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.