Age-Related Changes in Blood Pressure
STEN LANDAHL, CALLE BENGTSSON, JOHAN A. SIGURDSSON, ALVAR SVANBORG,
AND KURT SVARDSUDD
SUMMARY This report is based on three different representative population samples of a total of
1304 men (50-79 years old) and 1246 women (38-79 years old) observed for up to 12 years. Subjects'
consumption of antihypertensive drugs and blood pressure levels in subjects with and without such
treatment are presented. The prevalence of treatment with antihypertensive drugs (including
/3-blockers and diuretics for other Indications) increased from 2% at age 50 years to 37% at 79 years of
age among the men and from 1% at 38 years to 61 % at 79 years of age among the women. The mean
systolic/diastolic blood pressure in untreated subjects increased from 138/91 mm Hg at age 50 years to
159/91 mm Hg at age 70 years in the men and from 123/79 mm Hg at age 38 years to 168/93 mm Hg at
age 70 years in the women. At age 79 years the mean systolic/diastolic blood pressure was 155/83 mm
Hg in the men and 161785 mm Hg in the women. In a longitudinal follow-up of reexamined subjects,
there was an increase in systolic blood pressure levels up to age 75 years and a reduction in diastolic
blood pressure after age 75 years in both sexes. (Hypertension 8: 1044-1049, 1986)
KEY WORDS • blood pressure levels
• antihypertensive treatment
longitudinal study • epidemiological study
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S
SBP or DBP at higher ages. 4 6 Generally, reference
values for arterial blood pressures are lacking for elderly people. At the same time, however, the prescription
and consumption of antihypertensive drugs increase
sharply at ages above 60 years. 13 ' 14
This report is based on results from three different
longitudinal population studies of men and women
living in Goteborg and representing the age interval 38
to 79 years in women and 50 to 79 years in men.
Goteborg is the second largest city in Sweden, with
450,000 inhabitants within the city borders and about 1
million in the metropolitan area. It has a considerable
amount of industry, the biggest harbor in the country,
and an advanced school and university system. Goteborg is located on the west coast and has a milder
climate than the middle and northern parts of Sweden.
All three studies were designed to obtain samples
representative of the general population,13-17 and reports of comparisons between responders and nonresponders are available.15"19
The aim of this report was to describe blood pressure
levels studied both longitudinally over 9- to 12-year
periods and cross-sectionally in the total sample population as well as in those without drugs influencing the
blood pressure.
EVERAL previous studies from industrialized
countries have reported age-associated changes
in both systolic (SBP) and diastolic (DBP)
blood pressures. These changes seem to be different
for SBP and DBP and have also been reported to be
different in male and female subjects.1"12 The majority
of these studies have been performed on age groups
below 60 to 65 years of age. Blood pressure measurements on representative groups of populations above
these ages are lacking, although certain previous reports indicate that there is no further age-related rise in
From the Department of Geriatric and Long-term Care Medicine
(S. Landahl, A. Svanborg), Vasa Hospital, and the Department of
Primary Health Care (C. Bengtsson, J.A. Sigurdsson), and the
Department of Medicine I (K. Svfirdsudd), 5stra Hospital, University of Goteborg, Gdteborg, Sweden.
The study of 70-year-old persons in Goteborg was made possible
through grants from the Swedish Ministry of Health and Social
Affairs, the Commission for Social Research, the Swedish Medical
Research Council, the Gdteborg Medical Services Administration,
the Goteborg Administration of Social Services, and the Wilhelm
and Martina Lundgren Foundation.
Address for reprints: Sten Landahl, Department of Geriatric and
Long-term Care Medicine, Vasa Hospital, S-411 33 Go'teborg,
Sweden.
Received June 10, 1985; accepted June 3, 1986.
1044
1045
AGE-RELATED CHANGES IN BLOOD PYiESSUREJLandahl et al.
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Study Populations and Methods
The number of participants at different ages is
shown in Table 1. The study of men born in 1913 and
192313 started in 1963 and included a sample of 973
men, all born in 1913. Theresponserate was 88%, and
comparisons between responders and nonresponders
have been described.18- " Certain differences in mean
income, marital status, and alcoholism were observed.
