• Blood tests: The FDA has cleared additional blood-based tests, including Roche’s Elecsys pTau217 assay, to help assess Alzheimer-related amyloid pathology in people with cognitive symptoms. These tests support evaluation but do not replace a clinician’s full assessment. Alzheimer’s Association update
• Leqembi (lecanemab): A subcutaneous starter-dose option was approved, expanding a treatment already used for early Alzheimer’s disease. Anti-amyloid drugs can slow decline modestly in selected patients, but require confirmation of amyloid and safety monitoring, particularly for ARIA brain swelling or bleeding seen on MRI. Leqembi update
• Agitation treatment: Auvelity (dextromethorphan-bupropion, AXS-05) has been approved in the US for agitation associated with Alzheimer’s disease, adding an option for a distressing behavioral symptom. Non-drug approaches such as predictable routines and environmental changes remain first-line where feasible. Approval announcement
• Tau PET imaging: The FDA approved florquinitau F 18 (Tauklarify) for PET imaging to identify tau neurofibrillary-tangle pathology in adults being evaluated for Alzheimer’s disease. FDA approval list
• Research pipeline: Trials are increasingly targeting more than amyloid, including tau, inflammation, metabolism, synapses, and prevention in people who have biomarkers but no symptoms. Multiple phase 3 trials are expected to report during 2026. 2026 pipeline report

Medicines for memory and daily functioning

• Donepezil, rivastigmine, galantamine: nausea, vomiting, diarrhoea, reduced appetite/weight, dizziness, slow heart rate or fainting in susceptible people.
• Memantine: dizziness, headache, constipation, confusion in some people.

New anti-amyloid medicines

Treatment beyond medication

• Confirm that memory problems are truly Alzheimer’s, rather than depression, thyroid disease, vitamin B12 deficiency, medication effects, stroke-related dementia, or another condition.
• Treat hearing/vision issues, sleep disturbance, diabetes, hypertension, depression, pain, constipation, and infection.
• Maintain routine physical activity, safe social engagement, familiar activities, good sleep, nutrition, and caregiver support.
• Make the home safer: fall prevention, medication supervision, stove and driving assessment, and plans for wandering or getting lost.
• Agitation, hallucinations, insomnia, or aggression should first prompt a search for pain, delirium, infection, constipation, or environmental triggers. Sedative or antipsychotic medicines are sometimes used only when symptoms create serious distress or danger, and should be clinician-supervised.

Pediatric blood pressure measurement and interpretation

1. Age
2. Sex
3. Height percentile
4. Systolic BP (SBP) and diastolic BP (DBP)

1. Who should have BP measured?

• All children from age 3 years: at least annually during routine healthcare visits.
• Children under 3 years: measure BP when they have risk factors such as:
  • Prematurity or low birth weight
  • Congenital heart disease
  • Kidney disease, urinary tract abnormalities, recurrent UTI, or renal scarring
  • Diabetes
  • Organ or bone-marrow transplant
  • Cancer treatment associated with hypertension
  • Medicines that raise BP, such as corticosteroids, stimulants, calcineurin inhibitors, or decongestants
  • Raised intracranial pressure, systemic illness, or a strong family history of inherited renal disease

2. Correct technique for BP measurement

Preparation

• Avoid caffeine, nicotine exposure, exercise, and stimulant medications immediately before measurement where possible.
• The child should empty their bladder if needed.
• Let the child sit quietly for 3 to 5 minutes.
• The child should be seated, relaxed, and not talking.
• Back supported, feet supported and uncrossed if able.
• The arm should be bare, relaxed, supported at the level of the heart.
• Use the right upper arm when possible. This gives a standard comparison with reference tables and can help identify coarctation when upper and lower limb readings are compared.

Cuff selection: the commonest cause of error

• Width: about 40% of the mid-upper arm circumference
• Length: encircle 80% to 100% of the arm circumference

Direction of error

Auscultatory measurement

1. Place the cuff about 2 to 3 cm above the antecubital fossa.
2. Position the bladder center over the brachial artery.
3. Place the stethoscope lightly over the brachial artery, not under the cuff.
4. Inflate the cuff to about 20 to 30 mmHg above the level at which the radial pulse disappears.
5. Deflate slowly, about 2 to 3 mmHg per second.
6. Record:
   • SBP: first clear Korotkoff sound, phase I
   • DBP: disappearance of Korotkoff sounds, phase V

Oscillometric or automated devices

• Ensure the device is validated for paediatric use.
• If the reading is high, repeat it and then confirm with manual auscultation using the correct cuff.
• Do not diagnose paediatric hypertension from one automated reading alone.

