Hypertension is a significant global health problem due to its increasing prevalence and the resulting morbidity and mortality. Using the criteria for hypertension as systolic blood pressure (SBP) ≥140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg, the global prevalence of hypertension is reported to be between 18 and 32%, with a reported incidence rate of 1.28 million adults aged 30 to 79 years in 2023. It is reported that only about 50% of subjects are aware of their hypertension, and only one in five hypertensive subjects has their blood pressure controlled. ¹

Hypertension is often referred to as a silent killer because it doesn't produce specific clinical symptoms. If symptoms do occur, they are typically caused by abnormalities in the target organ. Target organ abnormalities from hypertension include cardio-renal-cerebrovascular disorders. Cerebrovascular disorders due to hypertension can consist of stroke (hemorrhagic or non-hemorrhagic) as well as cognitive impairment and dementia. ¹

Cognitive impairment refers to a condition characterized by a loss or impairment of thinking skills, including memory, attention, problem-solving, and executive functions, which affect a person's ability to process information, learn, and make informed decisions. This condition can range from mild to severe and is a physiological condition of the aging process. It can also be caused by various pathological conditions such as neurodegenerative diseases, psychiatric disorders, metabolic diseases, and hypertension.²

The link between hypertension and cognitive impairment has been widely reported in several studies. A study by Pallangyo et al. in Tanzania showed that 43.6% of hypertensive patients experienced cognitive impairment.³ In a meta-analysis study by Qin et al., it was revealed that cognitive impairment in hypertension patients in Asia was 26% and in Europe was 40%.⁴ The length of time hypertension influences the effect of hypertension on cognitive disorders is unclear, whether blood pressure is controlled or not, and the antihypertensive medication used.⁵⁻⁷

Previous research has been conducted in Indonesia regarding factors influencing cognitive dysfunction in hypertensive patients. Research by Rizki et al. reported that hypertension grade is associated with cognitive impairment in hypertensive patients.⁸ In a study by Larasati et al., they also reported a relationship between hypertension grade and cognitive function in elderly patients with primary hypertension, and no relationship between smoking habits and sleep quality and cognitive function in hypertensive patients. However, these studies were conducted in elderly patients with hypertension.⁹ Research on factors associated with cognitive impairment in adult hypertensive patients is still rare and has never been performed in Indonesia. Identifying factors that influence cognitive function in patients with hypertension is crucial for effective prevention and management. This study aims to investigate the factors that affect cognitive function in patients with hypertension.

This study employed a cross-sectional design and was conducted at Dr. Wahidin Sudirohusodo Hospital in Makassar and Hasanuddin University Hospital from May to July 2025. The population consisted of hypertensive patients visiting both hospitals, with consecutive sampling selected to achieve a minimum sample size based on a sample size calculation (α = 0.05; power = 80%). Inclusion criteria included men and women aged 18–60 years who were diagnosed with hypertension and willing to participate in the study by signing an informed consent form. Exclusion criteria included a history of head trauma, stroke, severe mental disorders, severe visual or hearing impairment, and reading disabilities. The study has obtained ethical approval from the Research Ethics Committee of the Faculty of Medicine, Hasanuddin University (No. 228/UN4.6.4.5.31/PP36/2025).

Hypertension was characterized by a systolic blood pressure of≥ 140 mmHg and/or a diastolic blood pressure of≥ 90 mmHg. Cognitive function was measured using the Montreal Cognitive Assessment-Indonesian Version (MoCA-INA). A MoCA-INA <26 indicates cognitive impairment. Factors measured included age, gender, marital status, hypertension control (JNC VII: controlled < 140/90 mmHg), duration of hypertension, education level (high school or lower or college), and type 2 diabetes mellitus (medical history, antidiabetic medication, or glucose test ≥ 200 mg/dL with classic symptoms). Data analysis was performed using the chi-square test and multiple logistic regression test with a significance level of p < 0.05.

This study involved 317 patients with hypertension under the age of 60. Most patients were under 50 years of age, female, had hypertension for more than 5 years, had uncontrolled hypertension, did not have diabetes mellitus, had a high school education or less, and were married (Table 1). A total of 283 patients (89.3%) had cognitive impairment.

