Statins for Primary Prevention in Older Adults-Moving Toward Evidence-Based Decision-Making

Patterns of Statin Therapy Use and Associated Outcomes in Older Veterans Across Kidney Function

BACKGROUND

Despite significant morbidity and mortality related to atherosclerotic cardiovascular disease, to date, most major clinical trials studying the effects of statin therapy have excluded older adults. The objective of this analysis was to evaluate the effect of initiating statin therapy on incident dementia and mortality among individuals 75 years of age or older across the complete spectrum of kidney function.

METHODS

We conducted a retrospective cohort study of 640,191 VA health system patients who turned 75 years of age between 2000 and 2018. Patients on statin therapy received the medication for an average of 6.3 years (standard deviation 4.6 years). The primary outcome of interest included incident dementia diagnosis during the study period. The secondary outcome was all-cause mortality. Cox-proportional hazard analysis was used to evaluate the adjusted association of statin initiation with these outcomes.

RESULTS

There was a higher rate of incident dementia in the No Statin group (4.7%) versus the Statin group (3.2%). Additionally, we observed a 22% all-cause mortality benefit associated with statin therapy. We did not observe a treatment effect with respect to primary or secondary outcomes across varying levels of kidney function.

CONCLUSION

This large cohort study did not reveal an association between the initiation of statin therapy and incident dementia. A survival benefit was seen in statin users compared to non-users. Prospective studies in more diverse populations including older adults will be needed to verify these findings.

Sex and stroke risk factors: A review of differences and impact

OBJECTIVES

There is an increase in stroke incidence risk over the lifetime of women, given their longer life expectancy. However, an alarming trend for sex disparities, particularly in certain stroke risk factors, shows a concerning need for focus on sex differences in stroke prevention and treatment for women. In this article, we are addressing sex differences in both traditional and sex-specific stroke risk factors.

METHODS

We searched PubMed from inception to December 2022 for articles related to sex differences and risk factors for stroke. We reviewed full-text articles for relevance and ultimately included 152 articles for this focused review.

RESULTS

Women are at increased risk for stroke from both traditional and non-traditional stroke risk factors. As women age, they have a higher disease burden of atrial fibrillation, increased risk of stroke related to diabetes, worsening lipid profiles, and higher prevalence of hypertension and obesity compared to men. Further, women carry sex hormone-specific risk factors for stroke, including the age of menarche, menopause, pregnancy, and its complications, as well as hormonal therapy. Men have a higher prevalence of tobacco use and atrial fibrillation, as well as an increased risk for stroke related to hyperlipidemia. Additionally, men have sex-specific risks related to low testosterone levels.

CONCLUSIONS

By identifying biological sex-specific risk factors for stroke, developing robust collaborations, researching, and applying the knowledge for risk reduction strategies, we can begin to tailor prevention and reduce the global burden of stroke morbidity and mortality.

Effect of statin use for the primary prevention of cardiovascular disease among older adults: a cautionary tale concerning target trials emulation

OBJECTIVES

Evidence concerning the effect of statins in primary prevention of cardiovascular disease (CVD) among older adults is lacking. Using Quebec population-wide administrative data, we emulated a hypothetical randomized trial including older adults >65 years on April 1, 2013, with no CVD history and no statin use in the previous year.

STUDY DESIGN AND SETTING

We included individuals who initiated statins and classified them as exposed if they were using statin at least 3 months after initiation and nonexposed otherwise. We followed them until March 31, 2018. The primary outcome was the composite endpoint of coronary events (myocardial infarction, coronary bypass, and percutaneous coronary intervention), stroke, and all-cause mortality. The intention-to-treat (ITT) effect was estimated with adjusted Cox models and per-protocol effect with inverse probability of censoring weighting.

RESULTS

A total of 65,096 individuals were included (mean age = 71.0 ± 5.5, female = 55.0%) and 93.7% were exposed. Whereas we observed a reduction in the composite outcome (ITT-hazard ratio (HR) = 0.75; 95% CI: 0.68-0.83) and mortality (ITT-HR = 0.69; 95% CI: 0.61-0.77) among exposed, coronary events increased (ITT-HR = 1.46; 95% CI: 1.09-1.94). All multibias E-values were low indicating that the results were not robust to unmeasured confounding, selection, and misclassification biases simultaneously.

CONCLUSION

We cannot conclude on the effectiveness of statins in primary prevention of CVD among older adults. We caution that an in-depth reflection on sources of biases and careful interpretation of results are always required in observational studies.

Awaiting the verdict: Statins and the road ahead for primary prevention in older adults

This editorial comments on the article by Orkaby et al. in this issue.

Marginal structural models with latent class growth analysis of treatment trajectories: Statins for primary prevention among older adults

Latent class growth analysis is increasingly proposed as a solution to summarize the observed longitudinal treatment into a few distinct groups. When latent class growth analysis is combined with standard approaches like Cox proportional hazards models, confounding bias is not properly addressed because of time-varying covariates that have a double role of confounders and mediators. We propose to use latent class growth analysis to classify individuals into a few latent classes based on their medication adherence pattern, then choose a working marginal structural model that relates the outcome to these groups. The parameter of interest is defined as a projection of the true marginal structural model onto the chosen working model. Simulation studies are used to illustrate our approach and compare it with unadjusted, baseline covariates adjusted, time-varying covariates adjusted, and inverse probability of trajectory groups weighted adjusted models. Our proposed approach yielded estimators with little or no bias and appropriate coverage of confidence intervals in these simulations. We applied our latent class growth analysis and marginal structural model approach to a database comprising information on 52,790 individuals from the province of Quebec, Canada, aged more than 65 and who were statin initiators to estimate the effect of statin-usage trajectories on a first cardiovascular event.

Effect of statin treatment on mortality in elderly patients with type 2 diabetes mellitus patients: a retrospective cohort study

BACKGROUND

The effects of statins on the reduction of mortality in individuals aged 75 years or older remain controversial. We conducted this study to investigate whether there is an association between statin therapy and mortality in patients with type 2 diabetes mellitus (T2DM) who are over the age of 75 years.

METHODS

The present study used data from the Staged Diabetes Targeting Management Study, which began in 2005. A total of 518 T2DM patients older than 75 years were included. Cox regression analyses were used to evaluate the association between statins and specific causes of death in patients with T2DM.

RESULTS

After a follow-up period of 6.09 years (interquartile range 3.94-8.81 years), 111 out of 518 patients died. The results of Cox regression analyses showed that there was no significant association between statin use and all-cause mortality (HR 0.75; 95% CI 0.47, 1.19) after adjustment for all potential confounders. Subgroup analysis indicated that statins had no association with the risk of all-cause mortality or deaths caused by ischemic cardiovascular diseases in T2DM patients with or without coronary heart disease.

CONCLUSIONS

Our study found no significant association between all-cause mortality and statin use in T2DM patients over the age of 75 years. More evidence is needed to support the use of statins in the elderly T2DM patients.

Association Between Age and Low-Density Lipoprotein Cholesterol Response to Statins : A Danish Nationwide Cohort Study

BACKGROUND

There is large patient-to-patient variability in the low-density lipoprotein cholesterol (LDL-C) response to statin treatment. The reduction in LDL-C may depend on the age of the patient treated-particularly in older adults, who have been substantially underrepresented in randomized controlled trials.

