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Blood Pressure as a Biomarker in Gerontological Research

Summary and Keywords

Blood pressure is a frequently used measure in studies of adult development and aging, serving as a biomarker for health, physiological reactivity, and task engagement. Importantly, it has helped elucidate the influence of cardiovascular health on behavioral aspects of the aging process, with research demonstrating the negative effect of chronic high blood pressure on various aspects of cognitive functioning in later life. An important implication of such research is that much of what is considered part and parcel of getting older may actually be reflective of changes in health as opposed to normative aging processes. Research has also demonstrated that situational spikes in blood pressure to emotional stressors (i.e., reactivity) also have implications for health in later life. Although research is still somewhat limited, individual differences in personal traits and living circumstances have been found to moderate the strength of reactive responses, providing promise for the identification of factors that might ameliorate the effects of age-related changes in physiology that lead to normative increases in reactivity. Finally, blood pressure has also been successfully used to assess engagement levels. In this context, recent work on aging has focused on the utility of blood pressure as a reliable indicator of both (a) the costs associated with cognitive engagement and (b) the extent to which variation in these costs might predict both between-individual and age-related normative variation in participation in cognitively demanding—but potentially beneficial—activities. This chapter elaborates on these three approaches and summarizes major research findings along with methodological and interpretational issues.

Keywords: blood pressure, biomarker, hypertension, reactivity, aging, effort

The use of cardiovascular (CV) responses has a relatively long history in psychological research. Researchers have assessed them as physiological indices of psychological functions that, when used in conjunction with behavioral assessments, can provide a richer understanding of specific phenomena. Research has also examined how CV responses vary across individuals in reaction to stressful situations, with an emphasis on the health-related implications associated with the frequency and intensity of these reactions. Studies in health psychology have also examined the impact of CV functioning and disease on behavior, and the impact of behavioral factors on CV functions.

Within the field of gerontology, CV responses have been used in a similar fashion to address problems specific to the aging. Although there are several types of CV responses that can be assessed and used to uniquely address particular issues, blood pressure—and, in particular, systolic blood pressure (SBP)—has been one of the more frequently used measures. There are several reasons for this. One is that it is a basic index of CV functioning that is relatively easy to assess. More importantly, however, it is also a marker of sympathetic nervous system functioning, and is meaningfully linked to both physical and psychological functioning. For example, aging is associated with increased blood pressure reactivity in responses to stressful situations (Uchino, Birmingham, & Berg, 2010). In addition, high levels of reactivity are linked to chronic elevation of blood pressure (i.e., hypertension), which is a risk factor for heart attack and stroke, the most common causes of death and disability. Adaptive coping responses to stressful events in later life may be particularly important in counteracting this increased reactivity and the associated negative health implications (e.g., Charles, 2010).

The earliest and most frequent use of blood pressure in gerontological research was as a marker of CV health that was used to predict both individual and age-related differences in psychological functioning. Aging is associated with a normative increase in blood pressure among otherwise healthy older adults (Lakatta, 1993), and elevated blood pressure has been shown to be associated with lower levels of cognitive functioning as well as compromised brain structure and function (e.g., general and regional blood flow, prevalence of white-matter hyperintensities [WMH]1 (for review, see Waldstein, Wendell, & Katzel, 2010). Such effects tend to be exacerbated in those older adults with hypertension, which also increases in incidence in later life. Thus, an interesting question concerns the extent to which the normative increase in blood pressure with age could potentially account for some of the age-related variance in certain aspects of cognitive functioning. Indeed, some researchers have suggested that much of what is typically identified as “age-related” variance can be accounted for by changes in health-related systems, such as those having to do with CV functioning (e.g., Spiro & Brady, 2011). Of further interest is the degree to which potentially pathological changes in blood pressure exacerbate the negative effects of aging and increase the probability of Alzheimer’s disease and other types of dementia.

A second—and somewhat related—way in which blood pressure has been used is as an index of reactivity to stressors in life. This reflects more of a context-specific response as opposed to the chronic-level approach used in the just-discussed research on health. In addition, reactivity is assessed in situations that Obrist (1981) characterized as involving either passive or active coping—that is, reactivity in response to emotionally evocative stressors over which the individual has little versus high instrumental control. Importantly, high levels of reactivity and prolonged reactivity negatively impact health and functioning (Waldstein et al., 2010), and thus can be considered risk factors. Within the field of aging, a major concern has to do with the extent to which reactivity changes with age, and thus increases the vulnerability of older adults to these effects, particularly since it is assumed that older adults have fewer resources with which to control or recover from reactive responses.

Finally, a third, more recent use of blood pressure in studies of aging is as a measure of engagement or effort expenditure. Specifically, building on Wright’s (1996) integration of Obrist’s (1981) active coping model with motivational intensity theory (Brehm & Self, 1989), SBP has been shown to be a valid reflection of factors associated with task engagement, including motivation and task difficulty. For example, individuals who are highly motivated to do well in a given situation exhibit higher levels of SBP than do those who are less motivated, and SBP increases systematically with task difficulty as long as the individual believes that the task is within their capabilities and engagement is worthwhile (for review, see Gendolla, Wright, & Richter, 2012). Note that this use of SBP is similar to that associated with reactivity in that it reflects a response to a specific situation. In this context, however, SBP is thought to represent more active instrumental responses on the part of the individual as he or she attempts to actively cope with the demands of a given situation. With respect to aging, differences in levels and patterns of SBP in response to task demands have been used to examine age differences in general task engagement—as a reflection of motivation—and the effort expenditure required to achieve a specific level of objective task performance.

In the following sections, research associated with each of these three roles of SBP is reviewed. This examination of the literature is not intended to be exhaustive. Rather, the focus is both on how blood pressure has been used and on representative findings within each area of investigation. Specific interpretational and methodological issues are also discussed.

