Neurovascular Hemodynamics and Neurological Deficits: A Comprehensive Analysis of Antihypertensive Pharmacotherapy in the Aging Brain

The global demographic shift toward an aging population has made the management of cardiovascular and cerebrovascular health a critical challenge. While systemic arterial hypertension is a prevalent modifiable risk factor for macrovascular events and microvascular complications, pharmacological management in the elderly is frequently complicated by the risk of treatment-induced cerebral hypoperfusion. This comprehensive review evaluates the complex relationship between antihypertensive therapy and cerebral perfusion in older adults. It delineates the physiological mechanisms of cerebral autoregulation, examining how chronic hypertension induces vascular remodeling and a dangerous "rightward shift" of the autoregulatory curve. This shift leaves the aging brain highly vulnerable to ischemic injury when systemic blood pressure is aggressively or rapidly lowered. We detail the spectrum of acute and chronic neurological deficits directly associated with blood pressure medications, including orthostatic hypotension, low-flow transient ischemic attacks, and acute delirium. Furthermore, the report evaluates the latest clinical trial data regarding cognitive outcomes and cerebral small vessel disease, offering a comparative risk analysis of specific antihypertensive drug classes (e.g., RAS inhibitors, calcium channel blockers, beta-blockers, and diuretics). Finally, we outline clinical frameworks for target individualization and structured deprescribing protocols to maximize neuroprotection in vulnerable and frail geriatric populations. Keywords: Cerebral Autoregulation; Hypertension; Antihypertensive Pharmacotherapy; Aging Brain; Orthostatic Hypotension; Vascular Dementia; Delirium; Deprescribing; Cerebrovascular Hemodynamics; Geriatric Medicine