OBJECTIVE

To investigate the association between age and the LDL-C reduction by statins.

DESIGN

Nationwide, register-based cohort study.

SETTING

Denmark, 2008 to 2018.

PARTICIPANTS

82 958 simvastatin or atorvastatin initiators with LDL-C measurements before and during statin use.

MEASUREMENTS

Statin response, defined as percentage reduction in prestatin LDL-C level, and percentage reduction differences (PRDs) according to age and simvastatin or atorvastatin dose based on a longitudinal model for LDL-C.

RESULTS

Among 82 958 statin initiators, 10 388 (13%) were aged 75 years or older. With low- to moderate-intensity statins, initiators aged 75 years or older had greater mean LDL-C percentage reductions than initiators younger than 50 years-for example, 39.0% versus 33.8% for simvastatin, 20 mg, and 44.2% versus 40.2% for atorvastatin, 20 mg. The adjusted PRD for initiators aged 75 years compared with initiators aged 50 years was 2.62 percentage points. This association was consistent for primary prevention (2.54 percentage points) and secondary prevention (2.32 percentage points) but smaller for initiators of high-intensity statins (atorvastatin, 40 mg: 1.36 percentage points; atorvastatin, 80 mg: -0.58 percentage point).

LIMITATION

Use of administrative data, observational pre-post comparison with a moderately high proportion of missing data, lack of information on body mass index, and the mainly White study population may limit generalizability.

CONCLUSION

Low- to moderate-intensity statins were associated with a greater reduction in LDL-C levels in older persons than younger persons and may be more appealing as initial treatment in older adults who are at increased risk for adverse events.

PRIMARY FUNDING SOURCE

The Independent Research Fund Denmark, Brødrene Hartmanns Fond, and Fonden til Lægevidenskabens Fremme.

Assessing the Link Between Statins and Insulin Intolerance: A Systematic Review

There has been mixed and inconclusive evidence regarding the relationship between statin usage and insulin intolerance. This systematic review aims to comprehensively explore the link between the use of statins and insulin intolerance. We systematically searched MEDLINE, PubMed, PubMed Central (PMC), and Google Scholar databases for online English articles with full text. We excluded conference proceedings, editorials, commentaries, preclinical studies, abstracts, and preprints. The search across databases initially identified 667 articles. After eliminating duplicates and analyzing the remaining articles based on the inclusion and exclusion criteria, 11 articles were selected. The included studies had a total of 46,728,889 participants. The findings suggest that the use of statins is associated with a decrease in insulin sensitivity and insulin resistance. This systematic review provides evidence that the use of statins may have an adverse effect on insulin sensitivity and increase insulin resistance. These findings may have important clinical implications for individuals on statin therapy, especially those at risk of developing diabetes.

Pragmatic evaluation of events and benefits of lipid lowering in older adults (PREVENTABLE): Trial design and rationale

Whether initiation of statins could increase survival free of dementia and disability in adults aged ≥75 years is unknown. PREVENTABLE, a double-blind, placebo-controlled randomized pragmatic clinical trial, will compare high-intensity statin therapy (atorvastatin 40 mg) with placebo in 20,000 community-dwelling adults aged ≥75 years without cardiovascular disease, disability, or dementia at baseline. Exclusion criteria include statin use in the prior year or for >5 years and inability to take a statin. Potential participants are identified using computable phenotypes derived from the electronic health record and local referrals from the community. Participants will undergo baseline cognitive testing, with physical testing and a blinded lipid panel if feasible. Cognitive testing and disability screening will be conducted annually. Multiple data sources will be queried for cardiovascular events, dementia, and disability; survival is site-reported and supplemented by a National Death Index search. The primary outcome is survival free of new dementia or persisting disability. Co-secondary outcomes are a composite of cardiovascular death, hospitalization for unstable angina or myocardial infarction, heart failure, stroke, or coronary revascularization; and a composite of mild cognitive impairment or dementia. Ancillary studies will offer mechanistic insights into the effects of statins on key outcomes. Biorepository samples are obtained and stored for future study. These results will inform the benefit of statins for increasing survival free of dementia and disability among older adults. This is a pioneering pragmatic study testing important questions with low participant burden to align with the needs of the growing population of older adults.

Atorvastatin Can Modulate DNA Damage Repair in Endothelial Cells Exposed to Mitomycin C

HMG-CoA reductase inhibitors (statins) are widely used in the therapy of atherosclerosis and have a number of pleiotropic effects, including DNA repair regulation. We studied the cytogenetic damage and the expression of DNA repair genes (DDB1, ERCC4, and ERCC5) in human coronary artery (HCAEC) and internal thoracic artery endothelial cells (HITAEC) in vitro exposed to mitomycin C (MMC) (positive control), MMC and atorvastatin (MMC+Atv), MMC followed by atorvastatin treatment (MMC/Atv) and 0.9% NaCl (negative control). MMC/Atv treated HCAEC were characterized by significantly decreased micronuclei (MN) frequency compared to the MMC+Atv group and increased nucleoplasmic bridges (NPBs) frequency compared to both MMC+Atv treated cells and positive control; DDB1, ERCC4, and ERCC5 genes were upregulated in MMC+Atv and MMC/Atv treated HCAEC in comparison with the positive control. MMC+Atv treated HITAEC were characterized by reduced MN frequency compared to positive control and decreased NPBs frequency in comparison with both the positive control and MMC/Atv group. Nuclear buds (NBUDs) frequency was significantly lower in MMC/Atv treated cells than in the positive control. The DDB1 gene was downregulated in the MMC+Atv group compared to the positive control, and the ERCC5 gene was upregulated in MMC/Atv group compared to both the positive control and MMC+Atv group. We propose that atorvastatin can modulate the DNA damage repair response in primary human endothelial cells exposed to MMC in a cell line- and incubation scheme-dependent manner that can be extremely important for understanding the fundamental aspects of pleoitropic action of atorvastatin and can also be used to correct the therapy of patients with atherosclerosis characterized by a high genotoxic load.

Statins for extension of disability-free survival and primary prevention of cardiovascular events among older people: protocol for a randomised controlled trial in primary care (STAREE trial)

INTRODUCTION

The world is undergoing a demographic transition to an older population. Preventive healthcare has reduced the burden of chronic illness at younger ages but there is limited evidence that these advances can improve health at older ages. Statins are one class of drug with the potential to prevent or delay the onset of several causes of incapacity in older age, particularly major cardiovascular disease (CVD). This paper presents the protocol for the STAtins in Reducing Events in the Elderly (STAREE) trial, a randomised double-blind placebo-controlled trial examining the effects of statins in community dwelling older people without CVD, diabetes or dementia.

METHODS AND ANALYSIS

We will conduct a double-blind, randomised placebo-controlled trial among people aged 70 years and over, recruited through Australian general practice and with no history of clinical CVD, diabetes or dementia. Participants will be randomly assigned to oral atorvastatin (40 mg daily) or matching placebo (1:1 ratio). The co-primary endpoints are disability-free survival defined as survival-free of dementia and persistent physical disability, and major cardiovascular events (cardiovascular death or non-fatal myocardial infarction or stroke). Secondary endpoints are all-cause death, dementia and other cognitive decline, persistent physical disability, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, heart failure, atrial fibrillation, fatal and non-fatal cancer, all-cause hospitalisation, need for permanent residential care and quality of life. Comparisons between assigned treatment arms will be on an intention-to-treat basis with each of the co-primary endpoints analysed separately in time-to-first-event analyses using Cox proportional hazards regression models.

