institute of Medical Sciences and Research, Peelamedu, Coimbatore, Tamil Nadu, India.
E-mail: muralimd


Cognitive impairment has evolved as major health and social issue. As age advances cognitive tasks involving processing speed, working memory and executive function get affected. Cognitive impairment is also influenced by modifiable risk factors such as hypertension, diabetes mellitus and hypercholesterolemia.


To find out the effect of age and hypertension on cognition.

Materials and Methods

The total study participants were divided into three groups based on their age as group I (18-29) group II (30-59) and group III (above 60) with 20 participants (n= 20) in each group. Their cognition was assessed using Mini Mental State Examination, Picture word Learning test, Stroop colour word test, Letter digit coding test, Verbal fluency and Logic memory tests. Disease history and known co morbidities (hypertension) were noted. Post-hoc test (Bonferroni) was employed to assess age-wise comparison of cognition and Pearson’s chi-square test was used to compare cognition between hypertensive and normotensives.


Group II had impaired cognition when compared with group I (p-value- 0.000). Group III had impaired cognition when compared with group I (p-value- 0.000) and group II (p-value 0.001). The hypertensives in group II and III had statistically significant impairment in cognition when compared with normotensives (p-value -0.001) in the same group.


Cognitive functions are impaired as a result of increase in age. Furthermore, there is also a significant decrease in cognitive functions amongst those suffering from hypertension. Hence, we conclude there is decrease in cognitive function as age advances and the co-existence of hypertension hastens this decline.

How to cite this article

Deepalakshmi Kaliyaperumal, Vijayabas Karan Shanmuga Varadharajan, Varsha Viswanathan, Murali Alagesan, .EFFECT OF AGE AND HYPERTENSION ON COGNITION: A CROSS-SECTIONAL STUDY.Journal of Clinical and Diagnostic Research [serial online]2018 Sep[cited:2019 May 23] 09 OC05 - OC08
 Available from


The word cognition comes from the Latin verb cognosco meaning ‘I know, perceive’ or ‘to recognise or conceptualise. Cognitive functions are those which include cerebral activities that lead to knowledge and encompass reasoning, memory, attention and language. Ageing can also have diverse effects on cognitive function. The spectrum of cognitive decline ranges from normal cognitive ageing (healthy” or “successful” Ageing), mild Cognitive impairment (does not prevent them from performing daily activities) and severe cognitive deficits (impede the ability to live independently [1]. Cognitive impairment has evolved as major health and social issue as the life span of both men and women has increased dramatically. Cognitive impairment accounts for about 40% of hospital admissions among the older individuals [2]. As age advances cognitive tasks involving rapid processing and transformation of information, which includes processing speed, working memory and executive function gets affected [3].

These age-related cognitive declining results from structural and functional changes that affect neuronal structure like loss of synapses and dysfunction of neuronal networks [4]. Cognitive impairment is also influenced by modifiable risk factors such as hypertension, diabetes mellitus and hypercholesterolemia [5]. Among these factors hypertension, which causes vascular changes resulting in cerebral infarction and diffuse ischaemic changes contribute to cognitive impairment [6].

Age related cognitive decline is already stated by several studies [7,8] earlier; but none of them used six tests which examine the different domains of cognition and there are only a few studies [9,10] that have included co-morbid condition such as hypertension to study the decline in cognition as age advances.

Hence, we aimed to conduct a study to find out the effect of age on cognition with the help of series of cognitive assessment tests. In this study we also analysed the effect of more common and prevalent (33.8% in urban parts of India) [11] co-morbid condition, hypertension on cognition especially amongst the vulnerable elderly group of individuals.

Materials and Methods

This cross-sectional study was conducted during the month of January 2014 for the period of two months among students, staff and patients of PSG Institute of Medical Sciences and Research, Coimbatore after obtaining the ethical clearance from institutional ethical committee (Ethics registration file No 13/328). A total of 60 participants after getting their written informed consent were included in the study. Participants were grouped based on their age Group-I (18-29), Group II (30-59), Group III (above 60). Participants younger than 18 years of age and those suffering from co-morbidities apart from hypertension such as diabetes mellitus; chronic respiratory diseases, chronic liver diseases, thyroid diseases, renal and neurological disorders were excluded from the study. Hypertensive participants (Systolic BP of more than 140mm Hg, Diastolic BP of more than 90 mm Hg) for more than two years duration and on anti hypertensive treatment were included the study.

Study participants were assessed for their cognitive performance by using a series of tests. An initial interview of subjects was conducted where they were asked about their education, occupation and age at retirement for group III. Disease history and known co-morbidities (hypertension) were noted.