How many readings at the visit?

1. Repeat at least twice during the same visit.
2. Average the repeat readings.
3. Confirm persistent elevation by manual auscultation.

3. Interpreting BP in children aged 1 to under 13 years

Key rules

• Classify according to the higher category produced by either SBP or DBP.
• A normal systolic value does not cancel a high diastolic value, and vice versa.
• Percentile thresholds are mandatory in children below age 13. For example, 118/76 mmHg could be normal in one child but high in a smaller, younger child.
• Hypertension is generally diagnosed only when auscultatory BP is at or above the hypertensive threshold on 3 separate visits.

4. Interpretation in adolescents aged 13 years and older

• 14-year-old, 124/74: elevated BP
• 15-year-old, 132/76: stage 1 hypertension
• 16-year-old, 128/84: stage 1 hypertension because DBP is 84
• 17-year-old, 142/78: stage 2 hypertension because SBP is 142

5. What to do after an elevated reading

Normal BP

• Continue routine annual screening.

Elevated BP

• Recheck by auscultation, usually in about 6 months.
• Begin lifestyle measures: healthy diet, less salt and highly processed food, physical activity, sleep, and weight management if needed.
• If elevated BP persists for around 12 months, ambulatory BP monitoring and further evaluation are usually considered.

Stage 1 hypertension, no symptoms

• Repeat manual BP in about 1 to 2 weeks.
• Check both arms and one leg.
• If still stage 1, repeat again over subsequent visits.
• Persistent stage 1 hypertension across 3 visits warrants confirmation, often with ambulatory BP monitoring, plus evaluation for causes and organ effects.

Stage 2 hypertension, no symptoms

• Recheck and arrange specialist assessment within about 1 week, sooner if the value is very high or the child has risk factors.
• Measure upper and lower extremity BP and assess for coarctation.

Urgent or emergency assessment

• Severe headache, vomiting, altered behavior, confusion, seizures, or weakness
• Visual symptoms
• Chest pain, shortness of breath, pulmonary edema
• Acute kidney injury, blood in urine, or very little urine
• Heart failure signs
• Suspected hypertensive encephalopathy

6. Ambulatory blood pressure monitoring (ABPM)

• Confirming persistent clinic hypertension
• Detecting white-coat hypertension: high clinic BP but normal out-of-clinic BP
• Detecting masked hypertension: normal clinic BP but high out-of-clinic BP
• Assessing nocturnal BP and normal sleep-related BP dipping
• Children with chronic kidney disease, diabetes, obesity, repaired coarctation, or transplant history

7. Common pitfalls

1. Using an adult cuff in a small child
   Usually gives a falsely low result if oversized, or falsely high if an adult cuff is improvised and too narrow.
2. Using too small a cuff in obesity
   A major source of false hypertension.
3. Measuring during crying, pain, fever, anxiety, or immediately after activity
   Repeat once the child is calm.
4. Making a diagnosis from one visit
   Repeated, properly obtained readings are needed.
5. Using only age-based “normal values”
   Below 13 years, height and sex are also required.
6. Trusting a high automated reading without confirmation
   Confirm with auscultation.
7. Ignoring diastolic hypertension
   The higher of SBP or DBP category determines classification.
8. Not considering secondary hypertension in young children
   In younger children, renal disease is a frequent cause. In adolescents, primary hypertension becomes more common, particularly with obesity and family history. Comprehensive Clinical Nephrology, Changes in Systolic and Diastolic Blood Pressure With Age section.

8. Practical documentation example

BP: 118/76 mmHg, right arm, seated after 5 minutes rest, appropriate cuff, average of 3 readings, manual auscultation.
Interpretation: Use age, sex, and height percentile calculator before labelling as normal/elevated/hypertensive.

• BP value
• Arm and position
• Cuff size or confirmation it was appropriate
• Method: automated versus manual
• Number of readings and average
• Child’s age, sex, height and height percentile
• Clinical state: calm, crying, pain, fever, stimulant use, etc.