ETHICS AND DISSEMINATION

STAREE will address uncertainties about the preventive effects of statins on a range of clinical outcomes important to older people. Institutional ethics approval has been obtained. All research outputs will be disseminated to general practitioner co-investigators and participants, published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT02099123.

Older adult preferences regarding benefits and harms of statin and aspirin therapy for cardiovascular primary prevention

Objective

Personalizing preventive therapies for atherosclerotic cardiovascular disease (ASCVD) is particularly important for older adults, as they tend to have multiple chronic conditions, increased risk for medication adverse effects, and may have heterogenous preferences when weighing health outcomes. However, little is known about outcome preferences related to ASCVD preventive therapies in older adults.

Methods

In May 2021, using an established online panel, KnowledgePanel, we surveyed older US adults aged 65-84 years without history of ASCVD on outcome preferences related to statin therapy (benefit outcomes to be reduced by the therapy: heart attack, stroke; adverse effects: diabetes, abnormal liver test, muscle pain) or aspirin therapy (benefit outcomes: heart attack, stroke; adverse effects: brain bleed, bowel bleed, stomach ulcer). We used standardized best-worst scores (range of -1 for "least worrisome" to +1 for "most worrisome") and conditional logistic regression to examine the relative importance of the outcomes.

Results

In this study, 607 ASCVD-free participants (median age 74, 46% male, 81% White) were included; 304 and 303 completed the statin and aspirin versions of the survey, respectively. For statin-related outcomes, stroke and heart attack were most worrisome (score 0.55; 95% CI 0.51, 0.60) and (0.53; 0.48, 0.58), followed by potential harms of diabetes (-0.07; -0.10, -0.03), abnormal liver test (-0.25; -0.29, -0.20), and muscle pain (-0.77; -0.82, -0.73). For aspirin-related outcomes, stroke and heart attack were similarly most worrisome (0.48; 0.43, 0.52) and (0.43; 0.38, 0.48), followed by brain bleed (0.30; 0.25, 0.34), bowel bleed (-0.31; -0.33, -0.28), and stomach ulcer (-0.90; -0.92, -0.87). Conditional logistic regression and subgroup analyses by age, sex, and race yielded similar results.

Conclusions

Older adults generally consider outcomes related to benefits of ASCVD primary preventive therapies-stroke and heart attack-more important than their adverse effects. Integrating patient preferences with risk assessment is an important next step for personalizing ASCVD preventive therapies for older adults.

Primary prevention statin therapy in older adults

PURPOSE OF REVIEW

The purpose of this review is to assess the evidence for primary prevention statin treatment in older adults, within the context of the most recent guideline recommendations, while also highlighting important considerations for shared decision-making.

RECENT FINDINGS

As the average lifespan increases and the older adult population grows, the opportunity for prevention of morbidity and mortality from cardiovascular disease is magnified. Randomized trials and meta-analyses have demonstrated a clear benefit for primary prevention statin use through age 75, with uncertainty beyond that age. Despite these data supporting their use, current guidelines conflict in their statin treatment recommendations in those aged 70-75 years. Reflecting the paucity of evidence, the same guidelines are equivocal around primary prevention statins in those beyond age 75. Two large ongoing randomized trials (STAREE and PREVENTABLE) will provide additional insights into the treatment benefits and risks of primary prevention statins in the older adult population. In the meantime, a holistic approach in treatment decisions remains paramount for older patients.

SUMMARY

The benefits of primary prevention statin treatment are apparent through age 75, which is reflected in the current ACC/AHA and USPSTF recommendations. Ongoing trials will clarify the utility in those beyond age 75.

Lipid-Lowering Trials Are Not Representative of Patients Managed in Clinical Practice: A Systematic Review and Meta-Analysis of Exclusion Criteria

Background Randomized clinical trials (RCTs) might not be representative of the real-world population because of unreasonable exclusion criteria. We sought to determine which groups of patients are excluded from RCTs that included lipid-lowering therapy. Methods and Results We retrieved all trials from the Cholesterol Treatment Trialists Collaboration and systematically searched for large (≥1000 participants) lipid-lowering therapy RCTs, defined as statins, ezetimibe, and PCSK9 inhibitors. We predefined groups: older adults (>70 or >75 years), women, non-Whites, chronic kidney failure, heart failure, immunosuppression, cancer, dementia, treated thyroid disease, chronic obstructive pulmonary disease, mental illness, atrial fibrillation, multimorbidity (≥2 chronic diseases), and polypharmacy. We counted the number of RCTs excluding patients of the predefined groups and meta-analyzed the prevalence of included patients to obtain pooled estimates with a random-effects model. We included 42 RCTs (298 605 patients). Eighty-one percent of trials excluded patients with severe and 76% those with moderate kidney failure. Seventy-one percent of trials excluded groups of women, 64% excluded patients with moderate to severe heart failure, 64% those with immunosuppressant conditions, 48% those with cancer, 29% those with dementia, and 29% of trials excluded older adults. The pooled prevalence for patients >70 years of age was 25% (95% CI, 0%-49%), 11% (3%-18%) for >75 years of age, and 51% (38%-63%) for multimorbidity. Conclusions The majority of lipid-lowering therapy trials excluded patients with common diseases, such as moderate-to-severe kidney disease or heart failure or with immunosuppression. Underrepresenting certain populations, including women and older adults, might lead to limited transportability of study results and uncertainty on possible side-effects and efficacy in these groups. Future trials should promote diversity in the recruitment strategies and improve equity in cardiovascular research. Registration URL: ClinicalTrials.gov; Unique Identifier: CRD42021253909.

Around the EQUATOR with clinician-scientists transdisciplinary aging research (Clin-STAR) principles: Implementation science challenges and opportunities

The Institute of Medicine and the National Institute on Aging increasingly understand that knowledge alone is necessary but insufficient to improve healthcare outcomes. Adapting the behaviors of clinicians, patients, and stakeholders to new standards of evidence-based clinical practice is often significantly delayed. In response, over the past twenty years, Implementation Science has developed as the study of methods and strategies that facilitate the uptake of evidence-based practice into regular use by practitioners and policymakers. One important advance in Implementation Science research was the development of Standards for Reporting Implementation Studies (StaRI), which provided a 27-item checklist for researchers to consistently report essential elements of the implementation and intervention strategies. Using StaRI as a framework, this review discusses specific Implementation Science challenges for research with older adults, provides solutions for those obstacles, and opportunities to improve the value of this evolving approach to reduce the knowledge translation losses that exist between published research and clinical practice.

Association between willingness to deprescribe and health outcome priorities among U.S. older adults: Results of a national survey

BACKGROUND

It is not known whether older adults' willingness to deprescribe is associated with their health outcome priorities related to medications.

METHODS

A cross-sectional survey was conducted from March-April 2020 using a nationally representative online panel. The survey presented two vignettes: (1) a preventive medicine; and (2) a symptom-relief medicine. Participants were asked whether they would be willing to stop each medicine if their doctor recommended it, and to rate their level of agreement with two health outcome priorities statements: "I am willing to accept the risk of future side effects … to feel better now," and "I would prefer to take fewer medicines, even if … I may not live as long or may have bothersome symptoms sometimes." Ordinal logistic regression was used to examine associations between willingness to stop each medicine, baseline characteristics and health outcome priorities.