A total of 703 of the men have been observed for 10
years. Another 50-year-old cohort of 226 men (bom in
1923) was included in the study 10 years later.
The study of women in Goteborg started in
1968—1969 with a sample of 1622 women bom in
1930, 1922, 1918, 1914, and 1908. The response rate
was 90%, and comparisons between responders and
nonresponders have been reported.16 The nonresponders were studied through telephone interviews
and records from outpatient and inpatient departments.
No differences were found with respect to place of
birth, presence of heart disease, and blood pressure.
This report deals with the women bom in 1918 and
examined at ages 38, 44, and 50 years and those bom
in 1930 and examined at 50, 56, and 62 years of age.
Seventy-five percent of these women had been observed for 12 years.
The "70-year-old people in Goteborg" study started
in 1971-1972 with 973 women and men examined out
of a sample of 1148 persons bom in 1901-1902 (a
response rate of 85%). The representativity of this
sample has been demonstrated previously.17 The nonresponders (15%) did not differ with respect to such
variables as income, marital status, or previous hospital care. Recent observations showed a similar mortality at age 79 years in responders and nonresponders
(A. Svanborg, unpublished data, 1986). We were able
to follow up 46% of the originally examined men (208)
and 63% of the women (328) at age 79 years. Another
70-year-old cohort bom in 1906-1907 (473 men and
561 women) was examined in 1976-1977.
TABLE 1. Number of Participants at Different Ages
Women
Age (yr)
Men
38
372*
—
44
336*
—
50
308*
855t
—
54
792t
—
56
35Ot
—
60
718t
—
325*
62
70
449§
524||
75
329§
410||
208§
79
328||
•Women born in 1930.
tMen born in 1913.
tWomen born in 1918.
§Men born in 1901-1902.
I Women born in 1901-1902.
Blood pressure was measured manually with the
cuff method after the subjects had spent 5 minutes at
rest in a sitting position and wasregisteredto the nearest 5 mm Hg in every subject except for the women
bom in 1918 and 1930 and for the 60-year-old men,
when the nearest 2 mm Hg was used. As far as DBP is
concerned, Korotkoff s Phase IV and V were measured, but only Phase V data are used in this report,
with the exception of the 50-year-old men examined in
1963, for whom only Phase IV was used.
The majority of antihypertensive drugs used in these
populations included thiazide and thiazidelike diuretics, £-adrenergic receptor blocking agents, hydralazine, prazosin, calcium influx inhibitors, spironolactone, and a-methyldopa.
Results
The use of antihypertensive drugs at the time of the
analyses in subjects examined between 1963 and 1981
is shown in Table 2. The percentage treated was higher
in women than in men, and the prevalence of such
treatment was approximately doubled in both sexes for
every decade above 50 years. Table 2 also shows the
proportion treated because of hypertension, which was
known for the age interval 70 to 79 years.
The mean SBP at various ages among the different
cohorts is given in Table 3 and Figure 1. All persons
examined on each occasion, except for those treated
with antihypertensive drugs are included. There was
an increase in the mean SBP up to age 70 years and a
moderate decrease from age 70 to 75 years. The agerelated increase in SBP was less pronounced in men,
resulting in a higher (about 10 mm Hg) mean SBP in
women than in men after age 60 years. In men, there
was also a moderate decrease in the mean SBP after
age 70 to 75 years. In the total study population (treated patients included), the mean SBP in women was 1
to 7 mm Hg higher and in men 1 to 3 mm Hg higher
TABLE 2. Treatment with Blood Pressure-Lowering Drugs*
Percentage
Age (yr)
38
44
50
54
56
60
62
70
75
79
Men
—
—
2
6
—
10
—
Women
3
4
8
—
15
—
20
39 (30)
49 (39)
61 (39)
19 (13)
29 (17)
37 (19)
Numbers in parentheses indicate the percentage of subjects with a
history of antihypertensive treatment.