Blood Pressure as a Predictor of Functioning

As a result of the stiffening of large arteries that occurs with age, older adults tend to experience increases in SBP coupled with decreases in diastolic blood pressure (DBP) (Waldstein et al., 2010). Additionally, bodies become less efficient at maintaining homeostasis with age. Specifically, there are structural changes in the heart and cardiovascular system (i.e., degeneration of muscle cells; reduced elasticity of blood vessels) that cause older adults to have lower resting pulses than young and middle-aged adults. When the heart beats slowly, pressure is often increased on the vessels in an effort to fill the heart with blood more quickly (Pugh & Wei, 2001). In addition, the older body is less able to process sodium due to normal age-related decreases in kidney function. Older adults naturally have had more time to accumulate fat and sodium deposits in the arteries and blood stream, perturbing the functioning of their cardiovascular systems. In addition to the normative increase in blood pressure with age, the incidence of hypertension is also very high, with 90% of people experiencing it at some point throughout middle or older adulthood (Franklin et al., 2001). Of particular interest in the study of aging is the impact of these changes in the CV system on functioning, along with the factors that moderate this impact.

Associations Between Blood Pressure and Cognitive Functioning

Much attention has focused on the relationship between blood pressure and cognitive functioning in later life. This is quite reasonable given that changes in cortical structure and functioning have been associated with blood pressure in a number of different ways. On the one hand, high blood pressure in mid- to late life has been associated with larger losses of neurons and cerebral connective tissue, or brain atrophy (e.g., DeCarli et al., 1999; Hofman, Grobbee, de Jong, & van den Ouweland, 1991; Swan et al., 1998). On the other hand, low levels of blood pressure, or declines in blood pressure with age, have been associated with brain atrophy (e.g., Swan et al., 2000), with the effects being stronger for DBP and in those older than 85 (den Heijer et al., 2003; Skoog, Andreasson, Landahl, & Lernfelt, 1998). For example, older adults whose DBP declined more than 10 mmHg over the course of 20 years had more cortical atrophy than those whose DBP was more stable (den Heijer et al., 2003). Blood pressure is also related to brain connectivity. Older adults with hypertension are more likely to have weakened connectivity within the frontoparietal networks, including the frontoparietal control network (FCN), dorsal attention network (DAN), and ventral attention network (VAN) (Li et al., 2015; Wong et al., 2017).

A number of studies have demonstrated that WMH volume is associated with cerebrovascular disease risk factors such as hypertension and elevated fluctuations in blood pressure (e.g., Brickman et al., 2010; Swan et al., 1998). DBP may be more predictive of subcortical WMH, whereas SBP has been shown to predict periventricular WMH (Söderlund, Nyberg, Adolfsson, Nilsson, & Launer, 2003). One region of the brain in which white matter integrity may be particularly affected by high blood pressure is the splenium of the corpus callosum, which is a major commissure connecting regions across the posterior cortices including parietal, temporal, and visual areas (Knyazeva, 2013). Middle-aged (e.g., Gons et al., 2012) and older adults (e.g., Maillard et al., 2012; Wong et al., 2017) who are hypertensive tend to have lower white matter integrity in this region compared with non-hypertensives.

Given these cortical changes, it is not unreasonable to assume that blood pressure is related to some of the changes in cognitive functioning experienced by adults in later life. Gifford and colleagues’ (2013) meta-analysis of 12 articles found that blood pressure was significantly correlated with global cognition and episodic memory, weakly and non-significantly correlated with attention, and not related with language, executive functioning, information processing speed, or visuoperceptual abilities. Interestingly, compared with SBP, DBP was more strongly correlated with episodic memory. Although this meta-analysis did not find evidence for a link between executive functioning and blood pressure, other studies have. For example, the Maintenance of Balance, Independent Living, Intellect, and Zest in the Elderly of Boston study found hypertension to be associated with an increased risk for impaired executive function as indicated by the Trail Making Test Part B (Hajjar et al., 2009). Similarly, Wolfson and colleagues (2013) followed older adults over the course of four years and found that increases in WMH (which was associated with out-of-office blood pressure) were associated with decreases in performance on the Trail Making Test Part B. Processing speed is another specific ability found to be negatively associated with systolic blood pressure (Wong et al., 2017). More generally, in a study of older adults aged 60–91, SBP was significantly associated with cognitive performance on the Cambridge Examination for Mental Disorders of the Elderly–Cognitive Section and the Mini Mental State Examination (Budge, de Jager, Hogervorst, & Smith, 2002), such that higher SBP was predictive of worse scores. It should be noted, however, that moderate levels of hypertension have also been positively associated with cognitive performance. For example, a study of men found that individuals with Hypertension Stage 1 (SBP 140–150 mmHg or DBP 90–99 mmHg) tended to outperform those with normal blood pressure or higher levels of hypertension (André-Petersson, Hagberg, Janzon, & Steen, 2001).

Some studies have examined the use of composite cardiovascular risk scores, which include blood pressure, as predictors of future cognition. For example, the PATH Through Life Project followed individuals aged 40–44 over the course of eight years and used composite scores of cardiovascular risk burden (i.e., presence of hypertension, smoking, depression, high body mass index [BMI], diabetes, and insufficient physical activity) and examined their impact on cognitive development in midlife. Higher composite scores were associated with greater declines in processing speed and response time throughout this midlife period (Anstey et al., 2014). DeRight, Jorgensen, and Cabral (2015) did a meta-analysis of 19 studies examining composite cardiovascular risk scores, and found a significant association (r = −0.16) between these risk scores and performance on cognitive tests in the domains of global, executive, attentional, memory, and (although qualitatively weaker in its association) visuospatial functioning. This relationship was not significantly weakened when controlling for age.

Affective components of cognition also seem to be influenced by blood pressure. Specifically, there is an emotional dampening effect whereby individuals with high blood pressure tend to be less responsive to painful stimuli (Ghione, 1996) and have lower affective responses to pain (e.g., Fillingim, Maixner, Bunting, & Silva, 1998) and stress (e.g., Nyklíček, Vingerhoets, & Van Heck, 1996, 2001). Additionally, when presented with emotional cues, individuals with high blood pressure may have reduced ability to accurately recognize and respond to these cues. In a Perception of Affect Test (PAT), individuals with high blood pressure did worse compared with those with lower blood pressure, even after controlling for demographic variables (McCubbin et al., 2011). SBP and DBP were both significantly correlated with PAT scores (rs = −0.30 and −0.24, respectively).