RESULTS

Of 1193 panel members ≥65 years invited to participate, 835 (70%) completed the survey. Mean (SD) age was 73 years; 496 (59%) had taken a statin and 124 (15%) a prescription sedative-hypnotic. 507 (61%) were willing to stop preventive medicines; 276 (33%) were maybe willing. 419 (50%) were willing to stop symptom-relief medicines; 380 (46%) were maybe willing. Prioritizing fewer medicines was associated with higher odds of being willing to stop symptom-relief medicines (aOR 1.43 [95% CI 1.02-2.00]) and preventive medicines (aOR 1.52 [95% CI 1.05-2.18]). Prioritizing now over future was associated with lower odds of being willing to stop symptom-relief medicines (aOR 0.62 [95% CI 0.39-1.00]). Current/prior use of statins was associated with lower willingness to stop preventive medicines (aOR 0.66 [95% CI 0.48-0.91]).

CONCLUSIONS

Older adults' health outcome priorities related to medication use are associated with their willingness to consider deprescribing. Future research should determine how best to elicit patients' health outcome priorities to facilitate goal-concordant decisions about medication use.

Statin therapy for the primary prevention of cardiovascular disease: Pros

The initiation of statins for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) remains a debated subject, despite decades worth of clinical trial data demonstrating efficacy, effectiveness, and safety. Statin therapy, in addition to blood pressure-lowering drugs and efforts to reduce cigarette smoking, was a key component of the preventive cardiology renaissance that achieved a dramatic reduction in ASCVD-related mortality from the 1950s to 2010. However, deaths attributable to ASCVD have increased by approximately 13% in recent years, which are in part driven by incomplete treatment of risk factor burden starting in youth. Statins are a cornerstone of preventive cardiology practice, not only due to their lipid-lowering properties, but also in part due to their ability to exert pleiotropic effects that promote atherosclerotic plaque stability which reduces the likelihood of atherothrombotic clinical events. While the benefit of statin therapy undoubtedly depends on the presence and degree of atherosclerotic plaque burden, a broader statin allocation strategy on a population-based level should be considered especially in younger communities that are disproportionately affected by ASCVD risk factors. Thus, the era of precision medicine must be balanced with a pragmatic, cost-effective approach that maximizes ASCVD prevention across the life course. Herein, we examine the pros of statin pharmacotherapy in primary prevention while examining over three decades worth of basic science, translational, and clinical research in the setting of clinical practice guidelines.

Statins effect on insulin resistance after a meal and exercise in hypercholesterolemic pre-diabetic individuals

Aim

To study if statins, a widely prescribed, inexpensive medication to prevent coronary artery diseases may cause insulin resistance (IR).

Methods

Fasted (HOMA‐IR) and post‐meal insulin resistance were assessed in 21 pre‐diabetic hypercholesterolemic individuals treated with statins (STA trial). Measurements were compared to another trial conducted 96 h after statin withdrawal using placebo pills (PLAC trial). Trials were duplicated 16–18 h after a bout of moderate‐intensity exercise (500 kcal of energy expenditure) to reduce IR and better appreciate statin effects (EXER+STA and EXER+PLAC trials).

Results

Statin withdrawal did not affect fasting (HOMA‐IR; 2.35 ± 1.05 vs. 2.18 ± 0.87 for STA vs. PLAC trials; p = 0.150) or post‐meal insulin resistance (i.e., Matsuda‐index, STA 6.23 ± 2.83 vs. PLAC 6.49 ± 3.74; p = 0.536). A bout of aerobic exercise lowered post‐meal IR (p = 0.043), but statin withdrawal did not add to the exercise actions (p = 0.564). Statin withdrawal increased post‐meal plasma free glycerol concentrations (0.136 ± 0.073 vs. 0.185 ± 0.090 mmol·L⁻¹ for STA vs. PLAC trials; p < 0.001) but not plasma free fatty acids or fat oxidation (p = 0.981, and p = 0.621, respectively). Post‐meal fat oxidation was higher in the exercise trials (p = 0.002).

Conclusions

Withdrawal of statin medication does not affect fasting or post‐meal insulin resistance in pre‐diabetic hypercholesterolemic individuals. Furthermore, statin use does not interfere with the beneficial effects of exercise on lowering IR.

Association between low-density lipoprotein cholesterol and cardiovascular mortality in statin non-users: a prospective cohort study in 14.9 million Korean adults

BACKGROUND

Limited information is available on detailed sex/age-specific associations between low-density lipoprotein cholesterol (LDL-C) and cardiovascular disease (CVD) mortality and 'the optimal range' associated with the lowest CVD mortality in the general population.

METHODS

Korean adults (N = 14 884 975) who received routine health screenings during 2009-2010 were followed until 2018 for CVD mortality.

RESULTS

During 8.8 years (mean) of follow-up, 94 344 individuals died from CVD. LDL-C had U-curve associations with mortality from CVD and its subtypes, except haemorrhagic stroke. Optimal range was 90-149 mg/dL for CVD; 70-114 for ischaemic heart disease; 85-129 for ischaemic stroke; ≥85 for subarachnoid haemorrhage; ≥130 for intracerebral haemorrhage; 115-159 for hypertension and heart failure; and 100-144 for sudden cardiac death. Assuming linear associations between 100 and 300 mg/dL, LDL-C was positively associated with CVD mortality [hazard ratio (HR) per 39-mg/dL (1-mmol/L) higher LDL-C = 1.10], largely due to ischaemic heart disease (HR = 1.26), followed by sudden cardiac death (HR = 1.13), ischaemic stroke (HR = 1.11) and heart failure (HR = 1.05). Intracerebral haemorrhage (HR = 0.90), but not subarachnoid haemorrhage, had inverse associations. Women and older adults had weaker positive associations than men and younger adults (Pinteraction < 0.001 for both sex and age). Individuals aged 75-84 years had modest positive associations with CVD mortality, especially ischaemic heart disease and ischaemic stroke.

CONCLUSION

LDL-C had U-curve associations for CVD mortality. The associations and optimal ranges differed across CVD subtypes. Women and older adults had weaker positive associations than men and younger adults. Positive associations with ischaemic heart disease and ischaemic stroke were maintained in adults aged 75-84 years.

Research advances in the influence of lipid metabolism on cognitive impairment

Cognitive impairment (CI) is a mental disorder related to cognition and understanding, which is mainly categorized into mild CI and senile dementia. This disease is associated with multiple factors, such as chronic brain injury, aging, chronic systemic disease, mental state, and psychological factors. However, the pathological mechanism of CI remains unclear; it is usually associated with such underlying diseases as diabetes and hyperlipidemia. It has been demonstrated that abundant lipid metabolism indexes in the human body are closely related to CI, including total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, apolipoprotein, and so forth. As a crucial risk factor for CI, hyperlipidemia is of great significance in the occurrence and development of CI. However, the specific correlation between dyslipidemia and CI is still not fully elucidated. Besides, the efficacy of lipid-lowering drugs in the prophylaxis and treatment of CI has not been clarified. In this study, relevant advances in the influence of lipid metabolism disorders in CI will be reviewed, in an attempt to explore the effect of mediating blood lipid levels on the prophylaxis and treatment of CI, thus providing a reference for its clinical management.

