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Care of the Aging Patient: From Evidence to Action |

Evaluation and Treatment of Older Patients With Hypercholesterolemia A Clinical Review

Timo E. Strandberg, MD, PhD1,2,3; Laura Kolehmainen, MD, PhD4; Alpo Vuorio, MD, PhD5,6
[+] Author Affiliations
1Geriatric Clinic, Department of Medicine, University of Helsinki, Helsinki, Finland
2Institute of Health Sciences/Geriatrics, University and University Hospital of Oulu, Oulu, Finland
3Helsinki University Central Hospital, Helsinki, Finland
4Unit of Internal Medicine, North Karelia Central Hospital, Joensuu, Finland
5Mehiläinen Airport Health Centre, Vantaa, Finland
6Finnish Institute of Occupational Health, Lappeenranta, Finland
JAMA. 2014;312(11):1136-1144. doi:10.1001/jama.2014.10924.
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Importance  Hypercholesterolemia is common among people older than 80 years. Substantial functional heterogeneity exists among older patients, and decision making for statin use differs in older patients relative to younger ones.

Objective  To discuss the presentation, modifying factors, and treatment of hypercholesterolemia (usually with statins) among persons older than 80 years.

Evidence Review  MEDLINE and other sources were searched from January 1990 to June 2014. Personal libraries and a hand search of reference lists from guidelines and reviews from January 2000 to June 2014 were also used.

Findings  No randomized clinical trials (RCTs) of statin or any other hypocholesterolemic medication included persons older than 80 years at baseline. Findings from 75- to 80-year-old patients enrolled in RCTs and information from observational studies support statin treatment for secondary prevention of atherosclerotic cardiovascular disease (ASCVD) and probably in patients with diabetes without ASCVD. Harms from statin drugs are not increased in older patients, so the use of these agents for primary prevention is possible. Because people older than 80 years are biologically heterogeneous with varying life expectancy, may have frailty or comorbid conditions, and may take multiple medications, the decision to treat with statins must be individualized.

Conclusions and Relevance  Ideally, treatment of hypercholesterolemia for patients at risk of ASCVD should start before they turn 80 years old. No RCT evidence exists to guide statin initiation after age 80 years. Decisions to use statins in older individuals are made individually and are not supported by high-quality evidence.

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Suggested Treatment Algorithm for Statin Treatment in Patients Older Than 80 Years With Hypercholesterolemia and Without a Condition Seriously Limiting Life Expectancy

This approach is used by the authors and is based on the best available evidence but does not represent treatments validated in clinical trials, because the clinical features of the patients considered in this article have not been studied in randomized clinical trials. ASCVD indicates atherosclerotic cardiovascular disease; LDL-C, low-density lipoprotein cholesterol.

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