Why the Controversy?The controversy about treating cholesterol in older people stems from the fact that these individuals have been systematically excluded from most of the clinical trials proving the benefits of cholesterol treatment.
It is unfortunate that drug trials of all types have often purposely avoided enrolling elderly patients. This is not because drug companies consider older people to be unworthy of their attention, but rather for practical and economic reasons. Older people have a reduced life expectancy, so some of them are likely to die during the course of a long clinical trial for reasons completely unrelated to the treatment being tested. Also, older people tend to have more than one medical condition, and so often have an array of symptoms — which might then be incorrectly attributed to the test drug. Such "extraneous" deaths and symptoms can greatly complicate the analysis of a clinical trial, and might even threaten the eventual FDA approval of a new drug. So it's been easier (and cheaper) to just leave old people out of many clinical trials.
This exclusionary practice means that we know relatively little about the specific benefits and risks of treating elevated cholesterol levels in older people. And this, in turn, means that when an older patient has high cholesterol levels, doctors are often unsure if they should offer treatment.
Cholesterol and Cardiovascular Disease in the ElderlyIn people of both sexes over the age of 65, cardiovascular disease accounts for more than half of all deaths. In comparison, cancer produces "only" 24% of deaths in men in this same age group, and 20% in women. So a treatment that might reduce the risk of cardiovascular disease in older people should be a desirable thing.
Furthermore, elevated cholesterol is associated with an increased risk of heart disease in older people just as much as it is in younger people. In fact, at least some evidence suggests that cholesterol may be an even more important predictor of risk in older than in younger people.
Is It Useful To Lower Cholesterol Levels in Older People?Despite the fact that evidence from clinical trials on the benefits of cholesterol treatment is less definitive for older than younger patients, the preponderance of evidence nonetheless suggests that treating elevated cholesterol in older people is something that at least ought to be strongly considered.
Sufficient data is available from several of the randomized clinical trials on cholesterol therapy to permit subgroup analyses in older people. Studies pooling data from some of these trials have concluded that cardiac outcomes can be improved by treating elevated cholesterol levels with statin drugs in older people at least as much as in younger people. Furthermore, the reduction in cardiovascular risk in older people is often seen within just a few months of beginning therapy, so despite the fact that these patients are old, they're not "too old" to experience the benefits of cholesterol lowering with statins.
So while the potential benefits of cholesterol-lowering are less definitively proven in older people than in younger people, the best indications are that there is indeed a substantial benefit to treating cholesterol in the elderly.
What About the Side Effects of Statins in Older People?The available data further indicates that the incidence of side effects from statins is not any higher in older patients than it is in younger patients, but both doctors and patients must take into account that some of the potential side effects of statins (such as muscle problems and cognitive disorders) may be much more consequential in older than younger patients.
The Bottom LineIf you are an older person with elevated cholesterol levels, then despite the lack of definitive "proof" that treating your cholesterol is beneficial, enough evidence exists to make it a good idea to at least have a discussion about cholesterol therapy with your doctor.
For older people who have a lot of medical problems, the potential risks of adding yet another medication to an already complex drug regimen may very well outweigh the potential benefits. But for healthy older people with high cholesterol levels, cholesterol-lowering therapy ought to be seriously considered.
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