In an examination of hypertension and its cognitive correlates, the oldest old present an interesting case in that the reverse pattern is usually observed (Beckett, Peters, & Fletcher, 2008). For example, a study of centenarians in Japan found that those with the highest blood pressure had optimal functioning in terms of physical and cognitive abilities, whereas centenarians with the lowest blood pressure had the worst functioning in these areas (Shimizu et al., 2008). Similar findings have been found in centenarians in Australia (Richmond, Law, & Kay-Lambkin, 2011). Additionally, in a study of hypertensive veterans aged 80 and older, those with higher levels of SBP were significantly less likely to die over the next five years, compared with those who had lower levels of SBP (Oates, Berlowitz, Glickman, Silliman, & Borzecki, 2007). At this point, it is unclear whether and why hypertension in the oldest old may serve as a compensatory mechanism, thus indicating better health. One possibility is that elevated blood pressure may counteract restrictions in blood flow to the brain associated with reduced vascular flexibility, although there is no clear support for this hypothesis.

Blood pressure has also been associated with other aspects of performance that may be associated with cognition. For example, mobility, as measured by Short Physical Performance Battery (SPPB) scores, timed stair descent, and self-paced maximum velocity, has been related to WMH and blood pressure (Wolfson et al., 2013). Additionally hypertension has been associated with an increased likelihood of slow gait (Hajjar et al., 2009). In both cases, attentional issues may be important in supporting performance. Cognitive functioning may also be negatively affected by these types of mobility problems by determining the degree to which individuals may participate in activities that could benefit them socially, physically, and cognitively. This may further contribute to the relationship between hypertension and cognitive decline.

Related Measures

Although SBP and DBP are the primary measures used in research, additional indices related to blood pressure that may also be reflective of vascular integrity have also been used. Measures of pulse pressure, orthostatic hypotension, and lower ankle-brachial index (ABI) all incorporate or relate to traditional blood pressure measures used in the studies discussed above, and have been similarly associated with cognitive performance.

Pulse pressure is an index of arterial stiffness and vasoreactivity derived from taking the difference between SBP and DBP measures (Malone & Reddan, 2010). For individuals over age 70, pulse pressure has been negatively associated with cognitive performance (Obisesan et al., 2008). Scott and colleagues (2016) measured pulse pressure before and after exercise in the form of a six-minute walk test, and examined these measures in relation to scores on executive function tasks. Pulse pressure following this light exercise period was negatively associated with executive function and processing speed. Interestingly, post-exercise pulse pressure was a better predictor of executive function scores than pre-exercise pulse pressure, suggesting that level of reactivity to a physical stressor may be a better indicator of well-being than baseline cardiovascular functioning.

Another measure which incorporates blood pressure is orthostatic hypotension, which is a drop of 20 mmHg or more in SBP or a drop of 10 mmHg or more in DBP when moving from a seated to standing position. In a study of women aged 65 and older, orthostatic hypotension was negatively associated with global cognitive function and memory (Frewen, Savva, Boyle, Finucane, & Kenny, 2014b). In a study of adults aged 50 and older, those who had supine hypertension in addition to orthostatic hypotension had lower global and executive performance compared with those who had high supine hypertension without orthostatic hypotension (Frewen, Finucane, Savva, Boyle, & Kenny, 2014a).

Finally, ankle-brachial index, or ABI, is another indicator of vascular integrity which involves blood pressure. ABI is the ratio of blood pressure at the ankle to the blood pressure in the arm. Lower blood pressure in the leg is suggestive of blocked arteries, so lower ABIs are generally not desirable. Laukka, Starr, and Deary (2014) found that lower ABI was associated with worse cognitive performance—especially in processing speed tests, and this association was strongest for those over age 85.

Blood Pressure and Alzheimer’s Disease and Dementia

Aside from its association with cognitive changes that may be normative in older adulthood, blood pressure has also been associated with pathological changes in brain structure and function, as well as the associated conditions of Alzheimer’s disease and dementia. Because DBP has not been identified as a strong predictor of Alzheimer’s and dementia, the attention here is focused on SBP.

A number of studies have demonstrated that high blood pressure may be a precursor to Alzheimer’s or dementia. High levels of SBP in midlife have been significantly associated with developing dementia (e.g., Launer et al., 2000; Yamada et al., 2003) or Alzheimer’s disease (e.g., Kivipelto et al., 2001) later on in life. Hypertension in later adulthood may also be predictive of dementia, with findings from the Betula Study revealing an association between dementia diagnosis and high levels of SBP 10 years prior (Nilsson et al., 2004). The age of hypertension onset may be particularly important, with hypertension during midlife being a stronger predictor of problems than later life onset. For example, individuals whose hypertension began between the ages of 80 and 89 had a lower hazard ratio for developing dementia compared with younger age groups, and those who developed hypertension at age 90 or older had the lowest hazard ratio (Corrada et al., 2017). Skoog and Gustafson (2006) suggest that the development of subclinical Alzheimer’s disease may actually be responsible for increases in blood pressure that are observed prior to actual diagnosis. However, midlife hypertension seems to be the most sensitive period in terms of its association with Alzheimer’s. For example, even though those with Alzheimer’s disease had higher levels of SBP during midlife compared with non-demented controls (Ms = 152.7 and 143.9, respectively), the two groups had similar levels of SBP in older age (Ms = 150.4 mmHg and 151.5 mmHg, respectively) (Kivipelto et al., 2001).

It should be noted that there are other factors that may be more predictive of Alzheimer’s and dementia than hypertension. The presence of hypertension, high cholesterol, diabetes, and smoking at ages 40–44 were each associated with significant increases in the risk for dementia later on in life (Whitmer, Sidney, Selby, Johnston, & Yaffe, 2005), with hypertension being the weakest predictor of the risk factors included in this study. Furthermore, the strength of these relationships likely depends upon other factors, such as whether or not anti-hypertensive medication is utilized in midlife. For example, Launer and colleagues (2000) did not find an association between midlife blood pressure and dementia risk for those who received treatment. Therefore, midlife hypertension is not necessarily determinative of future neurological status, but rather points to the need for lifestyle changes and/or medical intervention as preventative measures. Vascular risk factors such as hypertension are modifiable.

