Treating Cholesterol In Older People

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Everyone knows that having an elevated cholesterol level is a major risk factor for coronary artery disease (CAD). If you have a high risk for developing CAD, or especially if you already have CAD, you can be sure your doctor will urge you to lower your cholesterol levels, and will likely prescribe a statin drug to help you do so.

So it may come as a surprise that for people above the age of 65 — the age group with the highest incidence of CAD — what to do about elevated cholesterol levels has been somewhat controversial.

Why the Controversy?

The controversy exists because older people have been systematically excluded from most of the clinical trials demonstrating the benefits of cholesterol treatment. It is unfortunate that drug trials of all types have often purposely avoided enrolling elderly patients.

This is not because drug companies consider older people to be unworthy of their attention, but rather for practical and economic reasons. Older people have a reduced life expectancy, so some of them are likely to die during the course of a long clinical trial for reasons completely unrelated to the treatment being tested. Also, older people tend to have more than one medical condition, so they often have an array of symptoms — some of which might then be incorrectly attributed to the test drug. Such "extraneous" deaths and symptoms can greatly complicate the analysis of a clinical trial, and could threaten the eventual FDA approval of a new drug.

So it has been safer (and cheaper) to just leave old people out of many clinical trials.

This exclusionary practice means that we know relatively little about the specific benefits and risks of treating elevated cholesterol levels in older people. And this, in turn, means that when an older patient has high cholesterol levels, doctors are often unsure if they should offer treatment.

Cholesterol and Cardiovascular Disease in the Elderly

In people of both sexes over the age of 65, cardiovascular disease accounts for more than half of all deaths. In comparison, cancer produces "only" 24% of deaths in men in this same age group, and 20% in women. So a treatment that might reduce the risk of cardiovascular disease in older people should be a desirable thing.

Furthermore, elevated cholesterol is associated with an increased risk of heart disease in older people just as much as it is in younger people. In fact, at least some evidence suggests that cholesterol may be an even more important predictor of risk in older than in younger people.

Is It Useful To Lower Cholesterol Levels in Older People?

Despite the lack of evidence from clinical trials in older people, the preponderance of evidence nonetheless suggests that treating elevated cholesterol in the elderly is something that at least ought to be strongly considered.

Sufficient data is available from several of the randomized clinical trials on cholesterol therapy to permit subgroup analyses in older people.

Studies pooling data from some of these trials have concluded that cardiac outcomes can be improved by treating elevated cholesterol levels with statin drugs in older people at least as much as in younger people. Furthermore, the reduction in cardiovascular risk in older people is often seen within just a few months of beginning therapy, so despite the fact that these patients are old, they're not "too old" to experience the benefits of cholesterol lowering with statins.

So, while the potential benefits of cholesterol-lowering are less definitively proven in older people than in younger people, the best available evidence says there is indeed a substantial benefit to treating cholesterol in the elderly.

What About the Side Effects of Statins in Older People?

The available evidence further indicates that the risk of side effects from statins is no higher in older patients than it is in younger patients. However, both doctors and patients need to take into account that some of the potential side effects of statins (such as muscle problems and cognitive disorders) may be much more consequential in older than younger patients.

The Bottom Line

If you are an older person with elevated cardiac risk - or especially if you already have CAD - then despite the lack of definitive "proof" that treating your cholesterol is beneficial, there is enough evidence to make it a good idea to at least have a discussion about cholesterol therapy with your doctor.

For older people who have a lot of medical problems, the potential risks of adding yet another medication to an already complex drug regimen may very well outweigh the potential benefits. But for healthy older people with high cholesterol levels, cholesterol-lowering therapy ought to be seriously considered.


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