Treatment of hypercholesterolaemia in older adults calls for a patient-centred approach

Abstract

Due to an increasing number of older adults with (risk factors for) cardiovascular disease (CVD), the sum of older adults eligible for lipid-lowering drugs will increase. This has risen questions about benefits and harms of lipid-lowering therapy in older adults with a varying number of (cardiovascular) comorbidities and functional status. The heterogeneity in physical and functional health increases with age, leading to a much wider variety in cardiovascular risk and life expectancy than in younger adults. We suggest treatment decisions on hypercholesterolaemia in adults aged ≥75 years should shift from a strictly 10-year cardiovascular risk-driven approach to a patient-centred and lifetime benefit-based approach. With this, estimated 10-year risk of CVD should be placed into the perspective of life expectancy. Moreover, frailty and safety concerns must be taken into account for a risk–benefit discussion between clinician and patient. Based on the Dutch addendum ‘Cardiovascular Risk Management in (frail) older adults’, our approach offers more detailed information on when not to initiate or deprescribe therapy than standard guidelines. Instead of using traditional risk estimating tools which tend to overestimate risk of CVD in older adults, use a competing risk adjusted, older adults-specific risk score (available at https://u-prevent.com). By filling in a patient’s (cardiovascular) health profile (eg, cholesterol, renal function), the tool estimates risk of CVD and models the effect of medication in terms of absolute risk reduction for an individual patient. Using this tool can guide doctors and patients in making shared decisions on initiating, continuing or deprescribing lipid-lowering therapy.

Statin Therapy in Very Old Patients: Lights and Shadows

“…One of the most representative characteristics of the old population is its wide range of clinical, functional, and cognitive statuses, which determine life expectancy and quality of life. This makes it necessary for physicians to individualize cardiovascular risk assessment in very old patients ( 21 ). Functional status must be evaluated when estimating cardiovascular risk, since it has more weight in estimating mortality in old individuals than traditional cardiovascular risk factors ( 22 ).…”

Categorization using the Dementia Assessment Sheet for Community‐Based Integrated Care System 8‐items (DASC‐8) based on cognitive function and activities of daily living predicts frailty, disability and mortality in older adults

“…Life expectancy, frailty, and functional prognosis are necessarily considered when treating older adults with chronic diseases, including hypertension, dyslipidemia, or diabetes mellitus. [1][2][3][4] In particular, guidelines for treating diabetes mellitus in the elderly indicate that glycemic targets should be determined by categories based on the assessment of cognitive function, activities of daily living (ADLs), and comorbidities. 4 This categorization can be performed easily using the total points of the Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8), which assesses eight questions on cognition, instrumental ADLs (IADLs), and basic ADLs on a 4-point scale.…”

“…Life expectancy, frailty, and functional prognosis are necessarily considered when treating older adults with chronic diseases, including hypertension, dyslipidemia, or diabetes mellitus 1–4 . In particular, guidelines for treating diabetes mellitus in the elderly indicate that glycemic targets should be determined by categories based on the assessment of cognitive function, activities of daily living (ADLs), and comorbidities 4…”

Underrepresentation of the elderly in clinical trials, time for action

“…The same serious consequences can be found in cases of drug induced cognitive deterioration/delirium and incontinence 3 . The presence of so‐called competing risks challenges the efficacy figures found in standard drug trials 7 …”