Mini Mental State Examination [12]

It is an 11 question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall and language. The maximum score is 30, a score of 23 or lower is indicative of cognitive impairment.

Picture Word Learning Test [13] Verbal Learning Test of Long-Term Memory

Fifteen pictures were successively presented at a rate of 1 per 2 seconds and the subjects were asked to recall as many pictures as possible. This was carried out three times. After 20 minutes delayed recall was performed. The main outcome variables are the accumulated number of recalled pictures over the three learning trials and the number of pictures recalled at delayed recall.

Stroop Colour Word Test [13]

This test involves reading colour names printed in incongruously coloured ink for example “green” printed in blue letters where the subject is to say “blue”. The main outcome variable is the time needed for the test.

Letter Digit Coding Test [14]

This test is used as a measure of the speed of processing the general information. The subject is asked to fill in digits near letters, according to a key presented on the top of the test sheet (with 9 consonants in random order), and to work as fast as possible. The outcome variable in the total number of correct variable is 60 seconds.

Verbal Fluency [15]

The participant has to say as many words as possible from a category in a given time (usually 60 seconds). This category can be phonemic for example words starting with the letter “p”. The outcome measure is the total number of words in 60 seconds.

Logic Memory I [16]

A story was read out to the participants and they were asked a few questions based on it. The outcome measure was the number of correct answers to the questions.

The test results were scored as good, moderate and severe and decline in cognition was noted. Data acquisition was done in an excel sheet and the scores were analysed among different age groups to study the effect of age and hypertension on cognitive function.

Statistical Analysis

Data was entered, analysed using SPSS software version 19. Descriptive statistics was employed for analysis. Data was expressed in percentages for categorical variables. Post-hoc Test – Bonferroni and Pearson’s chi-square test was used to analyse categorical variables.


Study participants were divided into three groups based on their age as group I (18-29), group II (30-59) and group III (above 60) with 20 participants in each group and their mean age in each group was found to be 19.3,40.75,67.75 years, respectively. In group I there were 12 males and 8 females, group II comprised of 11 males and 9 females and group consisted of 15 males and 5 females. Group I had nil hypertensives whereas group II and group III had three and six hypertensives respectively.

On analysing the scores of the cognitive tests in the age group I (18-29), 15% of the individuals had cognitive impairment based on Picture Word Learning test, 5% based on Letter Digit Coding, 65% based on verbal fluency and 20% based on logic memory. In group II (30-59), we observed cognitive impairment in all the individuals based on verbal fluency, 70-75% based on picture word learning test and logic memory. Less (10-40%) individuals were found to have cognitive impairment based on Mini mental state examination, stroop colour word test and logic memory. In group III (above 60 years) cognitive impairment was found to be 100% based on verbal fluency, logic memory and picture word learning test, 45% impairment based on Mini mental state examination, stroop colour word test and 65% based on letter digit coding [Table/Fig-1]. Significantly low scores of cognition were observed in group II and group III when compared between the three groups [Table/Fig-2].

Cognitive status among different age groups.

TestsGroup IGroup IIGroup III
Good cognitionImpaired cognitionGood cognitionImpaired cognitionGood cognitionImpaired cognition
Picture word learning test85% (17)15% (3)30% (6)70% (14)10% (2)100% (18)
Stroop colour word100% (20)-70%(14)30% (6)55% (11)45% (9)
Letter digit coding95% (19)5% (1)60% (12)40% (8)35% (7)65% (13)
Mini mental state examination100% (20)-90% (18)10%(2)55% (11)45% (9)
Verbal fluency35% (7)65% (13)-100% (20)25% (5)100% (15)
Logic memory16% (16)20% (4)25% (5)75% (15)-100% (20)

Age-wise comparison of cognition – Post-hoc Test - (Bonferroni).

Comparison between Age Groupsp-value
Group IGroup II0.004*0.2560.0571.0000.000*0.000*
Group IGroup III0.000*0.001*0.000*0.001*0.000*0.000*
Group IIGroup III0.001*0.1370.2260.006*1.0000.021*

* Significant (p-value <.05) PWL – Picture Word Learning test SCW- Stroop Colour Word test LDC – Letter Digit Coding MMSE – Mini Mental State Examination VF – Verbal Fluency LM – Logic Memory

When the hypertensives and normotensives were compared, group II hypertensives showed a statistically significant impaired cognition based on stroop colour word, verbal fluency and logic memory test whereas group III did not show statistically significant difference in their cognition level [Table/Fig-3].

Comparison of cognition between hypertensives and normotensives in different age groups (Pearson’s Chi-square test).

TestsAge Groups
Group IGroup IIGroup III

aNo statistics were computed because HTN is a constant.