Moderating Factors

Given the negative effects of elevated blood pressure on functioning in later life, research has also focused on factors that might moderate this impact. Such moderating factors may have implications for prevention and intervention. Due to limited space, the focus is on the role of a few factors that have received more attention in the literature: loneliness, social connectedness, and participation in exercise.

Both cross-sectional and longitudinal studies have demonstrated a positive association between loneliness or social isolation and blood pressure, suggesting that social factors may be important in determining the degree to which aging takes a physical toll on the body. In a cross-sectional study of younger and older women, older age predicted higher SBP and DBP only for those low in perceived support (Uchino, Cacioppo, Malarkey, Glaser, & Kiecolt-Glaser, 1995). Women who reported perceptions of having others available with whom to discuss their problems did not have this association between age and blood pressure. In a similar vein, age was associated with resting SBP and DBP only for those reporting low levels of social support (Uchino, Holt-Lunstad, Uno, Betacourt, & Garvey, 1999). It is important to note that these findings were not altered when controlling for a number of factors associated with health (i.e., BMI, sleep patterns, exercise patterns, caffeine consumption, and alcohol consumption), personality (i.e., extraversion, neuroticism, and hostility), and affect (i.e., life satisfaction, perceived stress, and depression). A study examining self-reports of loneliness and related factors in middle and older adults had similar findings: a relationship between age and SBP only existed for lonely individuals (Cacioppo et al., 2002). Examining longitudinal data from the Chicago Health, Aging, and Social Relations Study (CHASR), Hawkley, Thisted, Masi, and Cacioppo (2010) found that over the course of four years, lonely individuals experienced greater increases in blood pressure compared with their less lonely counterparts. On the other hand, data from the English Longitudinal Study of Ageing (ELSA) did not reveal an association between loneliness and blood pressure. However, increases in social isolation (as indicated by a count of the following factors: being single or living alone, having less than monthly contact with children, family, or friends, and not participating in community organizations) was significantly related to small increases in SBP and DBP (Shankar, McMunn, Banks, & Steptoe, 2011).

Exercise participation may reduce the risk of elevated blood pressure on cognitive declines in older adulthood. N.C.L. Hess and Smart (2017) suggest that isometric exercise interventions may reduce hypertension, which in turn may slow or prevent cognitive decline. Thus, exercise may be a protective factor for hypertensives with and without mild cognitive impairments (MCI). An analysis of data from the Survey of Midlife Development in the United States (MIDUS) revealed a relationship found in only older adults in which the effect of cardiovascular disease risk factors (including hypertension) on episodic memory skills was moderated by their level of physical activity participation (Lin, Friedman, Quinn, Chen, & Mapstone, 2012). Taken together, these studies suggest that physical activity is particularly beneficial in older adulthood. It should be noted that at this point, the directionality of effects between cardiovascular well-being and exercise participation is unclear.

These moderating factors point to the need for researchers to consider many characteristics of the individual when seeking to draw connections between cardiovascular and cognitive well-being. Feelings of anxiety about one’s cognitive abilities (Nguyen et al., 2016), anti-hypertensive medication use (e.g., Launer et al., 2000), presence of brain lesions (Wang et al., 2017), and presence of the APOE ɛ4 allele (Bender & Raz, 2012) are some other potentially moderating factors that have been explored in this realm that deserve mention but will not be discussed.


Older adults tend to experience increases in blood pressure with increasing age, largely as a result of decreases in the efficiency and strength of the heart. These changes in the cardiovascular system align with structural and functional changes in the brain, which may play a role in the cognitive decline that is normally observed in aging individuals. In general, hypertension is associated with lower levels of cognition as well as an increased risk for Alzheimer’s disease and dementia. However, a notable number of studies have found evidence for benefits of slightly elevated blood pressure, as well as elevated blood pressure in the oldest old. The onset of hypertension is a major consideration, with earlier onset tending to be more predictive of cognitive decline in older age than hypertension that starts later in life. Lastly, these trends should be considered within the context of both the individual and his or her environment. Given that hypertension is so prevalent among the increasingly large population of older adults, it is important for us to further identify the developmental consequences of high blood pressure as well as protective factors.

Blood Pressure as an Index of Reactivity

In the previous section, the focus was on variations in chronic blood pressure conditions (e.g., hypertension). There is also much interest, however, in situation-specific blood pressure responses and how these change across adulthood. Aging is associated with changes in the processes and functions of the autonomic nervous system that lead to increased blood pressure. Specifically, it is associated with increased sympathetic activity and decreased parasympathetic control. The preservation of α‎-adrenergic receptor sensitivity to vasoconstrictors and decreased β‎-adrenergic receptor sensitivity to vasodilators are related to elevations in peripheral resistance to blood flow, and subsequently increases in blood pressure. One consequence of these autonomic imbalances, which is generally seen among older adults, may be higher pressor responses to various stressors (Cooper, Katzel, & Waldstein, 2007).

Cardiovascular reactivity refers to an individual’s tendency to react more or less strongly physiologically to engaging or challenging stimuli (e.g., Manuck, 1994), with high levels of reactivity predictive of increased blood pressure and atherosclerosis, conditions associated with the development of various cardiovascular diseases (e.g., Treiber et al., 2003). Research has shown that SBP reactivity, but not DBP reactivity, increases consistently with age (e.g., Uchino, Birmingham, & Berg, 2010) and is predictive of future hypertension (Menkes et al., 1989), highlighting its importance for health in older adulthood. Given this, the focus is primarily on research that identifies the characteristics associated with persons and situations that both mediate and moderate SBP reactivity. Once again, an ultimate goal is to use this information for purposes of prevention and intervention.