*/9-blockers, diuretics, and/or other antihypertensive drugs.
HYPERTENSION
1046
TABLE 3. Systolic Blood Pressure at Various Ages in Subjects
Without Antihypertensive Treatment
Men
Age
(yr)
VOL
8, No
11, NOVEMBER
1986
TABLE 4. Diastolic Blood Pressure at Various Ages in Subjects
Without Antihypertensive Treatment
Men
Women
Women
SBP
(mm Hg)
No.
SBP
(mm Hg)
No.
Age
(yr)
DBP
(mm Hg)
No.
DBP
(mm Hg)
No.
—
—
123±14.4
369*
38
—
—
79±9.1
369*
38
44
—
—
124±16.4
322*
44
—
—
81 ±8.6
322*
50
138 ±20.5
841t
133±19.4
284*
50
91 + 12.8
8411
84±9.8
284*
54
142 ±20.1
747t
—
—
54
9O±11.8
747t
—
56
—
298*
56
—
—
84±9.1
60
144±22.2
62
—
70
159 + 25.0
75
79
—
134±18.8
—
60
88 ±12.7
643t
—
—
143+19.8
259*
62
—
—
86 ±10.0
259t
362§
168±25.5
321||
70
91 ±12.6
362§
93±13.2
321||
90±12.4
234§
89+12.9
209||
83±11.3
130§
85±9.9
127||
—
643t
158±24.5
234§
166±22.5
209||
75
155 + 24.6
13O§
161 ±2 2 . 1
127||
79
Systolic blood pressure (SBP) expressed as mean ± SD.
•Women bom in 1930.
tMen born in 1913.
tWomen bom in 1918.
§Men born in 1901-1902.
||Women bom in 1901-1902.
than in those without treatment. However, the pattern
of blood pressure change with age in the total population was identical to that among untreated subjects.
The mean DBP in women without antihypertensive
treatment also increased with age up to 70 years (Table
4; see Figure 1). In men, however, no change in DBP
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SBP
mmHg
/^>9
160 •
140
120 -
-Ago
40
—
298t
50
60
70
80
DBP
mmHg
—
Diastolic blood pressure (DBP) expressed as mean ± SD.
•Women bom in 1930.
tMen bom in 1913.
tWomen bom in 1918.
§Men bom in 1901-1902.
[Women bom in 1901-1902.
was observed between 50 and 70 years of age. After
age 70 to 75 years, the DBP decreased in both men and
women. In the total study population (treated patients
included), the mean DBP was 1 to 3 mm Hg higher in
both sexes than among those with no antihypertensive
treatment.
Table 5 shows the longitudinally observed changes
in blood pressure observed in subjects without hypotensive drugs: women were examined at the age intervals 38 to 50, 50 to 62, and 70 to 79 years, and men
were examined at 50 to 60 and 70 to 79 years. The SBP
increased significantly in both sexes at least up to age
75 years. The lower value at the age interval 70 to 79
years compared with that at 70 to 75 years is due to a
decrease in SBP between ages 75 and 79 years. The
DBP in women still showed an increase at the age
interval 50 to 62 years but showed a decline after age
75 years, and no change was noted in DBP in men until
after age 75 years, when a significant decline was
observed.
Table 6 shows the blood pressure levels in those
probands born in 1901-1902 who werereexaminedat
both age 75 and 79 years. The DBP decreased after age
75 years in both sexes. The blood pressures were also
lower in this group of survivors at ages 70 and 75 years
than in the total study population. The longitudinal
changes showed a unimodal distribution.
100-
80-
-Age
40
50
60
70
80
FIGURE 1. Systolic (SBP) and diastolic (DBP) blood pressures in subjects without antihypertensive treatment. Crosssectional data.
Discussion
Previous epidemiological studies of possible agerelated changes in blood pressure are numerous (for a
review, see References 1-12) and have yielded somewhat controversial results. To a great extent, the discrepancies are due to variations in population sampling
procedures and the samples investigated, to differences in age-standardized morbidity and longevity be-
AGE-RELATED CHANGES IN BLOOD PRESSURE/Landahl et al.
