Management of high cholesterol levels in older people

Abstract

The management of hypercholesterolemia in older adults still represents a challenge in clinical medicine. The pathophysiological alterations of cholesterol metabolism associated with aging are still incompletely understood, even if epidemiological evidence suggests that serum cholesterol levels increase with ongoing age, possibly with a plateau after the age of 80 years. Age is also one of the main determinants of cardiovascular disease, according to all cardiovascular risk estimate tools. Cholesterol‐lowering treatment, therefore, would be expected to bring significant protection, even in these patients. Unfortunately, direct experimental evidence is extremely limited, particularly in the very old age strata of the population; a clinical benefit still seems to be present, but the risk for drug‐related adverse events is clearly higher. At any rate, at the present time, definite guidelines for the correct management of hypercholesterolemia in older patients are not available. Therefore, the decision whether or not a pharmacological treatment should be set up, and the choice of the drug, need to be tailored to the individual patient, and requires accurate clinical judgment. The specific aspects of frailty and disability, along with the actual age of the patients, have to be considered together, with a comprehensive assessment approach. The present review summarizes the evidence regarding the modifications of cholesterol metabolism in older patients, the impact of lipid‐lowering drugs on cardiovascular outcomes and focuses on the considerations that can help to define the most appropriate treatment strategy, in view of the individual functional profile. Geriatr Gerontol Int 2019; 19: 375–383.

Use of Lipid-Lowering Drugs and Associated Outcomes According to Health State Profiles in Hospitalized Older Patients

“…On the other hand, patients from Cluster IV had the highest prevalence of previous stroke/TIA (37.6%) and other conditions associated with a high cardiovascular risk, but they were also the oldest old with more severe cognitive impairment and loss of functional independence. On the whole, their health state profile apparently justifies the low prevalence of statin use, in agreement with guidelines and recommendations stemming from the literature, 4–8 , 31 , 32 but in contrast with the findings of Borne et al, who observed an overuse of statins for primary prevention in the community-dwelling population aged 80 years or more. 33 The observed relatively low prevalence of drug–drug interactions, albeit increasing in Cluster III further supports our concluding remark of an overall proper use of LLDs in this hospitalized population of older patients.…”

“…28 , 30 The use of statins should be carefully evaluated and generally avoided in patients with a small body frame, multimorbidity and exposed to polypharmacy, ie, the epitome of the frailest older people. 31 The decision to continue therapy in the oldest elderly may also be influenced by impaired physical and cognitive functions.…”