Person Characteristics: Stress Exposure and Psychosocial Moderators

Persistent or chronic stress in daily life may exacerbate the negative effects of aging on SBP reactivity. For example, the burden or stress associated with long-term caregiving predicts increases in allostatic load (e.g., Dich, Lange, Head, & Rod, 2015) and has both short- and long-term implications for an aging cardiovascular system in general. Longitudinal investigations indicate that β‎-adrenergic receptor sensitivity, which mediates processes associated with blood pressure, decreases over time among older caregivers of spouses with Alzheimer’s disease (Mausbach et al., 2008). In the short term, laboratory-based results indicate increased basal levels of SBP (Cacioppo et al., 2000; Uchino, Kiecolt-Glaser, & Cacioppo, 1994) and SBP reactivity to stressors (Atienza, Henderson, Wilcox, & King, 2001; cf. Uchino, Kiecolt-Glaser, & Cacioppo, 1992), especially among hypertensive caregivers (Vitaliano, Russo, Bailey, Young, & McCann, 1993). Socioeconomic status (SES) has also received some attention as a contributing source to allostatic load, though with mixed findings. Low SES—based on education (Steptoe, Kunz-Ebrecht, Wright, & Feldman, 2005) and occupational status (e.g., manual versus non-manual; Carroll, Phillips, Ring, Der, & Hunt, 2005)—is associated with increased SBP reactivity among young, middle-aged, and older adults. Similarly, Steptoe and colleagues (2002) found that older women with low relative to high employment grades (e.g., clerical versus professional) showed increases in reactivity.

Given the increased level of reactivity associated with chronic stressors, research has focused on potential buffers of such effects in the form of individual differences in psychological (e.g., personality) and psychosocial (e.g., social support, attitudes) factors. In terms of the former, intrinsic tendencies to respond to situations in negative, aggressive, and hostile ways as well as the presence of mood disorders (e.g., anxiety and depression) in older adults are related to increased SBP reactivity. For instance, when asked to recall an angry event in a relived emotion task or to provide a description of their spouse, individuals high in hostility (Fredrickson et al., 2000) and related coronary-prone behaviors (i.e., Type A personality, controlled anger, avoidance coping; Vitaliano et al., 1993) exhibited steeper SBP responses than their peers low on these factors. Similarly, the co-occurrence of anxiety and depression has been shown to predict increases in SBP reactivity (Robertson, Swickert, Connelly, & Galizio, 2015).

Social support has also been shown to be an important moderator of reactivity. Research has shown that the perceptions older adults have of the availability of social support or the quality of their social relationships moderate physiological reactivity. Low levels of social support (Howard, Creaven, Hughes, O’Leary, & James, 2017; Uchino et al., 1992) and social connectedness (Ong & Allaire, 2005), as well as feelings of loneliness (Cacioppo et al., 2002; Ong, Rothstein, & Uchino, 2012), have specifically been associated with higher SBP responses, particularly among older adults. Older adults show increases in reactivity in comparison with young adults when they report feeling lonely (Ong et al., 2012) and low levels of social support (Uchino et al., 1992). Additionally, on days when older adults report fewer positive relations with others, they also experience greater reactivity to negative affect (Ong & Allaire, 2005). Moreover, all types of social relationships do not lead to the same benefits, as the number of social relations characterized as both helpful and upsetting (i.e., ambivalent) have been shown to predict increases in SBP reactivity in older adults (Uchino, Kent de Grey, & Cronan, 2016).

Finally, work on the effects of personal attitudes and stereotypes about health and age suggest that positive attitudes may attenuate reactivity in older adults. For example, one study (Auman, Bosworth, & Hess, 2005) examined how health stereotypes and personal investment in autonomous lifestyles interacted to predict reactivity among hypertensive men in an outpatient setting. After indicating the degree to which they valued independent living, participants answered questions that drew attention either to negative aspects of their health (e.g., sicknesses, loss of control) or positive aspects (e.g., personally valued leisure activities). Older, but not middle-aged, men in the negative condition showed higher mean arterial pressure, derived from both systolic and diastolic readings, than those in the positive condition. In related work, older adults unconsciously primed with negative aging stereotypes have displayed a higher and more immediate increase in their SBP responses to mental tasks than those primed with positive stereotypes (Levy, Hausdorff, Hencke, & Wei, 2000; Levy et al., 2008).

Characteristics of the Situation

Research has also examined how the type of situation affects reactivity and age differences therein. The tasks that researchers use to elicit stress responses generally fit into two broad categories: those that involve instrumental coping (i.e., active coping) and those that do not (i.e., passive coping). The former allow individuals to exert control over task outcomes, whereas the latter do not allow individuals to do so. In research with younger adults, passive coping tasks (e.g., cold pressor, passive listening, film viewing) typically elicit lower levels of reactivity than do tasks involving active coping (e.g., mental arithmetic, competitive reaction time, speech presentation) (e.g., Light, Turner, Hinderliter, & Sherwood, 1993; Sherwood, Dolan, & Light, 1990).

In general, work with older adult samples (e.g., 60 years of age and older) is limited. Several studies have used active coping tasks in the laboratory involving public speaking and mental challenges (e.g., serial subtraction, verbal memory, attention, reaction time), with the results demonstrating an age-related increase in SBP reactivity (Boutcher & Stocker, 1996; Brown, Sollers, Thayer, Zonderman, & Waldstein, 2009; Carroll et al., 2000; Garwood, Engel, & Capriotti, 1982; Ginty, Phillps, Der, Deary, & Carroll, 2011; Howard et al., 2017; Levy et al., 2000; Levy et al., 2008; Lipman, Grossman, Bridges, Hamner, & Taylor, 2002; Steptoe et al., 2005; Steptoe, Moses, & Edwards, 1990; Uchino, Holt-Lunstad, Bloor, & Campo, 2005; Uchino et al., 2016; Uchino et al., 1992). A few studies that use these measures do not find this association (e.g., Cacioppo et al., 2000; Ditto, Miller, & France, 1987; Gintner, Hollandsworth, & Intrieri, 1986; Lipman et al., 2002). Additionally, those which have assessed ambulatory assessments reveal age differences in DBP reactivity (Uchino, Berg, Smith, Pearce, & Skinner, 2006), but no differences between middle-aged and older adults (Uchino et al., 2006) or in older adults more generally (Howard et al., 2017) in terms of SBP reactivity. This possibly suggests that active coping tasks in the laboratory place especially large demands on individuals and may therefore elicit stronger effects than those in daily life.