Table 1. Characteristics of research subjects

Analysis of the relationship between risk factors and cognitive status showed that age ≥50 years (OR=3.24; 95% CI: 1.30–8.08; p=0.014), uncontrolled hypertension (OR=2.33; 95% CI: 1.04–5.21; p=0.063), low education (OR=19.29; 95% CI: 2.51–148.25; p<0.001), secondary education (OR=6.39; 95% CI: 0.82–49.58), and divorce status (p=0.007) were associated with an increased risk of cognitive impairment (OR>1). In contrast, gender, duration of hypertension, and diabetes mellitus did not show a significant association (p>0.05) (Table 2).

Table 2. Risk factors for cognitive dysfunction in hypertensive patients

Chi-square test

Multiple logistic regression analysis showed that low education level and age ≥ 50 years were significant risk factors for cognitive impairment in hypertensive patients, increasing the risk by 3.06 times (95% CI: 1.59–5.90; p=0.001) and 2.86 times (95% CI: 1.12–7.31; p=0.029) compared to the reference group, respectively. In contrast, female gender (OR = 1.69; p = 0.175) and uncontrolled blood pressure (OR = 1.35; p = 0.506) only showed a tendency as risk factors but were not statistically significant after controlling for other variables. Overall, education level had a more dominant influence than age in the multivariate model (Table 3).

Table 3. Summary of the results of the multiple logistic regression test between education level, age, gender, and hypertension control on cognitive impairment

Multiple logistic regression test, HT = hypertension

Table 4. Distribution of cognitive disorders by education level and age group

Chi-square test

Table 4 shows that in low education, the proportion of cognitive impairment between ages ≥50 years (97.5%) and <50 years (96.6%) did not differ significantly (p=0.580), as did in secondary education between ages ≥50 years (94.4%) and <50 years (89.9%) (p=0.256). However, in higher education, there was a significant difference, where those aged ≥50 years had a higher proportion of cognitive impairment (92.9%) than those <50 years (70.2%) (p=0.015). These findings suggest that the effect of age on cognitive impairment is more pronounced in individuals with higher education, whereas in those with low and secondary education, the proportion remains high across all age groups.

The results of this study indicate that women have a 1.97 times higher risk of experiencing cognitive impairment compared to male respondents, but this is not significant. In the study by Kim et al., it was reported that cognitive impairment and dementia are more common in women than men because cognitive impairment in women develops faster. After all, they tend to have a shorter period of education and lower involvement in cognitive stimulation than men, but this difference is related to age distribution¹⁰. Furthermore, the relationship between gender and cognitive impairment remains controversial. A study by Morelent et al. reported that men have a higher risk of cognitive impairment than women, possibly due to the neuroprotective effects of estrogen. Increasing age and lower education levels are also strong predictors of cognitive decline¹¹.

In this study, patients aged ≥ 50 years had a 3.24 times higher risk of experiencing cognitive impairment compared to respondents aged < 50 years. These results indicate that advanced age is a significant risk factor for cognitive decline in hypertensive patients. This finding aligns with the study by Joycea et al., a meta-analysis of 67 independent study groups, which specifically evaluated 10 studies examining the relationship between hypertension in middle age and cognition in old age. Six studies found a negative relationship between age and memory function, visuospatial organization, executive function, global cognition, and psychomotor speed. Pathophysiologically, chronic hypertension in the elderly can accelerate the brain aging process through mechanisms such as vascular remodeling, impaired cerebral autoregulation, white matter lesions, and microinfarcts, which can cause degeneration of brain structures, including the prefrontal cortex and hippocampus¹². This study limited its patient population to those under 60 years of age. These results provide new evidence that hypertension induces cognitive impairment not only in the elderly but also in adulthood.

In this study, respondents with a history of hypertension for >15 years had a 1.41 times higher risk of developing cognitive impairment compared to respondents with hypertension for five years or less, but this difference was not significant. These results indicate that the duration of hypertension is not directly related to the incidence of cognitive impairment in the study population. Other factors, such as blood pressure control, age, and education level, may have a greater influence on cognitive function than the duration of hypertension alone. Although theoretically, the duration of chronic hypertension has the potential to cause progressive damage to the brain's vascular system, these results confirm that the duration of hypertension alone is not necessarily a direct determinant of cognitive decline⁵. However, different results were reported by Menezes et al., who found that although hypertension was generally associated with faster cognitive decline, the duration of hypertension diagnosis did not show a significant relationship to the incidence of cognitive impairment¹³. This result suggests that the impact of hypertension on the brain is not only determined by the length of time since diagnosis, but also by other factors such as the level of blood pressure control, blood pressure fluctuations, and response to therapy.