* Significant (p-value <.05)


In the present study it was observed that certain cognitive domains are subjected to the decline as age advances. This may be due to physiological process such as inflammation, neurobiological changes, diet and life style [17]. In our study, we found that there is increase in cognitive impairment among older individuals when compared to middle-aged and younger individuals as there occurs changes in sensory perception inhibitory ability, processing speed, memory and reasoning which lead to cognitive decline.

Results from this study revealed ability of processing speed starts to decline from the third decade of life and the impact of the loss of speed processing affects other cognitive domains such as memory, spatial ability, reasoning, working memory, executive functions, orientation, recall ability, registration and calculation. Salthouse TA had also suggested that processing speed affects cognitive function [7].

Slowing of speed processing plays an integral role in age-related memory changes as well. In our study memory is found to be affected more in older and middle-aged individuals. Burke DM et al., had suggested that as age advances the word-finding difficulties may occur due to weaker memory system which is unable to link one unit to another [18]. Naveh-Benjamin M et al., had also proposed that associative memory deficit in older adults’ is due to loss of episodic memory [19].

In our present study, changes were observed among group II and III in mini mental state examination, verbal fluency and stroop colour word tests which gives information on selective and divided attention of the individuals. Hasher L et al., had proposed that older adults’ are unable to concentrate on irrelevant information while they are focusing attention on relevant information [20]. Attention impairment was found to be associated with increased incidence of automobile accidents among older individuals [21].

Genetic, medical, psychological, social and lifestyle factors which determines cognitive ageing that impaires people’s independence and quality of life [22]. In our study there exists a significant increase in the cognitive impairment among hypertensives belonging to group II and III. It was well-supported by many longitudinal studies that elevated blood pressure is associated with cognitive decline [23].

In our study hypertensives belonging to the age group II showed a statistically significant impaired cognition based on stroop colour word test, verbal fluency and logic memory. Long standing hypertension in some patients may cause not only stroke but also chronic end organ damage of the brain in the form of demyelination of the white matter, with cognitive decline [24]. In the Framingham study, Elias MF et al., had opined that untreated BP level is inversely proportional to cognitive function [25]. Launer LJ et al., had reported in his study that midlife systolic blood pressure is a significant predictor of reduced cognitive function in later life. He also suggested that early control of systolic blood pressure levels may reduce the risk of cognitive impairment in old age [26].

Several follow-up studies conducted among hypertensives showed inverse relationship of systolic as well as diastolic blood pressure with their cognitive performance [25,27]. In a study conducted among hypertensives of various stages, Andre-Petersson L et al., observed stage 3 Hypertension was associated with lower performance on psychomotor, speed and visuo-spatial memory tests; stage 1 hypertension is associated with higher performance on tests measuring verbal and constructional ability [28].


The small sample size is a limitation of this study. The factors like ethnicity, hyperinsulinaemia, homocystinaemia, duration of hypertension, level of blood pressure control and choice of antihypertensive treatment affect cognition. There are studies that have mentioned the protective effect of antihypertensive drugs over cognitive decline on hypertensive patients as age advances. In this study these factors were not taken into account and add to the limitations.


Cognitive domains such as general intellect, reaction time, memory, vigilance and attention are impaired as a result of increase in age. Furthermore, there is also a significant decrease in cognitive functions amongst those suffering from hypertension. Hence, we conclude there is decrease in cognitive function as age advances and the co existence of hypertension hastens this decline.

* Significant (p-value <.05) PWL – Picture Word Learning test SCW- Stroop Colour Word test LDC – Letter Digit Coding MMSE – Mini Mental State Examination VF – Verbal Fluency LM – Logic MemoryaNo statistics were computed because HTN is a constant.* Significant (p-value <.05)


References[1]O’Caoimh R, Timmons S, Molloy DW, Screening of mild cognitive impairment: Comparison of “MCI Specific” screening instruments J Alzheimes Dis 2016 51(2):619-29.

[2]Gruber-Baldini AL, Zimmerman S, Morrison RS, Grattan LM, Hebel JR, Dolan MM, Cognitive impairment in hip fracture patients; timing of detection and longitudinal follow up J Am Geriatr Soc 2003 51:1227-36.

[3]Glisky EL, Changes in cognitive function in human ageing in Brain Ageing: Models, Methods, and Mechanisms, ed. D. R. Riddle 2007 Boca Ratón, FLCRC Press:3-20.

[4]Murman DL, The impact of age on cognition Seminars in Hearing 2015 36(3):111-21.

[5]Ganguli M, Fu B, Snitz BE, Unverzagt FW, Loewenstein DA, Hughes TF, Vascular risk factors and cognitive decline in a population sample Alzheimer Disease and Associated Disorders 2014 28(1):9-15.