Statin Therapy in Very Old Patients: Lights and Shadows

Atherosclerotic cardiovascular diseases (ASCVD) are the leading cause of death worldwide. High levels of total cholesterol—and of low-density lipoprotein cholesterol in particular—are one of the main risk factors associated with ASCVD. Statins are first-line treatment for hypercholesterolemia and have been proven to reduce major vascular events in adults with and without underlying ASCVD. Findings in the literature show that statins reduce coronary and cerebrovascular morbidity and mortality in middle-aged people, but their benefits in older adults are not as well-established, especially in primary prevention. Furthermore, many particularities must be considered regarding their use in old subjects, such as age-related changes in pharmacokinetics and pharmacodynamics, comorbidities, polypharmacy, and frailty, which decrease the safety and efficacy of statins in this population. Myopathy and a possible higher risk of falling along with cognitive decline are classic concerns for physicians when considering statin use in the very old. Additionally, some studies suggest that the relative risk for coronary events and cardiovascular mortality associated with high levels of cholesterol decreases after age 70, making the role of statins unclear. On the other hand, ASCVD are one of the most important causes of disability in old subjects, so cardiovascular prevention is of particular interest in this population in order to preserve functional status. This review aims to gather the current available evidence on the efficacy and safety of statin use in very old patients in both primary and secondary prevention.

Use of Lipid-Lowering Drugs and Associated Outcomes According to Health State Profiles in Hospitalized Older Patients

Objective

To assess how lipid-lowering drugs (LLDs) are administered in the hospitalized patients aged 65 and older and their association with clinical outcomes according to their health-related profiles.

Design

This is a retrospective study based on data from REPOSI (REgistro POliterapie SIMI - Italian Society of Internal Medicine) register, an Italian network of internal medicine hospital wards.

Setting and Participants

A total of 4642 patients with a mean age of 79 years enrolled between 2010 and 2018.

Methods

Socio-demographic characteristics, functional abilities, cognitive skills, laboratory parameters and comorbidities were used to investigate the health state profiles by using multiple correspondence analysis and clustering. Logistic regression was used to assess whether LLD prescription was associated with patients' health state profiles and with short-term mortality.

Results

Four clusters of patients were identified according to their health state: two of them (Cluster III and IV) were the epitome of frailty conditions with poor short-term outcomes, whereas the others included healthier patients. The average prevalence of LLD use was 27.6%. The lowest prevalence was found among the healthier patients in Cluster I and among the oldest frail patients with severe functional and cognitive impairment in Cluster IV. The highest prevalence was among multimorbid patients in Cluster III (OR=4.50, 95% CI=3.76-5.38) characterized by a high cardiovascular risk. Being prescribed with LLDs was associated with a lower 3-month mortality, even after adjusting for cluster assignment (OR=0.59; 95% CI = 0.44-0.80).

Conclusion

The prevalence of LLD prescription was low and in overall agreement with guideline recommendations and with respect to patients' health state profiles.

Assessment of Patient-Preferred Language to Achieve Goal-Aligned Deprescribing in Older Adults

IMPORTANCE

How clinicians communicate about deprescribing, the structured process of reducing or stopping unnecessary, potentially harmful, or goal-discordant medicines, may be associated with the extent to which older adults are willing to do it.

OBJECTIVE

To examine older adults' preferences regarding different rationales a clinician may use to explain why a patient should stop an unnecessary or potentially harmful medication.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study was conducted from March 25 to April 19, 2020, among a nationally representative, probability-based online survey panel (KnowledgePanel). KnowledgePanel members aged 65 years and older were recruited by random digit dialing and address-based sampling. Data were analyzed from May 4 to July 8, 2020.

EXPOSURES

The survey presented 2 vignettes involving hypothetical older adults. One described a statin being used for primary prevention by a person with functional impairment and polypharmacy. The second described a sedative-hypnotic, such as zolpidem, being used for insomnia by a person with good functional status.

MAIN OUTCOMES AND MEASURES

After each vignette, participants expressed preferences using a best-worst scaling method for 7 different phrases a clinician may use to explain why they should reduce or stop the medication. Conditional logistic regression was used to quantify respondents' relative preferences.

RESULTS

A total of 1193 KnowledgePanel members were invited, and 835 respondents (70.0%) completed the survey. The mean (SD) age was 73 (6) years, 414 (49.6%) were women, and 671 (80.4%) self-identified as White individuals. A total of 496 respondents (59.8%) had ever used a statin, and 124 respondents (14.9%) had ever used a sedative-hypnotic. For both medications, the most preferred phrase to explain deprescribing focused on the risk of side effects. For statins, this phrase was 5.8-fold (95% CI, 5.3-6.3) more preferred than the least preferred option, which focused on the effort (treatment burden) involved in taking the medicine. For sedative-hypnotics, the phrase about side effects was 8.6-fold (95% CI, 7.9-9.5) more preferred over the least preferred option, "This medicine is unlikely to help you function better."

CONCLUSIONS AND RELEVANCE

These findings suggest that among older adults, the most preferred rationale for deprescribing both preventive and symptom-relief medicines focused on the risk of side effects. These results could be used to inform clinical practice and improve effective communications around deprescribing in older adults.

Association of Statin Use With Disability-Free Survival and Cardiovascular Disease Among Healthy Older Adults

BACKGROUND

There is clinical uncertainty regarding the benefits and harms of prescribing statins in healthy subjects ≥70 years of age.

OBJECTIVES

The aim of this study was to examine the association among statins, dementia-free and disability-free survival, and cardiovascular disease (CVD) among healthy older adults using data from the ASPREE (Aspirin in Reducing Events in the Elderly) trial.

METHODS

ASPREE was a randomized trial of 19,114 community-dwelling persons in Australia and the United States ≥65 years of age and free of documented CVD, dementia, and disability. Data were collected for those ≥70 years of age, and participants who took statins at baseline were compared with those who did not using Cox proportional hazards regression with inverse probability weighting. The primary outcome, referred to as "disability-free survival," was a composite of all-cause mortality, dementia, or persistent physical disability. Other outcomes included the individual components of the composite outcome, major adverse cardiovascular events, fatal CVD, myocardial infarction, and stroke.

RESULTS

Of the 18,096 included participants (median age 74.2 years, 56.0% women), 5,629 took statins at baseline. Over a median follow-up period of 4.7 years, baseline statin use was not associated with disability-free survival or with the risk for all-cause mortality or dementia. However, it was associated with lower risks for physical disability and all cardiovascular outcomes.

CONCLUSIONS

Among healthy community-dwelling adults ≥70 years of age, statin use may be beneficial for preventing physical disability and CVD but not beneficial for prolonging disability-free survival or avoiding death or dementia. Future clinical trials are needed to confirm these findings.

Lessons from my Elders on Recruitment and Retention into Health Research

In this brief report, the author shares lessons from Loretta Jones, MA and William Jenkins, PhD, two elders who shaped her research with communities that occupy intersecting marginalized categories. These lessons were echoed and amplified by the community panelists at the RCMAR workshop on recruitment and retention of diverse elders. They include centering the priorities of communities themselves, helping community members envision the types of positive transformations that research can help bring about, engaging and valuing the contributions of diverse sectors of the community, and recognizing the desire of aging individuals and communities to leave a legacy. Because heath care, research, and governmental institutions have engendered so much mistrust in racial/ethnic minority communities, researchers must learn first the particular histories and experience of the populations they intend to study. Equipped with this knowledge, cultural humility, and a willingness to listen, researchers can then use these strategies to earn the trust necessary for successful recruitment and retention in research.