In this study, hypertensive respondents with uncontrolled blood pressure had a 2.33 times higher risk of experiencing cognitive impairment compared to respondents with controlled hypertension, but this was not significant. Theofilis et al.'s study stated that exposure to high blood pressure, especially when inadequately controlled, increases the risk of cognitive decline. Uncontrolled hypertension can cause chronic cerebral perfusion disorders, damage to the blood-brain barrier, microinfarcts, and brain atrophy, all of which are the pathophysiological basis of cognitive decline¹⁴. However, the relationship between blood pressure control and cognitive function is not always linear. A large-scale study in China by Yao et al., involving a national population from 30 provinces, found that elderly patients with excessively low blood pressure (SBP <120 mmHg) had an increased risk of cognitive impairment compared to those with SBP between 120–140 mmHg. Hypotension can cause cerebral hypoperfusion, especially in the elderly population, which ultimately leads to cognitive dysfunction⁶.

The findings of this study emphasize the importance of blood pressure control, not only in the context of cardiovascular disease prevention but also in maintaining brain function integrity. Individualized evaluation of blood pressure targets based on age, comorbidities, and baseline cognitive status is strongly recommended to optimize a safe and practical approach to hypertension treatment.

In this study, hypertensive respondents with diabetes mellitus had a 1.28 times greater risk of experiencing cognitive impairment compared to respondents without diabetes mellitus, but this was not significant. Different results were reported by Wu et al. in an extensive case-control study involving 40,103 subjects, which showed that hypertension, diabetes, and their comorbidities have a significant cumulative effect on the risk of cognitive impairment in the elderly. Pathophysiologically, both hypertension and diabetes can negatively impact brain structure and function. Chronic hyperglycemia and insulin resistance have been shown to impair brain microcirculation function, trigger neuroinflammation, and accelerate the formation of amyloid plaques, which contribute to the development of cognitive impairment¹⁵. On the other hand, damage to the blood-brain barrier and myelin degradation caused by hypertension and diabetes can disrupt nerve signal transmission and accelerate neuronal apoptosis, thereby worsening cognitive function¹. Although the findings in this study did not demonstrate a statistically significant association, it is essential to note that the level of diabetes control, disease duration, and the presence of microvascular complications may be confounding variables that were not thoroughly analyzed in this study. Therefore, although not significant in this study, diabetes mellitus still warrants attention as a potential risk factor for cognitive impairment, particularly in the context of coexisting hypertension. Optimal integrated management of both conditions is an essential strategy for maintaining long-term cognitive health in high-risk populations.

In this study, education level was shown to be significantly associated with the incidence of cognitive impairment in hypertensive patients. Patients with low education had a 19.29 times higher risk of cognitive impairment compared to respondents with higher education, while those with secondary education had a 6.39 times higher risk. These results suggest a significant correlation between low educational attainment and cognitive decline. Low education has long been identified as a major modifiable risk factor for cognitive impairment. In a meta-analysis by Meng and D'Arcy, individuals with low education had a pooled odds ratio (OR) of 2.61 for developing cognitive impairment compared to those with high education³. Furthermore, education is known to enhance cognitive reserve, the brain's ability to withstand pathological damage without causing clinical symptoms. Intellectual activity and continued learning throughout life have been shown to increase this cognitive reserve capacity.

Studies in Xixiangtang District and by Yating et al. support these findings, showing that higher education (at least high school level or above) is a protective factor against mild cognitive impairment (MCI) in the elderly with hypertension¹⁶. This result is related to increased central nervous system plasticity resulting from consistent intellectual stimulation during education. This stimulation strengthens neural networks and enhances cognitive functions, including abstract thinking, logic, and long-term memory.

