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. And a large retrospective study of Veterans Health Administration data found statins produced good results for those over 75.

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".

A 2019 meta-review of 28 studies of over 190,000 patients concluded that statins cut risks of cardiovascular disease and death in people over age 75, as well as younger people. While acknowledging that risks exist the authors concluded the benefits “massively outweighed” those.

The study of VHA data completed in 2020 found statins continued to lower the risk of cardiovascular events and strokes in people past age 75 and even past 90 years of age.

A BBC article noted that only a third of UK residents past age 75 take statins but under accepted medical wisdom many more should. This review was conducted by the The Cholesterol Treatment Trialists' Collaboration which has been monitoring statin effects for decades. One of the authors was quoted saying the results make “a case to reduce LDL cholesterol in people at risk of cardiovascular events regardless of age”

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.

Statins and Dementia in the Elderly

There has been concerns and some evidence that statins have a negative effect on memory. Elderly people often see a dceline in memoery so it is difficult to tease our which parts are due to statins and which to other causes. From what researchers have found, advanced age does not increase the risk of statin-related memory loss. Some also claim that statins protect against cognitive decline; that a better brain is one of the pleiotropic effects. However, the evidence for that is weak.

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. There is even some evidence statins benefit the brains of older patients.

Adherence

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.

See also

Among older adults, statin use tied to decreased risk of death