Reactivity in passive coping situations may be more consequential given that it reflects responses in situations where individuals have little control. Although passive psychological coping tasks have been used less extensively in studies of aging and blood pressure reactivity, the results are generally consistent with those for active coping tasks. For instance, older adults exhibited larger SBP responses than younger age groups when viewing a disgusting film (i.e., eye surgery; Kunzman, Kupperbusch, & Levenson, 2005) and emotionally evocative images that varied in valence and arousal (Gomez, Gunten, & Danuser, 2016). A meta-analysis of this research has reached a similar conclusion, revealing no effect of task type on age effects in SBP reactivity (Uchino et al., 2010).

The distinction between active and passive coping, however, may not tell the whole story regarding situational influences on age differences in reactivity. The evocativeness of the task, for instance, has been shown to moderate age-related effect sizes. The most stressful tasks (i.e., those that induce the greatest changes in blood pressure) produce stronger age effects on average (Uchino et al., 2010). This suggests that the affective component of the task may also be important in determining age differences. Typical mental challenges, such as serial subtraction or Stroop, might tap into so-called “cold” executive processes, whereas those that include social, emotional, and motivational aspects tap into “hot” processes. Thus, in addition to the nature of the coping involved, situations might also be ordered on a continuum from cold to hot, with the strength of age effects on reactivity potentially decreasing toward the “hot” end. For example, some studies have included narrative-style writing (e.g., Heffner, Devereux, Ng, & Borchardt, 2013), emotion word learning (e.g., Hogan et al., 2012), and social problem-solving (e.g., Luong & Charles, 2014; T. W. Smith et al., 2009) tasks. In these cases, older adults display similar SBP responses to younger adults during disagreements with their spouses (T.W. Smith et al., 2009) or other social partners (Luong & Charles, 2014), when recalling stressful life events (Heffner et al., 2013), and in response to emotional word pairs (Hogan et al., 2012). Thus, this suggests minimal age effects in SBP reactivity associated with processing emotional content, though systematic investigations examining blood pressure responses in these situations are generally few.


Aging is associated with an increase in reactivity to psychological stressors, which has important implications given the negative effects of cardiac reactivity for health outcomes. Importantly, the strength of these responses and associated age effects are moderated both by personal factors related to stress exposure, behavioral dispositions, social resources, and attitudes, and perhaps to a lesser degree by situational factors associated with type of coping and emotionality. Together, findings are suggestive of a large degree of inter-individual variability in reactivity.

In considering the work in this area, several qualifiers need to be noted. First, some evidence indicates that assessments of reactivity in the laboratory may differ from those in other contexts (e.g., few age-related differences in the case of ambulatory assessments). Fruitful avenues of new research may include examinations of measures of SBP reactivity both in the laboratory and in real-world settings to better determine the generalizability of effects. Second, the relative absence of work using passive tasks prevents strong conclusions about how such procedures relate to SBP reactivity. A third concern is the fact that the research reviewed is almost entirely cross-sectional in nature. One longitudinal study does suggest age-related increases in reactivity over a 10-month period (Uchino et al., 2005), but much more work is needed to determine how SBP reactivity changes over an extended length of time throughout older adulthood along with the impact of potential moderators.

Another consideration in evaluating extant research is that samples across studies have consisted almost entirely of people from European backgrounds. One exception (Levy et al., 2008) does suggest that the impact of age stereotypes does not depend on race or ethnicity. However, given that the prevalence of cardiovascular disease varies between different racial or ethnic groups, further work on how groups differ in their reactivity as a function of other socioeconomic and psychosocial variables could lead to better understanding of the factors that influence outcomes in at-risk populations. For example, research with younger adult samples has shown that African Americans, relative to European Americans, exhibit stronger task-specific increases in total peripheral resistance (Light et al., 1993), which relates to increases in SBP.

Finally, given the variety of situations in which reactivity has been examined, there is still not a good understanding of the specific circumstances under which age effects will be most evident. The broad distinction between active and passive coping is useful, but failure to directly compare the effects of these types of coping using tasks of similar levels of complexity, meaningfulness, and emotionality has limited the understanding of age effects. More recent work has attempted to more systematically examine task factors within the context of active coping (see ‘SBP as a Measure of Engagement’). It is possible that a potentially orthogonal component to coping requirements—emotionality of the situation—may also be important in characterizing aging effects. This dimension may be particularly important given influential theoretical perspectives that argue that aging is associated with changes in the ability to regulate affect (e.g., Labouvie-Vief, Grühn, & Mouras, 2009).

SBP as a Measure of Engagement

The third context in which blood pressure has been utilized productively to examine aging-related processes is through its use as a measure of engagement in situations involving active coping. This work builds on Wright’s (1996) integrative model. Within Obrist’s (1981) framework, active coping occurs in those situations where an individual’s actions are perceived as necessary to cope effectively with a potentially stressful situation. Such actions are thought to result in sympathetic nervous system activation of the heart and a concomitant increase in the force of myocardial contraction. As opposed to other measures of cardiovascular response such as DBP or heart rate (HR), SBP response (i.e., change from baseline) in such situations is thought to be a relatively direct reflection of sympathetic (β‎-adrenergic) activity upon the myocardium. Specifically, SBP is a measure of peak arterial pressure during myocardial contraction (i.e. the period of systole in the cardiac cycle), which is influenced by sympathetically induced elevations of myocardial contractile force (Guyton, 1991; Vick, 1984).

Although other standard measures of CV responsivity have been used to assess active coping, they tend to be less “pure” indices of sympathetic activation (Richter, Friedrich, & Gendolla, 2008). For example, HR does respond to sympathetic activation, but parasympathetic dominance of this measure results in a less sensitive index of active coping (Berntson, Quigley, & Lozano, 2007). Similarly, although DBP is also often used to assess coping, it is less influenced by myocardial contraction than SBP because it measures arterial pressure during the period of cardiac relaxation in the cardiac cycle (i.e., the diastole). Peripheral vascular resistance (PVR) (or the resistance to blood flow throughout the systemic vasculature) is the primary determinant of DBP. This may (a) increase during a sympathetic response due to vasoconstriction, (b) not change significantly due to the countervailing influence of vasodilation, or (c) decrease due to increased vasodilation, especially following maximal exercise (Guyton, 1991; Piepoli et al., 1993; Wright & Kirby, 2001).