Impact of an 8-Year Intensive Lifestyle Intervention on an Index of Multimorbidity

BACKGROUND/OBJECTIVES

Type 2 diabetes mellitus and obesity are sometimes described as conditions that accelerate aging. Multidomain lifestyle interventions have shown promise to slow the accumulation of age-related diseases, a hallmark of aging. However, they have not been assessed among at-risk individuals with these two conditions. We examined the relative impact of 8 years of a multidomain lifestyle intervention on an index of multimorbidity.

DESIGN

Randomized controlled clinical trial comparing an intensive lifestyle intervention (ILI) that targeted weight loss through caloric restriction and increased physical activity with a control condition of diabetes support and education (DSE).

SETTING

Sixteen U.S. academic centers.

PARTICIPANTS

A total of 5,145 volunteers, aged 45 to 76, with established type 2 diabetes mellitus and overweight or obesity who met eligibility criteria for a randomized controlled clinical trial.

MEASUREMENTS

A multimorbidity index that included nine age-related chronic diseases and death was tracked over 8 years of intervention delivery.

RESULTS

Among individuals assigned to DSE, the multimorbidity index scores increased by an average of .98 (95% confidence interval [CI] = .94-1.02) over 8 years, compared with .89 (95% CI = .85-.93) among those in the multidomain ILI, which was a 9% difference (P = .003). Relative intervention effects were similar among individuals grouped by baseline body mass index, age, and sex, and they were greater for those with lower levels of multimorbidity index scores at baseline.

CONCLUSIONS

Increases in multimorbidity over time among adults with overweight or obesity and type 2 diabetes mellitus may be slowed by multidomain ILI. J Am Geriatr Soc 68:2249-2256, 2020.

Thoughtful Prescribing and Deprescribing

Polypharmacy, the use of five or more medications, is common in older adults. It can lead to the use of potentially inappropriate medications and severe adverse outcomes. Deprescribing is an essential step of the thoughtful prescribing process and it can decrease the use of potentially inappropriate medications. Studies have demonstrated that deprescribing is feasible in the clinical setting, especially when it incorporates patient preferences, shared decision making, and an interdisciplinary team. Medication-specific algorithms can facilitate deprescribing in the clinical setting.

PURL: How old is too old for statins?

When to start, continue, or stop statins in those ages ≥ 75 years has been a quandary. Here's what 2 studies have to say.

Treating Dyslipidemias in the Primary Prevention of Atherosclerotic Cardiovascular Disease in Older Adults with Diabetes Mellitus

People with diabetes mellitus (DM), especially those who are older, are at higher risk for premature morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD). Clinical practice guidelines recommend statin therapy for people with DM ages 40 to 75 years. The evidence for those greater than 75 years of age is relatively limited at present. Other health problems should be considered when planning ASCVD primary prevention in adults ages greater than 75 years with DM. Clinicians should discuss the risks and benefits of each plan with these patients and their caregivers.

Prevalent Statin Use in Long-Stay Nursing Home Residents with Life-Limiting Illness

OBJECTIVES

To evaluate the prevalence and factors associated with statin pharmacotherapy in long-stay nursing home residents with life-limiting illness.

DESIGN

Cross-sectional.

SETTING

US Medicare- and Medicaid-certified nursing home facilities.

PARTICIPANTS

Long-stay nursing home resident Medicare fee-for-service beneficiaries aged 65 years or older with life-limiting illness (n = 424 212).

MEASUREMENTS

Prevalent statin use was estimated as any low-moderate intensity (daily dose low-density lipoprotein-cholesterol [LDL-C] reduction <30%-50%) and high-intensity (daily dose LDL-C reduction >50%) use via Medicare Part D claims for a prescription supply on September 30, 2016, with a 90-day look-back period. Life-limiting illness was operationally defined to capture those near the end of life using evidence-based criteria to identify progressive terminal conditions or limited prognoses (<6 mo). Poisson models provided estimates of adjusted prevalence ratios and 95% confidence intervals for resident factors.

RESULTS

A total of 34% of residents with life-limiting illness were prescribed statins (65-75 y = 44.0%, high intensity = 11.1%; >75 y = 31.1%, high intensity = 5.4%). Prevalence of statins varied by life-limiting illness definition. Of those with a prognosis of less than 6 months, 23% of the 65 to 75 and 12% of the older than 75 age groups were on statins. Factors positively associated with statin use included minority race or ethnicity, use of more than five concurrent medications, and atherosclerotic cardiovascular disease or risk factors.

CONCLUSION

Despite having a life-limiting illness, more than one-third of clinically compromised long-stay nursing home residents remain on statins. Although recent national guidelines have expanded indications for statins, the benefit of continued therapy in an advanced age population near the end of life is questionable. Efforts to deprescribe statins in the nursing home setting may be warranted. J Am Geriatr Soc 68:708-716, 2020.

Primary Prevention Statins in Older Adults: Personalized Care for a Heterogeneous Population

The 2018 American College of Cardiology/American Heart Association guidelines on the management of cholesterol acknowledge a lack of robust randomized clinical trial data to support routine use of statin therapy for primary prevention in adults older than 75 years. Shared decision making is emphasized because potential recommendations should reflect limitations of the current data, as well as heterogeneity of the older adult population, spanning the robust to the most frail. Although the National Institute on Aging recently funded PRagmatic EValuation of EvENTs And Benefits of Lipid-Lowering in OldEr Adults (PREVENTABLE), a trial to study benefits of statins in very old adults, data are not anticipated for 5 years. Thus interim guidance is essential. Furthermore, even when PREVENTABLE is completed, individual idiosyncrasies among older adults suggest that decisions for each patient will still need to be personalized, relative to their unique clinical situation. In this article, we present three case studies to highlight dynamics that commonly impact choices regarding statins in older adults. Details underlying shared decision making are also described including the evolving application of coronary artery calcium to inform this practice. J Am Geriatr Soc 68:467-473, 2020.

Association between Statin Use and Physical Function among Older Chinese Inpatients with Type 2 Diabetes

PURPOSE

Multiple statin-associated muscle symptoms (SAMS) risk factors usually coexist in a given older diabetic patient, but the association between statin use and physical function in older Asian persons with T2MD remains uncertain. The present study therefore sought to provide insight into this uncertainty through a focused assessment of statin-associated outcomes in Chinese diabetic adults.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included 146 participants with T2MD in the Center of Gerontology and Geriatric, West China Hospital.

MEASUREMENTS

The participants received the comprehensive geriatric assessment (CGA). Statin use and other medical data for each patient were determined via assessment of the inpatient hospital information system. Assessments of physical functions included ADLs, IADLs and the Timed "Up and Go" (TUG) test. Multiple regression analyses were then performed in order to determine the relationship between statin utilization and physical function.

RESULTS

The average age of these 146 participants (32 women, 21.9%) was 80.00±5.60 years. At enrollment, 78 (53.4%) of the 146 patients were treated with statins. Among the statin users, 48.7% presented with a lack of TUG ability, which was significantly greater than in non-statin users (27.9%). However, the rates of IADL and ADL disabilities did not differ significantly between groups. In a multiple regression analyses, statin use was associated with a three-fold (95% CI 1.06, 9.51) increase in the risk of TUG inability, after adjusted all covariates.