[6]Gorelick PB, Scuteri A, Black SE, Decarli C, Greenberg SM, Iadecola C, Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the American Heart Association/ American Stroke Association Stroke 2011 42(9):2672-713.

[7]Salthouse TA, When does age-related cognitive decline begin? Neurobiology of ageing 2009 30(4):507-14.

[8]Harada CN, Natelson Love MC, Triebel K, Normal Cognitive Ageing Clinics in geriatric medicine 2013 29(4):737-52.

[9]Lanari A, Silvestrelli G, De Dominicis P, Tomassoni D, Amenta F, Parnetti L, Arterial hypertension and cognitive dysfunction in physiologic and pathologic ageing of the brain Am J Geriatr Cardiol 2007 16(3):158-64.

[10]Cherubini A, Lowenthal DT, Paran E, Mecocci P, Williams LS, Senin U, Hypertension and cognitive function in the elderly Am J Ther 2007 14(6):533-54.

[11]Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, Hypertension in India: a systematic review and meta- analysis of prevalence, awareness and control of hypertension Journal of Hypertension 2014 32(6):1170-77.

[12]Pangman VC, Sloan J, Guse L, An Examination of psychometric properties of the Mini-Mental Status Examination and the standardized Mini – Mental Status Examination: Implications for Clinical Practice Applied Nursing Research 2000 13(4):209-13.

[13]Stroop JR, Studies of interference in serial verbal reactions Journal of Experimental Psychology 1992 2(1):15-23.

[14]Nouchi R, Taki Y, Takeuchi H, Hashizume H, Nozawa T, Kambara T, Brain training game boosts executive functions, working memory and processing speed in the young adults: a randomized controlled trial PLoS ONE 2013 8(2):e55518

[15]Contador I, Almondes K, Fernndez-Calvo B, Boycheva E, Semantic verbal fluency: normative data in older Spanish adults from NEDICES population- based cohort Archives of Neuropsychology 2016 31(8):954-62.

[16]Rabin LA, Barr WB, Bertin LA, Assessment practices of clinical neuropsychologists in the United States and Canada: a survery of INS, NAN and APA division 40 members Archives of Clinical Neuropsychology 2005 20:33-65.

[17]Ian J, Deary Janie Corley, Alan J, Sarah E, Lorna M, Age – associated cognitive decline Br Med Bull 2009 92:135-52.

[18]Burke DM, Shafto MA, Ageing and language production Curr Dir Psychol Sci 2004 13(1):21-24.

[19]Naveh Benjamin M, Brav TK, Levv O, The associative memory deficit of older adults: the role of strategy utilization Psychol Ageing 2007 22(1):202-08.

[20]Hasher L, Chung C, May CP, Foong N, Age, Time of Testing, and Proactive Interference Canadian Journal of Experimental Psychology 2002 56(3):200-07.

[21]Marottoli RA, Cooney Jr LM, Wagner DR, Doucette J, Tinetti ME, Predictors of automobile crashes and moving violations among elderly drivers Ann Intern Med 1994 121:842-46.

[22]Williams KN, Kemper S, Interventions to reduce cognitive decline in ageing J Psychosoc Nurs Ment Health Serv 2010 48(5):42

[23]Wysocki M, Luo X, Schmeidler J, Dahlman K, Lesser GT, Grossman H, Hypertension is associated with cognitive decline in elderly people at high risk for dementia The American Journal of Geriatric Psychiatry 2012 20(2):179-87.

[24]Van Swieten JC, Geyskes GG, Derix MM, Peeck BM, Ramos LM, Van Latum JC, Hypertension in the elderly is associated with white matter lesions and cognitive decline Ann Neurol 1991 30(6):825-30.

[25]Elias MF, Wolf PA, D’Agostino RB, Cobb J, White LR, Untreated blood pressure level is inversely related to cognitive functioning: the framingham study Am J Epidemiol 1993 138(6):353-64.

[26]Launer LJ, Masaki K, Petrovitch H, Foley D, Havlik RJ, The association between midlife blood pressure levels and late life cognitive function. The Honolulu – Asia ageing study JAMA 1995 274:1846-51.

[27]Rebecca P, Webster G, Helen P, Kamal H, Lenore J, Lon R, Antihypertensive medication use and risk of cognitive impairment: the Honolulu – Asia gaining study Neurology 2013 81(10):888-95.

[28]Andre-Petersson L, Hagberg B, Janzon L, a comparison of cognitive ability in normotensive and hypertensive 68-year-old men: results from population study “men born in 1914” In Malmo, Sweden Exp Ageing Res 2001 27(4):319-40.