Statin Use in the Elderly
Discussion of whether statins should be given to elderly patients generally revolves around whether the cost/benefit calculation changes as people age. There have not been as many formal studies of patients in this range as there have been of middle-aged patients, so the science is a little less firm, although experts feel the results of experiments on statins in a broad age range apply to older people.
Some discussion of this issue classifies elderly as those past age 75, and some as those past age 85. People in this age range have a risk for cardiovascular events no matter how healthy they are and no matter what types of medication they take.
One factor used to determine whether a patient should get a statin is risk of cardiovascular problems in the next 20 years, as calculated by the Framingham Risk Score or a similar system. Even unhealthy people (high TDL, low HDL,, hypertension, obese) under the age of 40 are almost always under 10% risk of having a problem in the next 20 years. Among older people, the opposite is true. Even people in great physical condition at age 70 have a greater than 10% chance of an event as calculated by the FRS.
There is also a recognition that cholesterol level is a surrogate for cardiovascular health and a good thing to focus on in middle-aged people, but less relevant for the very old. So even if statins do lower LDL in the elderly, it is not apparent they really affect risk for heart attacks. The 2013 ACA/AHA guidelines, if implemented, would result in a vast expansion in the use of statins. The criteria of 10-year 7.5% CVS risk means that practically everyone past age 65 qualifies for statin use even if they have no other risk factors. Although giving the medicine to people in their late 60s is not as controversial, both doctors and patients sometime balk at starting a statin regimen in those over 75, or particularly 85.
The Reluctance of Doctors to Give Statins to the Elderly
Doctors have been more reticent to prescribe statins to elderly patients than middle-aged ones.
Various reasons have been proposed:
- Unclear about whether the drug makers and FDA recommend these medications for the elderly.
- Concerns about cognitive effects (as the elderly tend to have more memory problems than the middle-aged)
- Concerns about myopathy and muscle effects (as the elderly tend to suffer from sarcopenia).
- Concerns about drug-drug interactions, as people in this age range take lots of drugs.
- Worry about nonadherence and desire of patients to not take pills
Nevertheless, there are voices advocating for expanded drug statin use in this age range. An editorial in Circulation, a journal published by the American Heart Association, called cardiovascular risk of the elderly "demonstrably undermanaged". Maybe, but the reluctance of doctors to give the very old statins is understandable.
Before 2002 there had been few formal studies on the elderly. Evidence for efficacy in older people came from larger studies with a broader age range. But there are now some evidence that patients in this age range can benefit from statins.
In an article in the Journal of the American Gerontological Society, Neil Stone, MD concluded "in summary, there are important reasons to recommend statin therapy in individuals aged 85 and older who have established ASCVD."
He points to randomized control trials on statin use in people past age 75 that show good results. Other studies addressing doctors’ concerns support statin usage in the elderly.
A study of sedentary people aged 70 to 89 found that statin use did not adversely affect their physical therapy or exercise - http://www.ncbi.nlm.nih.gov/pubmed/26988662 Further, although memory problems are a known side effect of statins, the medications do not seem to increase the risk for dementia or Alzheimer’s Disease.
Compliance – getting patients to take the statins prescribed them – is a problem in general, and is worse in the elderly than in middle-aged people. Whether or not the elderly patient has a history of heart problems seems to have no bearing on compliance rates.