1047
TABLE 5. Longitudinal Changes in Systolic and Diastolic Blood Pressure Among Reexamined Subjects Without
Antihypertensive Treatment
ASBP (mm Hg)
Age interval
Whole
interval
No.
ADBP (mm Hg)
Per
year
Whole
interval
Per
year
0.5
Women
38-50
284
12.4± 16.12*
1.0
6.2±8.64*
50-62
251
12.5 ±17.63*
1.0
3.2 ±8.76*
0.3
70-75
127
1.2
-1.5+11.24
-0.3
70-79
127
6.2 ±20.09*
4.3±23.38t
—
- 4 . 5 ±1 1 . 5 3 *
-0.5
1.0
0.7+ 12.83
0.8
1.1+9.81
—
-5.6+11.48*
Men
70-75
130
9.5± 18.91*
4.1±19.80t
70-79
130
3.7±23.O8
50-^0
639
0.1
0.2
-0.6
Changes in systolic (SBP) and diastolic (DBP) blood pressure expressed as mean ± SD.
*p < 0.001, tp < 0.05 (paired t test).
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tween, for example, populations in developing and
developed countries, and to cultural and environmental differences.12 The Swedish population is presently
the oldest in the world, with no less than 17% aged 65
years or more. Compared with most other countries,
numeric and cultural differences between different age
groups are rather small.
The majority of epidemiological studies in countries
with high longevity indicate that the SBP rises with
age. This is obviously the case in Goteborg, as well as
in Framingham, Massachusetts, USA, 7 and Glostrup,
Denmark,11 up to age 70 to 75 years. The age-related
rise indicated by both cross-sectional and longitudinal
comparisons was found to be faster in women than in
men. Cross-sectional comparison showed that the regression lines representing SBP versus age in the two
sexes cross each other at age 45 years in the Framingham study but not until age 60 to 70 years in the
present investigation. Available data indicate that in
the Japanese population the female line does not approach the male line until ages above 70 years.20 Longitudinal blood pressure measurement results from the
Framingham study7 indicate that, although the agerelated rise was faster in women than in men and the
TABLE 6. Systolic and Diastolic Blood Pressures in Subjects
70-79 Years of Age Who Attended All Three Examinations and
Received No Antihypertensive Treatment
Men (/» = 130)
Women (n= 127)
(mm Hg)
SBP
(mm Hg)
DBP
(mm Hg)
152±19.8
88±9.5
156±17.9
89+10.4
156±22.4*
89+10.4
163±19.8t
88+11.1
155 ±24.6
8 3 ±1 1 . 3 j
161 ±22.1
84 + 9.9J
Age
(yr)
SBP
(mm Hg)
70
75
79
DBP
Systolic (SBP) and diastolic (DBP) blood pressure expressed as
mean + SD.
*p < 0.05, tp < 0.001 (paired t test), compared with same-sex
SBP in 70-year-old age group; tp < 0.001 (paired / test), compared
with same-sex DBP in 75-year-old age group.
female lines approach the male ones at about age 70
years, these lines never cross. The present results
showed a rate of change of about 1 mm Hg per year in
both men and women up to age 75 years longitudinally, while the cross-sectional comparisons showed a
faster increase in women than in men. These findings
might either imply a higher selective mortality of
women with higher blood pressure than of men, or
result from the fact that the proportion of women treated with blood pressure-lowering drugs was much
higher (see Table 2), resulting in different sex distributions of the untreated groups. There are no data available in the Swedish mortality statistics indicating that
women below the age of 70 to 75 years have a higher
risk than men of having cardiovascular complications
due to hypertension. We therefore conclude from the
present results that available epidemiological data
indicate that the rate of age-related increase in SBP
is faster in women than in men and that at age 70 years,
a higher clinical reference value for SBP has to be
accepted in women than in men. How great such a
physiological difference should be accepted to be —
cross-sectionally women had blood pressure levels that
were 10 mm Hg higher — remains to be studied
in populations with a similar rate of treatment with
antihypertensive drugs.