The validity of SBP as an assessment of active coping is further bolstered by research with younger adults based within Wright’s (1996) integrative model. Specially, Motivational Intensity Theory (MIT; Brehm & Self, 1989) asserts that people will exert effort in a challenging situation that is proportional to the demands of the task, given that they perceive the task to be worthwhile and within their capabilities. Using SBP response as a measure of effort—reflective of sympathetic influence on the heart—research has provided strong support for this theory and for the use of SBP as an index of engagement. For example, SBP response generally increases with task difficulty (Wright & Dill, 1993; Wright, Dill, Geen, & Anderson, 1998; Wright et al., 2007, Experiment 1). In addition, individuals with lower levels of ability—and presumably lower perceptions of their ability to do well—exhibit higher levels of response at low levels of task demands than do high ability individuals, and also withdraw efforts—as reflected in reductions in SBP response—when task difficulty is high (Wright & Dill, 1993; Wright et al., 1998). Variations in SBP response have also been meaningfully linked with other situational and individual-differences factors associated with task difficulty and motivation. For example, SBP response is positively associated with level of ego involvement (Gendolla & Wright, 2005), and increased under conditions of social accountability or observation (Gendolla & Richter, 2006; Wright et al., 1998). Thus, consistent with expectations drawn from MIT, SBP is positively associated with task difficulty, perceived ability to do well, and perceptions of the worthwhile nature of the task.

With respect to aging, T. M. Hess and Ennis (2014) have also argued that SBP is a reasonable measure to assess active coping in older adults and to make comparisons across age groups. This is based on the results of a wide-ranging meta-analysis (Uchino et al., 2010) showing similar SBP sensitivity to emotionally evocative stimulus conditions across adult age groups. This same analysis found that the strength of reactivity also increased with age, which was interpreted as a potential decline in self-regulatory functions under stressful conditions. T.M. Hess and Ennis (2014) argued, however, that such reactivity may be a manifestation of the increased costs hypothesized to be associated with active coping in later life (e.g., T. M. Hess, 2014). That is, it may not so much be a decline in self-regulatory functions as it is an increase in the effort required to engage such functions. It is interesting that Uchino et al. (2010) did not find a difference in age effects associated with active versus passive coping, which might suggest that observed age differences in SBP during active coping may simply reflect more general reactivity. A simple way to determine this is by assessing responses during active coping while controlling for reactivity associated with passive coping.

One potential issue associated with making direct comparisons of SBP across adult age groups to assess active coping relates to normative changes in the cardiovascular system that may impact responses. Resting levels of SBP have been found to be greater in older than in younger adults due to stiffness or lack of compliance of the aorta and large arteries (Folkow & Svanborg, 1993; Pinto, 2007). In spite of this, SBP responsivity during exercise is not appreciably different in young and older adults without coronary artery disease (Rodeheffer et al., 1984; Taylor et al., 1991). This appears to be due to somewhat different mechanisms. Along with PVR, a primary determinant of SBP is cardiac output (CO), or the amount of blood pumped by the heart per minute (Pinto, 2007; Vick, 1984). CO is determined by HR and stroke volume (i.e., the amount of blood pumped by the left ventricle in one contraction) (Vick, 1984). Relative to young adults, however, decreased responsiveness to β‎-adrenergic stimuli attenuates HR in older adults (Ferrari et al., 2003). CO is maintained at levels similar to young adults during exercise, however, due to an age-related increase in end-diastolic volume (i.e., the blood remaining in the left ventricle) stretching cardiac muscle and subsequently increasing the force of cardiac contraction. This results in elevated stroke volume, enabling healthy older adults to meet the energy demands of physical exercise and maintain CO levels similar to those of young adults (Docherty, 1990; Ferrari et al., 2003; Guyton, 1991; Lakatta, 1993; Rodeheffer et al., 1984).2 Thus, even though age differences exist in the mechanisms underpinning the SBP response, the similar degree of response to moderate physical exertion suggests that the SBP response can be reliably used to make age comparisons in effort.

Most studies that have examined SBP in testing contexts consistent with what Obrist (1981) defined as involving active coping used change in SBP response following involvement in a task as a measure of reactivity. This measure was then often simply used as an index of age effects or examined in relation to other participant characteristics and outcomes. There was typically little attention paid to systematic changes in responses as a function of task demands or motivational factors. In general, this research has observed an age-related increase in SBP reactivity in a variety of situations. For example, Jennings et al. (1997) found that SBP reactivity to a series of cognitive challenges (e.g., Stroop test) in a large sample of Finnish men increased from age 46 to 64. Boutcher and Stocker (1996) also examined responses to the Stroop test and found that older adults had higher SBP than younger adults both during the task and during a recovery period immediately afterward. Although they did not find any significant age differences in relative reactivity (i.e., response above baseline), there was a trend indicating that such responses were greater in older adults. The small sample size (N = 30) in this study, however, may have limited the power to identify such effects.

A variety of other types of mental challenges have been used in other studies examining SBP responses during active coping, including verbal learning tasks (Hogan et al., 2012; Steptoe, et al., 2005), arithmetic problems (Carroll et al., 2000; Garwood et al., 1982; Uchino et al., 2005; Uchino, Uno, Holt-Lunstad, & Flinders, 1999), matrix reasoning (Steptoe et al., 1990; Steptoe et al., 2005), and N-back (Schapkin, Freude, Gajewski, Wild-Wall, & Falkenstein, 2012). In all of these cases, age was positively associated with SBP response to the cognitive stressor. Additionally, Jennings et al. (1997) demonstrated that such age effects were independent of those associated with disease, suggesting that changes in SBP responses with age are not simply reflections of health, but represent normative increases in sympathetic activation. Researchers have also examined active coping in psychosocial tasks. For example, Uchino and colleagues (Uchino, Uno, Holt-Lunstad, & Flinders, 1999; Uchino, Holt-Lunstad, Bloor, & Campo, 2005) examined SBP responses to a public speaking task and found age differences in SBP response that were similar to those observed with cognitive challenges. Notably, there have been studies where null age effects have been observed, but these may be related to either small samples sizes (e.g., Boutcher & Stocker, 1996) or failure to include participants beyond middle adulthood (e.g., Gintner et al., 1986). For others (e.g., Carroll et al., 2005), the reason for discrepancy from the majority of studies is more difficult to discern, but may be related to the specific tasks used and associated demands.