CONCLUSIONS

There was a significant association between statin use and TUG inability in older Chinese inpatients with diabetes.

Treatment of hypercholesterolaemia in older adults calls for a patient-centred approach

Due to an increasing number of older adults with (risk factors for) cardiovascular disease (CVD), the sum of older adults eligible for lipid-lowering drugs will increase. This has risen questions about benefits and harms of lipid-lowering therapy in older adults with a varying number of (cardiovascular) comorbidities and functional status. The heterogeneity in physical and functional health increases with age, leading to a much wider variety in cardiovascular risk and life expectancy than in younger adults. We suggest treatment decisions on hypercholesterolaemia in adults aged ≥75 years should shift from a strictly 10-year cardiovascular risk-driven approach to a patient-centred and lifetime benefit-based approach. With this, estimated 10-year risk of CVD should be placed into the perspective of life expectancy. Moreover, frailty and safety concerns must be taken into account for a risk–benefit discussion between clinician and patient. Based on the Dutch addendum ‘Cardiovascular Risk Management in (frail) older adults’, our approach offers more detailed information on when not to initiate or deprescribe therapy than standard guidelines. Instead of using traditional risk estimating tools which tend to overestimate risk of CVD in older adults, use a competing risk adjusted, older adults-specific risk score (available at https://u-prevent.com). By filling in a patient’s (cardiovascular) health profile (eg, cholesterol, renal function), the tool estimates risk of CVD and models the effect of medication in terms of absolute risk reduction for an individual patient. Using this tool can guide doctors and patients in making shared decisions on initiating, continuing or deprescribing lipid-lowering therapy.

Statins for Primary Prevention in Those Aged 70 Years and Older: A Critical Review of Recent Cholesterol Guidelines

The risk of atherosclerotic cardiovascular disease rises with age and remains the leading cause of death in older adults. Evidence for the use of statins for primary prevention in older adults is limited, despite the possibility that this population may derive significant clinical benefit given its increased cardiovascular risk. Until publication of the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the Management of Blood Cholesterol, and the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, guidelines for statin prescription in older adults remained unchanged despite new evidence of possible benefit in older adults. In this review, we present key updates in the 2018 and 2019 guidelines and the evidence informing these updates. We compare the discordant recommendations of the seven major North American and European guidelines on cholesterol management released in the past 5 years and highlight gaps in the literature regarding primary prevention of cardiovascular disease in older adults. As most cardiovascular events in older adults are nonfatal, we ask how clinicians should weigh the risks and benefits of continuing a statin for primary prevention in older adults. We also reframe the concept of deprescribing of statins in the older population, using the Geriatrics 5Ms framework: Mind, Mobility, Medications, Multi-complexity, and what Matters Most to older adults. A recent call from the National Institute on Aging for a statin trial focusing on older adults extends from similar concerns.

Benefits, risks and impacts on quality of life of medications used in multimorbid older adults: a Delphi study

Background Multimorbidity and polypharmacy are common in older people. Despite the existence of quality criteria for medication use among this population, there is little guidance for managing the complex pharmacological arsenal in a multimorbidity context. Objective To establish consensus on benefits, risks and impacts on quality of life of medications used in an older adult with three chronic diseases that require complex pharmacotherapy. Setting International experts in pharmacology. Method A panel of experts responded to three rounds of a Delphi survey. They assessed the benefits, risks and positive impacts on quality of life of 50 different medications or medication classes that could be used by a hypothetical multimorbid older patient aged 65-75 years, with type 2 diabetes, heart failure and chronic obstructive pulmonary disease. Each aspect was evaluated on a 5-level Likert scale. Main outcome measure Percentage of agreement on each of the three aspects for all medication. Results Consensus was reached on 95% of items (166/174). Only two medication classes were associated with both the highest category of benefits and positive impacts on quality of life, and the lowest risk category: long-acting anticholinergics and long-acting beta-2-agonists. Nine other medications/classes of medications were categorized within the highest benefits level (metformin, DPP-4-inhibitors, short-acting beta-2-agonists, ACE inhibitors, beta-blockers, warfarin, non-vitamin K oral anticoagulants, nitrates and acetaminophen). Fifteen medications were included in the highest level of risks, among which warfarin and Non-vitamin K oral anticoagulants. Conclusions Medications recommended in clinical guidelines for individual diseases are generally considered positive for multimorbid older patients. Nevertheless, a non-negligible number of medications was deemed negative or very negative by our panelists. For multimorbid patients, individualizing treatment according to their preferences seems of utmost importance.

Long-Acting Injectable Statins-Is It Time for a Paradigm Shift?

In recent years, advances in pharmaceutical processing technologies have resulted in development of medicines that provide therapeutic pharmacokinetic exposure for a period ranging from weeks to months following a single parenteral administration. Benefits for adherence, dose and patient satisfaction have been witnessed across a range of indications from contraception to schizophrenia, with a range of long-acting medicines also in development for infectious diseases such as HIV. Existing drugs that have successfully been formulated as long-acting injectable formulations have long pharmacokinetic half-lives, low target plasma exposures, and low aqueous solubility. Of the statins that are clinically used currently, atorvastatin, rosuvastatin, and pitavastatin may have compatibility with this approach. The case for development of long-acting injectable statins is set out within this manuscript for this important class of life-saving drugs. An overview of some of the potential development and implementation challenges is also presented.

Genetically-predicted life-long lowering of low-density lipoprotein cholesterol is associated with decreased frailty: A Mendelian randomization study in UK biobank

Background

High circulating low-density lipoprotein cholesterol (LDL-C) is a major risk factor for atherosclerosis and age-associated cardiovascular events. Long-term dyslipidaemia could contribute to the development of frailty in older individuals through its role in determining cardiovascular health and potentially other physiological pathways.

Methods

We conducted Mendelian randomization (MR) analyses using genetic variants to estimate the effects of long-term LDL-C modification on frailty in UK Biobank (n = 378,161). Frailty was derived from health questionnaire and interview responses at baseline when participants were aged 40 to 69 years, and calculated using an accumulation-of-deficits approach, i.e. the frailty index (FI). Several aggregated instrumental variables (IVs) using 50 and 274 genetic variants were constructed from independent single-nucleotide polymorphisms (SNPs) to instrument circulating LDL-C concentrations. Specific sets of variants in or near genes that encode six lipid-lowering drug targets (HMGCR, PCSK9, NPC1L1, APOB, APOC3, and LDLR) were used to index effects of exposure to related drug classes on frailty. SNP-LDL-C effects were available from previously published studies. SNP-FI effects were obtained using adjusted linear regression models. Two-sample MR analyses were performed with the IVs as instruments using inverse-variance weighted, MR-Egger, weighted median, and weighted mode methods. To address the stability of the findings, MR analyses were also performed using i) a modified FI excluding the cardiometabolic deficit items and ii) data from comparatively older individuals (aged ≥60 years) only. Several sensitivity analyses were also conducted.