Education also impacts quality of life and access to health information, enabling individuals to better manage vascular risk factors such as hypertension and diabetes. In the context of hypertensive patients, higher education may play a role in understanding the importance of blood pressure control and adherence to therapy, which indirectly contributes to protection against cognitive impairment. Thus, the results of this study reinforce the importance of increasing access to education as part of preventive efforts against cognitive impairment, particularly in high-risk populations such as patients with hypertension.

Marital status in this study showed that divorced hypertensive respondents had the highest proportion of cognitive impairment, and none had normal cognitive function. This difference was statistically significant compared to respondents with intact households, indicating that marriage can act as a protective factor against cognitive decline. This finding aligns with the study by Shen et al., a cross-sectional study involving a total of 9,525 adult patients. This study supports that married people have better physical and mental health status than those who are unmarried, live alone, or are widowed/widowed. Individuals who are unmarried or have a poor marriage are at higher risk of depression, high blood pressure, cardiovascular disease, and even premature death¹⁷.

The underlying mechanisms for this relationship include the critical role of spouses in providing emotional and social support, assisting with health monitoring, and enhancing social engagement. These factors directly enhance cognitive reserve and the ability to adapt to neurological stress. Living alone and loneliness have been associated with increased psychological stress, which activates the hypothalamic–pituitary–adrenal system, increases glucocorticoid levels, and potentially causes structural damage to the hippocampus. This can impact learning and memory, contributing to the accumulation of β-amyloid and tau proteins in the brain, two key mechanisms in the pathogenesis of dementia. Furthermore, in a social context, societies that place high expectations on marital status and childbearing make unmarried individuals more vulnerable to psychological distress and social isolation¹⁷.

This study has several limitations that should be taken into consideration. The cross-sectional design only describes associations at a single point in time, making it impossible to establish a causal relationship between risk factors and cognitive impairment. The MoCA assessment of cognitive function is potentially influenced by respondent subjectivity, particularly in subjects with low education who may have difficulty understanding instructions. Several other known influencing factors, such as economic status, physical activity, lifestyle, depression, and family history of dementia, were not evaluated, potentially introducing residual bias. Furthermore, the degree of glycemic control in patients with diabetes mellitus was not measured, although it can influence cognitive function. Other limitations include the sample's age limit (<60 years), which reduces the generalizability of the results to the elderly population; the absence of a non-hypertensive comparison group; and the potential for selection bias due to sampling patients attending healthcare facilities, who likely have different characteristics than the general population.

Based on the results of the study, factors significantly associated with cognitive impairment in hypertensive patients were age ≥ 50 years, low education, secondary education, and divorced social status, although uncontrolled blood pressure only showed a tendency to increase the risk without statistical significance. Multivariate analysis confirmed that low education and age ≥ 50 years were independent risk factors, while gender, duration of hypertension, blood pressure control, marital status, and diabetes mellitus did not have a significant effect after controlling for other variables. These findings emphasize the importance of early detection and control of blood pressure in hypertensive patients, not only to prevent cardiovascular complications, but also to reduce or slow down cognitive decline. Future studies are recommended to employ longitudinal designs to evaluate causal relationships and monitor the long-term effects of blood pressure control on cognitive function, as well as to consider other potential contributing risk factors.

Acknowledgments

The authors would like to thank the staff of Dr. Wahidin Sudirohusodo Hospital and Hasanuddin University Hospital for their assistance in data collection. The authors also acknowledge the contribution of the research assistants who supported the study logistics and patient coordination.

Funding Sources

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical Statement

The study protocol was reviewed and approved by the Research Ethics Committee of the Faculty of Medicine, Hasanuddin University (No. 228/UN4.6.4.5.31/PP36/2025). Written informed consent was obtained from all participants.

Conflict of Interests

The authors declare no conflict of interests.