Only a few of the just-cited studies have examined SBP responses in relation to systematic changes in the demands of the active coping task. Using a memory span task, Jennings, Nebes, and Yovetich (1990) found that increasing demands through addition of a secondary task resulted in greater increase in CV responses associated with SBP in older adults than in younger adults. Using easy and hard versions of the Raven’s Progressive Matrices, Steptoe et al. (1990) found that SBP increased with both task demands and participant age. They also observed a nonsignificant trend toward demands having a greater impact with increasing age, but the impact of age may have been attenuated given that the oldest participants in this study were only 60 years old. More recently, Schapkin et al. (2012) presented younger adults aged 21–35 and older adults aged 51–63 with an n-back task comprised of two levels of difficult (n = 0 vs. 2). They observed a greater increase in SBP with increased task difficulty in the old relative to the young, with the age effect (a) being greater for high than for low memory loads and (b) persisting during a post-task recovery period. One study also found a relationship between older adults’ SBP response and their performance in cognitive tasks (Wawrzyniak, Hamer, Steptoe, & Endrighi, 2016). The important implication that can be drawn from these admittedly nonsystematic investigations is that, similar to observations with younger adults, SBP responses are tied to task difficulty and are not simply reflections of individual or age-based differences in general sympathetic reactivity. This plus the finding that SBP response is associated with performance is suggestive of SBP being a valid means of assessing older adults’ flexibility in adapting to demands of situations involving active coping.

More recently, SBP responses have been examined more systematically as indicators of levels of engagement of cognitive resources in response to task demands. Most of the work has been conducted within the context of Selective Engagement Theory (SET; T. M. Hess, 2014), which argues that normative increases in the costs of cognitive engagement in later life result in changes in motivational levels which increase older adults’ selectivity in terms of expending cognitive effort. In this research, SBP response has been used as an indicator of the amount of effort participants expend while engaged in a task. This, in turn, permits a test of the proposition concerning normative increases in costs by examining SBP response at different levels of task demands in order to determine the extent to which age differences exist in the effort required to achieve successful performance—which is one definition of costs. Using SBP as an indicator of engagement also permits tests of age differences in selectivity. Specifically, if age differences in engagement levels are moderated by factors such as personal relevance and difficulty as suggested by the theory, then age differences in SBP response should be meaningfully tied to these factors. For example, the strength of age differences in SBP response should be inversely proportional to the personal relevance of the task due to older adults being more likely to disengage from tasks that they do not find congruent with personal goals.

To this point, research exploring these ideas has provided results consistent with expectations derived from SET. In an initial study, T. M. Hess and Ennis (2012) had younger and older community-dwelling adults repeatedly perform either a simple (adding 1) or difficult (subtracting 3) arithmetic operation for five minutes, followed by three minutes of two-digit multiplication problems. In line with expectations from SET, SBP responses in older adults were higher and increased more with difficulty relative to those younger adults. Fatigue effects—another type of cost—were also greater in older adults, as reflected in SBP responses in the second task. A subsequent study more systematically manipulated task demands in a memory scan task by varying the memory load from two to 10 items (Ennis, Hess, & Smith, 2013). SBP once again varied with task difficulty, with the impact of difficulty being disproportionately greater for the old than the young. Significantly, at very high task demands, SBP responses in both the young and old began to decline, suggesting withdrawal of cognitive resources—or disengagement—as task difficulty made performance difficult and presumably exceeded participants’ expectations regarding their ability to perform well. Notably, older adults on average disengaged at a lower level of difficulty than did younger adults, reflecting the relatively greater cognitive costs associated with engagement.

Two additional studies examined age differences in engagement related to motivation and subjective perceptions of costs. Using a personal accountability manipulation designed to enhance ego involvement in task performance, B. T. Smith and Hess (2015) found that older adults exhibited a disproportionate increase in engagement relative to younger adults in response to this manipulation. This was reflected not only in a disproportionate increase in SBP response, but also in greater sensitivity of responses to task demands—suggestive of active modulation of resource allocation. These findings are consistent with SET predictions regarding age-related selectivity. In a subsequent study (T. M. Hess, Smith, & Sharifian, 2016), engagement in older adults was also found to be sensitive to subjective perceptions of task difficulty. In other words, SBP response was modulated both by the objective demands of the task—memory load—and by how demanding the task was perceived to be. Importantly, subjective perceptions had a disproportionately greater impact on SBP responses in older adults.

In conclusion, SBP responses have frequently been used as measures of engagement associated with active coping tasks. It has also been argued (T. M. Hess & Ennis, 2014) that examination of age differences in SBP responses in such tasks provides a valid means for assessing age differences in effort expenditure. One important consideration in this context, however, is that the meaning of SBP responses is dependent on a coherent conceptual framework that is supported by methodology that allows for reasonable interpretation of the data within this framework. For example, within Wright’s (1996) framework, valid interpretations of differences in effort expenditure between groups or across task demands are dependent upon the value placed on the task and perceptions of one’s ability to perform the task. Such considerations become especially important in comparing the performance of older adults to that of younger individuals, since both factors may exhibit normative change with age in adulthood (e.g., T. M. Hess, 2014). This can be dealt with relatively easily, however, through examination of participants’ subjective perceptions of the task and/or ability in relation to the experimental conditions employed.


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                                                                                                                                                                                                                                                                                    (1.) WMH reflect demyelination of neural pathways related to reduced blood flow. They are associated with aging, dementia, and cardiovascular disease.

                                                                                                                                                                                                                                                                                    (2.) Age differences in CO responses, however, do emerge during maximal aerobic and prolonged exercise, so comparability of response only occurs up to a certain limit (Correia et al., 2002; Fleg et al., 1995).