Findings

On average 0.14% to 0.23% and 0.16% to 0.31% decrements in frailty were observed per standard deviation reduction in LDL-C exposure, instrumented by the general IVs consisting of 50 and 274 variants, respectively. Consistent, though less precise, associations were observed in the HMGCR-, APOC3-, NPC1L1-, and LDLR-specific IV analyses. In contrast, results for PCSK9 were in the same direction but more modest, and null for APOB. All sensitivity analyses produced similar findings.

Interpretation

A genetically-predicted life-long lowering of LDL-C is associated with decreased frailty in midlife and older age, representing supportive evidence for LDL-C's role in multiple health- and age-related pathways. The use of lipid-lowering therapeutics with varying mechanisms of action may differ by the extent to which they provide overall health benefits.

Role of Statin Therapy in Primary Prevention of Cardiovascular Disease in Elderly Patients

Purpose of Review

Hypercholesterolemia and statin treatment are nowadays common among people older than 75 years, but clinical heterogeneity in this increasing age group is wide, and treatment decisions may differ from those in younger patients. Aim is to discuss the presentation, modifying factors, and treatment decisions of hypercholesterolemia (usually with statins) in older persons and focusing on primary prevention.

Recent Findings

There are no randomized controlled trials in persons older than 80 years at baseline. Randomized controlled trial findings in younger patients and 75+ subgroups and in observational studies support treatment in secondary prevention of atherosclerotic cardiovascular disease (ASCVD), but trial evidence in primary prevention is less clear. Available data do not imply specific harms in older patients, and, therefore, also, judicious primary prevention is possible. However, persons older than 75 years are biologically a very heterogeneous group with frequent frailty, comorbid conditions, and multiple concomitant drugs. All these, as well as personal preferences, must be taken into account in treatment decisions.

Summary

Statin treatment is only one way to prevent ASCVD in older people. Treatment of hypercholesterolemia should be started far before 75–80 years, and there is no need to discontinue statin treatment due to chronological age alone. After 75 years, treatment should be started in patients with ASCVD and judiciously in primary prevention. Like all prevention, statin treatment should be discontinued when palliative treatment is started. Ongoing and planned trials in 70+ individuals will give more information about primary prevention in older persons.

Management of high cholesterol levels in older people

The management of hypercholesterolemia in older adults still represents a challenge in clinical medicine. The pathophysiological alterations of cholesterol metabolism associated with aging are still incompletely understood, even if epidemiological evidence suggests that serum cholesterol levels increase with ongoing age, possibly with a plateau after the age of 80 years. Age is also one of the main determinants of cardiovascular disease, according to all cardiovascular risk estimate tools. Cholesterol-lowering treatment, therefore, would be expected to bring significant protection, even in these patients. Unfortunately, direct experimental evidence is extremely limited, particularly in the very old age strata of the population; a clinical benefit still seems to be present, but the risk for drug-related adverse events is clearly higher. At any rate, at the present time, definite guidelines for the correct management of hypercholesterolemia in older patients are not available. Therefore, the decision whether or not a pharmacological treatment should be set up, and the choice of the drug, need to be tailored to the individual patient, and requires accurate clinical judgment. The specific aspects of frailty and disability, along with the actual age of the patients, have to be considered together, with a comprehensive assessment approach. The present review summarizes the evidence regarding the modifications of cholesterol metabolism in older patients, the impact of lipid-lowering drugs on cardiovascular outcomes and focuses on the considerations that can help to define the most appropriate treatment strategy, in view of the individual functional profile. Geriatr Gerontol Int 2019; 19: 375-383.

Use of statins in the elderly according to age and indication-a cross-sectional population-based register study

PURPOSE

To investigate statin use in the elderly by age (≥ 80 vs. 65-79 years) in relation to established indications.

METHODS

A population-based cohort, including data from four registers, encompassing inhabitants in Region Västra Götaland, Sweden, was used. Statin users were defined as those filling statin prescriptions ≥ 75% of the year 2010. Primary care and hospital diagnoses in 2005-2010 regarding ischemic heart disease, stroke, transient ischemic attacks, and diabetes were considered established indications.

RESULTS

A total of 278,205 individuals were analyzed. In individuals aged ≥ 80 and 65-79 years (n = 81,885 and n = 196,320, respectively), 17% (95% confidence interval 17%; 18%) and 23% (23%; 23%) respectively, were statin users. Among the statin users, 74% (73%; 74%) of those aged ≥ 80 and 60% (59%; 60%) of those aged 65-79 years had ≥ 1 established indication. Conversely, of those with ≥ 1 established indication, 30% (30%; 31%) and 53% (52%; 53%) were on statins in the respective age groups. Logistic regression revealed that age, nursing home residence, and multi-dose drug dispensing were the most prominent negative predictors for statin use; adjusted odds ratios (95% confidence interval): 0.45 (0.44; 0.46), 0.39 (0.36; 0.42), and 0.47 (0.44; 0.49), respectively.

CONCLUSIONS

In the oldest old (≥ 80 years), statin users were fewer and had more often an established indication, suggesting that physicians extrapolate scientific evidence for beneficial effects in younger age groups to the oldest, but require a more solid ground for treatment. As the oldest old, nursing home residents, and those with multi-dose drug-dispensing were statin users to a lesser extent, physicians may often refrain from treatment in those with lower life expectancy, either due to age or to severely reduced health status. In both age groups, our results however also indicate some over- as well as undertreatment.

AGS Report on Engagement Related to the NIH Inclusion Across the Lifespan Policy

After passage of the 21st Century Cures Act, the National Institutes of Health held a workshop in 2017 to consider expanding its inclusion policy to encompass individuals of all ages. American Geriatrics Society (AGS) leaders and members participated in the workshop and formal feedback period. AGS advocacy clearly impacted the resulting workshop report and Inclusion Across the Lifespan policy that eliminates upper-age limits for research participation unless risk justified and changes the language used to describe older adults and other vulnerable groups. AGS recommendations that were not specifically stated in the updated policy were to encourage active recruitment of older adults, add standard measures of function and/or frailty, and change review criteria to ensure the health status of a study population mirrors typical clinical populations. The updated inclusion policy ultimately offers academic geriatrics programs the opportunities to expand knowledge about health in aging and to continue to provide leadership for research and advocacy efforts on behalf of older adults. J Am Geriatr Soc 67:211-217, 2019.

Correction of Hypercholesterolemia in Primary and Secondary Prevention of Cardiovascular Diseases: Features and Controversial Issues

The article discusses the current prevalence of hypercholesterolemia in everyday clinical practice in patients of different risk categories and approaches to its correction in the most frequently used clinical guidelines. High prevalence of hypercholesterolemia in practical health care with little change over time is shown. The existing problems of the practical implementation of the principles of a healthy lifestyle as the basis for reducing cardiovascular risk and possible solutions are described. Attention is focused on a low number of patients taking statins, and even less – reaching recommended target cholesterol levels. It is emphasized the validity of lower, compared to previous, target cholesterol levels in National recommendations on the correction of dyslipidemia in patients with proven atherosclerosis-related cardiovascular diseases as well as the feasibility in some cases of combined lipidlowering therapy (statins in combination with intestinal cholesterol absorption blockers, PCSK9 inhibitors, high doses of ethyl eicosopentaenoic acid). It is commented the need to prescribe statins in persons older than 75 years, but with a careful approach. Particular attention is paid to the use of statins in the primary prevention of cardiovascular complications. The validity of prescribing fixed moderate doses of statins for this purpose is discussed, which is both scientifically based and more realistic in practical terms.