1. Segai-Gidan F. Cognitive Screening Tools. Physician Assist Rev Panel. 2013; 23(1): 12–9.
2. McKenzie JA, Spielman LJ, Pointer CB, Lowry JR, Bajwa E, Lee CW, et al. Neuroinflammation as a Common Mechanism Associated with the Modifiable Risk Factors for Alzheimer’s and Parkinson’s Diseases. Generic placeholder image Curr Aging Sci. 2017; 10(3): 158–76.
3. Pallangyo P, Mkojera ZS, Komba M, Mgopa LR, Bhalia S, Mayala H, et al. Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study. BMC Neurol. 2021; 21(1): 1–12. DOI:10.1186/s12883-021-02467-3.
4. Qin J, He Z, Wu L, Wang W, Lin Q, Lin Y, et al. Prevalence of mild cognitive impairment in patients with hypertension: a systematic review and meta-analysis. Hypertens Res. 2021; 44(10): 1251–60. DOI:10.1038/s41440-021-00704-3.
5. Liu C, Li Q, Li Z, Wang L, Wang C, Du X, et al. Association between the incident hypertension duration and cognitive performance in older adults: data from the NHANES 2011–2014. Aging Clin Exp Res. 2024; 36(1): 1–10. DOI:10.1007/s40520-024-02836-1.
6. Yao J, Wang S, Li M, Song B, Lan C, Jia J, et al. Correlation between blood pressure control status and cognitive impairment in older adults: A national cross-sectional study. PLoS One. 2025; 20(2 February): 1–12. DOI:10.1371/journal.pone.0317861.
7. Novak V, Hajjar I. The Relationship Between Blood Pressure and Cognitive Function Nat Rev Cardiol. 2010; 7(12): 686–98. DOI:10.1038/nrcardio.2010.161.
8. Rizky HM, Makmur T. Hubungan Kategori Hipertensi Dengan Penurunan Fungsi Kognitif Pada Lanjut Usia Di Puskesmas Sambirejo 2021. Ibnu Sina J Kedokt dan Kesehat - Fak Kedokt Univ Islam Sumatera Utara. 2022; 21(2): 240–50. DOI:10.30743/ibnusina.v21i2.304.
9. Larasati RD, Marselina M, Nisa NA. Factors Related To Cognitive Function in Elderly People With Primary Hypertension At Sangurara Health Center. Jambura J Heal Sci Res. 2023; 5(1): 253–62. DOI:10.35971/jjhsr.v5i1.17274.
10. Kim M, Park JM. Factors Affecting Cognitive Function According to Gender of in Community-dwelling Elderly Factors affecting cognitive function according to gender in community-dwelling elderly individuals. Epidemiol Heal. 2017; 39: 0–29.
11. Morelenta Y, Meilinab ST, Azkiyaa H, Nofriannic E, Sumiantod, Putrie W, et al. Addressing cognitive impairment in hypertensive patients: Risk factors and clinical implications. J Clin Neurosci. 2025; 133.
12. Joyce OC, McHugh C, Mockler D, Wilson F, Kelly ÁM. Midlife hypertension is a risk factor for some, but not all, domains of cognitive decline in later life: A systematic review and meta-analysis. J Hypertens. 2024; 42(2): 205–23. DOI:10.1097/HJH.0000000000003614.
13. De Menezes ST, Giatti L, Brant LCC, Griep RH, Schmidt MI, Duncan BB, et al. Hypertension, Prehypertension, and Hypertension Control: Association With Decline in Cognitive Performance in the ELSA-Brasil Cohort. Hypertension. 2021; 77(2): 672–81. DOI:10.1161/HYPERTENSIONAHA.120.16080.
14. Theofilis P, Doumani G, Tsatsani GC, Volis N, Kampourelli A, Thimis V, et al. The Role of Hypertension in Cognitive Dysfunction. J Clin Med. 2024; 13(19). DOI:10.3390/jcm13195979.
15. Wu J, Yin X, Ji W, Liu Y, Tang J, Zhang H, et al. Hypertension and diabetes on cognitive impairment: a case–control study in China. Alzheimer’s Res Ther . 2025; 17(1). DOI:10.1186/s13195-025-01761-3.
16. Jingyu L, Wen D, Liping Z, Xiaoling L. A nomogram for predicting mild cognitive impairment in older adults with hypertension. BMC Neurol. 2023; 23(1): 1–10. DOI:10.1186/s12883-023-03408-y.
17. Shen S, Cheng J, Li J, Xie Y, Wang L, Zhou X, et al. Association of marital status with cognitive function in Chinese hypertensive patients: a cross-sectional study. BMC Psychiatry. 2022; 22(1): 1–11. DOI:10.1186/s12888-022-04159-9.