How to measure blood pressure in a child

Equipment

• Validated paediatric automated BP monitor, or manual sphygmomanometer
• Multiple cuff sizes
• Stethoscope for manual measurement
• Height measurement and age/sex-specific BP percentile chart or calculator for interpretation

Step 1: Prepare the child

1. Ask the child to avoid exercise, running, caffeine-containing drinks, and smoking or nicotine exposure for about 30 minutes if possible.
2. Ask them to empty the bladder if needed.
3. Let them sit quietly for at least 3 to 5 minutes.
4. Explain simply what will happen. Anxiety and crying can significantly raise BP.
5. Do not measure while they are talking, eating, crying, in obvious pain, or immediately after activity. If unavoidable, document this.

Step 2: Position correctly

In a cooperative child

• Sit upright in a chair.
• Back supported.
• Feet supported, uncrossed, and not dangling if possible.
• Remove tight sleeves. Do not put the cuff over clothing.
• Keep the arm relaxed and supported on a table.
• Position the middle of the upper arm at heart level.
• Keep the palm facing upward.

In infants or children unable to sit

• They may lie supine.
• Keep the selected arm supported at heart level.
• Record the position used.

Step 3: Choose the correct cuff

• Width: approximately 40% of mid-upper arm circumference.
• Length: covers 80% to 100% of arm circumference.

Step 4: Apply the cuff

1. Use the right upper arm unless there is a reason not to, such as injury, IV line, vascular access, or surgery.
2. Wrap the cuff snugly around the bare upper arm.
3. The lower edge should be about 2 to 3 cm above the antecubital fossa.
4. Align the artery marker on the cuff, if present, with the brachial artery.
5. The cuff should be snug enough that you can insert about one fingertip underneath.

Manual BP measurement: auscultatory method

A. Estimate systolic BP by palpation

1. Palpate the radial pulse.
2. Inflate the cuff until the radial pulse disappears.
3. Inflate a further 20 to 30 mmHg above that point.
4. Slowly deflate until the pulse returns. Note this approximate systolic pressure.
5. Fully deflate the cuff and wait about 30 seconds before proceeding.

B. Measure with stethoscope

1. Place the stethoscope lightly over the brachial artery, just medial to the biceps tendon in the antecubital fossa.
2. Do not place the stethoscope under the cuff.
3. Inflate the cuff to about 20 to 30 mmHg above the estimated systolic pressure.
4. Deflate slowly and steadily at about 2 to 3 mmHg per second.
5. Listen for Korotkoff sounds:

1. Record the BP to the nearest 2 mmHg, for example, 104/66 mmHg.
2. Fully deflate the cuff.

Automated BP measurement

1. Use a device validated for children, with an appropriate cuff.
2. Apply the same preparation, position, arm support, and cuff-size rules.
3. Keep the child still and silent while the machine runs.
4. If the first result is high, wait 1 to 2 minutes and repeat.
5. If readings remain elevated, confirm with a manual auscultatory reading.

Step 5: Repeat readings

1. Take an initial reading.
2. If it is normal, document it.
3. If it is elevated, obtain at least two additional readings at the same visit, separated by about 1 to 2 minutes.
4. Use the average of the repeat readings, preferably manual readings, for interpretation.

Step 6: Record the measurement properly

BP 108/68 mmHg, right upper arm, seated, arm supported at heart level, appropriate cuff, manual auscultation, average of 3 readings, child calm after 5 minutes rest.

• Date and time
• Arm used
• Position: seated, supine, etc.
• Device or manual method
• Cuff size or arm circumference if relevant
• Whether the child was crying, febrile, in pain, anxious, or recently active
• Height, age, and sex, which are required to interpret BP in children below 13 years

Special situations

Suspected coarctation of the aorta

• Both arms
• At least one leg

Obesity

Arrhythmia

In shock or very low perfusion

Quick bedside checklist

• Child rested quietly for 3 to 5 minutes
• No talking, crying, or recent exercise
• Bare right upper arm used
• Arm supported at heart level
• Correct cuff width and length
• Cuff not too small
• At least two repeat readings if initially high
• High automated result confirmed manually
• Age, sex, and height used for interpretation if under 13 years