Accumulating evidence supports a causal role of hypertension for cognitive decline above and beyond its relationship to frank stroke. Hypertension-associated pathologic changes in the brain and its vasculature include vascular remodeling, impaired cerebral autoregulation, cerebral microbleeds, white matter lesions, unrecognized lacunar infarcts, and Alzheimer-like changes such as amyloid angiopathy and cerebral atrophy. White matter lesions and retinal vascular changes, both of which can be imaged noninvasively, may reveal the general condition of the cerebral vasculature or the presence of arteriosclerotic or hypertensive encephalopathy. These noninvasive indicators may also identify a subgroup in whom infarct prevention, particularly via blood pressure reduction, is of paramount importance. Optimal control of blood pressure on a population-wide basis, but particularly in those prone to cognitive loss, is thus a critically important but as yet elusive goal that should be fully exploited for its potential to reduce future cognitive impairment.