Treating Dyslipidemia in Old Age

Dan Noyes 

As the percentage of elderly people in the United States continues to grow faster than any other age group, the incidence of CVD grows too. According to Kannel , 1 CVD accounts for 58% of the mortality in persons >85 years, and the incidence of atherosclerotic disease in persons >65 years is more than double that in middle-aged persons.

Can anything be done to reduce fatal CVD in a population exposed to a lifetime of CV risk factors?

Despite skepticism from some physicians, Kannel thinks CV risk can be reduced in this population (see below); he cites studies showing that correction of hypertension and dyslipidemia reduces morbidity and mortality in both middle-aged and elderly people. The effectiveness of other measures has not been established but appears to warrant investigation, including:

• reducing homocysteine levels
• reducing fibrinogen levels
• smoking cessation
• exercise
• weight reduction

Implications of Dyslipidemia in older populations:
About 25% of men and 42% of women >65 years have serum TC levels >240 mg/dL, the level at which NCEP ATP-II guidelines recommend treatment. 2 Citing the Framingham Heart Study, Kannel notes that the median serum TC at which coronary events occurred was only 221 mg/dL in men and 246 mg/dL in women, leading to the conclusion that 50% or more coronary events in the elderly can be expected to occur at cholesterol levels below those recommended by NCEP ATP-II for initiating treatment.

What should the clinician look for?
Although total blood lipids measured after age 65 have not been consistently found to correlate with the development of coronary disease or the occurrence of strokes, when cholesterol fractions other than TC are evaluated, positive relations have been found: for example, the TC:HDL-C ratio efficiently predicts CHD in the elderly as well as the middle-aged. 1 According to NCEP guidelines, patients should not be excluded from consideration from lipid-regulating therapy on the basis of age alone, although quality-of-life issues acquire special importance in managing older patients. Because both dietary and drug therapy have additional clinical implications for older patients, treatment of the elderly should be individualized.

Are older patients getting adequate treatment?
Although the use of pharmacologic cholesterol lowering in middle-aged patients is generally accepted and is increasingly utilized, patients aged 65 to 75 who have a history of CHD and might benefit from cholesterol-lowering drugs are generally undertreated or not treated at all, according to a recent CHS report by Lemaitre et al. 3 The CHS was designed to investigate risk factors for CHD in men and women aged 65 and older (see below). It also provided an opportunity to examine the impact of the NCEP guidelines on physicians' prescribing patterns for elderly patients.