Management of older adults with hypercholesterolaemia.

Although the strength of total cholesterol levels as a relative risk factor for coronary heart disease (CHD) declines with age, the prevalence of CHD increases dramatically with age. Data from cholesterol treatment trials, although sparse in older adults, suggest that dyslipidaemia treatment has the potential to prevent CHD. In particular, dyslipidaemia treatment appears to be most beneficial in older adults with a history of CHD or who have several other CHD risk factors. Dyslipidaemia screening should be selective in the elderly, reserved for those whose health status would be amenable to nutritional or pharmacological therapy, and in whom several CHD risk factors or a history of CHD are present. Since high density lipoprotein cholesterol (HDL) levels retain their inverse association CHD in old age, cholesterol subfractions should be measured in persons being screened in order to adequately assess the severity of dyslipidaemia. Treatment decisions should be guided by the patient's dyslipidaemic class, which is determined by the cholesterol subfractions and serum triglycerides (TG). As in younger persons, nutritional therapy remains the first step in dyslipidaemia management in high risk, nondebilitated older adults. An array of cholesterol modifying medications are available which vary widely in treatment effects, adverse effects and cost. Extra care needs to be taken in prescribing these agents in older adults because of greater potential for adverse effects and interactions with other medications. The cost-effectiveness of pharmacological treatment decreases with age and increases with the severity of dyslipidaemia, a history of CHD, or the presence of multiple CHD risk factors. When comparing elderly to middle-aged adults, the relative cost-effectiveness of different cholesterol-lowering medications may be altered due to age-related changes in therapeutic efficacy and adverse effects.