AbstractBackgroundBlood pressure variability (BPV) is defined as fluctuations in blood pressure (BP) from visit‐to‐visit, day‐to‐day, hour‐to‐hour and beat‐to‐beat. While published evidence on visit‐to‐visit BPV have suggested an association between BPV and cognitive decline, but published research on beat‐to‐beat BPV and cognitive decline remains limited. This prospective study, therefore, aimed to determine the relationship between beat‐to‐beat BPV and changes in cognitive performance over a six‐year period.MethodThe first and fourth wave data from Malaysian Elders Longitudinal Research (MELoR) study, which included community dwellers aged 55 years and over at recruitment, were utilized. Non‐invasive continuous beat‐to‐beat BP was recorded at baseline using the vascular unloading method (TaskforceTM,CNSystems). Systolic (SBPV) and diastolic (DBPV) BPV were calculated using standard deviation (SD), coefficient of variation (CV) and average real variability (ARV), which were then dichotomized using median cut‐offs. The Montreal Cognitive Assessment (MoCA) Blind instrument was utilized to allow for telephone‐based assessments at Wave 4 which occurred during the COVID‐19 pandemic. Cognitive decline was defined as 2 points reduction in MoCA.ResultData were available from492 participants, mean (SD) age = 67.8 (6.8) years. Mean MoCA‐blinds scores had increased from 17.1 (3.0) to 18.6 (2.7) from baseline to follow‐up. Cognitive decline was observed in 65 (13%). Individuals with cognitive decline had lower depression scores at baseline . Lower SD‐DBPV (mean difference, MD (95%CI) = 0.56 (0.31,0.98) and CV‐DBPV (MD (95%CI) = 0.51 (0.28,0.91) were significantly increased cognitive change after adjustment for potential co‐founders.ConclusionLower BPV was associated with increased risk of cognitive decline in our population‐based study, which conflicted with available studies using primarily visit‐to‐visit and ambulatory BP measurements and involving mainly hospital‐based populations. Beat‐to‐beat BPV may be a measure of arterial stiffness which may is associated with increased risk of vasculopathy and development cognitive impairment. Future studies should determine whether interventions which lead to increased beat‐to‐beat BPV could reduce cognitive decline.