The present report is based on three different population studies in samples that obviously allow generalizations to be made about the total population of Goteborg. Indirect evidence such as available information
on the consumption of antihypertensive drugs in different areas of Sweden10 indicates that the present observations on age-related changes in SBP and DBP also
are relevant for the rest of the population in Sweden.
A comparison of the age-related change in DBP is
more difficult to make because of the proportionally
higher measurement error in relation to the age differences. The fact that KorotkofFs Phase IV was used in
the longitudinal analyses for men born in 1913 was
shown to be of minor importance, since the change
1048
HYPERTENSION
between 54 and 60 years of age showed no difference
compared with Phase V data. Also, the change in DBP
between 70 to 75 and 79 years of age was similar for
both phases. Most results were based onregistrationof
blood pressure to the nearest 5 mm Hg, except for the
two youngest female cohorts and the 60-year-old male
cohort. This methodological difference is of minor
importance as far as analyses of longitudinal changes
within the different cohorts are concerned but may
affect the comparison between the absolute blood pressure levels for different cohorts. In men, previous studies1"12 have shown an age-related increase, at least up
to age 50 to 60 years and thereafter a leveling off. The
present study of men older than 50 years showed a
further decline starting above age 70 to 75 years. There
was a sex difference with a further rise also in DBP up
to age 70 years in women, while both cross-sectional
and longitudinal data showed a decline in the DBP of
men and women after age 75 years, after which no sex
differences in these age-related trends in blood pressure levels can be seen.
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For ethical reasons all the participants in the population studies in Goteborg have had some medical intervention (e.g., the institution of antihypertensive treatment). From this point of view, the best cross-sectional
comparison can be made between the "starting" ages
(i.e., 38, 50, and 70 years) in the total study population. However, our main conclusions have been based
on both the cross-sectional analysis and the results
from longitudinal follow-ups in subjects without any
drug treatment influencing the blood pressure. The
decline in blood pressures during the age interval 75 to
79 years thus could not be due to any intervention
given during this age interval. It is also important to
bear in mind that the distribution of the blood pressure
changes was close to normal with a slightly more pronounced decrease.
The reason for the blood pressure decline has not
been addressed in this report. Other studies of the same
sample21 have shown a marked change of body mass
and body composition at these ages. Possible relationships between body mass, body cell mass, and blood
pressure can be anticipated. However, it should be
emphasized that similar changes in body mass and
body composition also took place at the age interval 60
to 70 years, when there still was an increase in SBP in
both sexes and in DBP in women. A marked decline in
body height could also affect blood pressure, for instance, by changing the demand of blood pressure to
ensure adequate cerebral blood flow. Selective mortality and observer bias may also be factors of some
importance for this decline in blood pressure.
One reason for the increase of SBP up to age 70 to
75 years is a gradual deterioration of elastic filaments
in the aorta and large arteries. This exchange of elastic
filaments with stiffer collagen elements increases the
"Windkessel" phenomenon in these vessels, leading to
increased pulse pressure. A decreasing ability with age
to handle exogenous blood pressure-affecting factors
such as salt intake, extracellular volume, and serum
proteins may also be of importance.22 Several previous
VOL 8, No
11, NOVEMBER
1986
studies23"29 have investigated possible age-related
changes in the production of catecholamines. The results are conflicting, but the majority of these studies
conclude that increased norepinephrine levels are balanced by a decrease in receptor sensitivity. Plasma
renin activity and renin concentrations have been reported to be lowered by increasing age, but similarly in
hypertensive and normotensive elderly.2630 Also,
plasma and urine aldosterone concentrations decrease
with age.31
The reason why the age-related SBP changes in
women are more pronounced than in men is unknown.
Neither do we know any reasons for the earlier leveling
off of the DBP in men than in women. Possible relationships to hormonal changes causing, for example,
differences in salt and water content of the body might
be considered. Recent studies have shown a less pronounced blood pressure increase after age 50 years in
women who are postmenopausal than in women who
still menstruate.32
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