Primary prevention: do the very elderly require a different approach?

Abstract

Recent cardiovascular prevention guidelines place a greater emphasis on randomized placebo-controlled trial data as the basis for recommendations. While such trial data are sparse for people over the age of 75 or 80 years, data demonstrate altered risk-benefit relationships in these older patients. Primary prevention strategy decisions should consider estimated life expectancy and overall function as well as cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. Data support treatment of systolic hypertension to reduce stroke, cardiovascular events, and dementia in older patients with at least a 2-year estimated lifespan with modifications in systolic blood pressure goals and a need for greater attention to non-cardiovascular side effects such as falls in the very old. Lowering of elevated cholesterol levels with HMG-CoA reductase inhibitors for primary prevention in people over the age of 75 years requires greater individual considerations, as benefits may not accrue for 3-5 years and there is the potential impact of adverse effects. There is a rationale for lipid-lowering treatment in the more highly functional older patient with cardiovascular (especially stroke) risk higher than side effect risks in the near term and with an estimated lifespan longer than the time to benefit. Aspirin has higher side effect risks and requires a longer time to achieve benefit. Trial data are lacking on exercise interventions, but multi-system benefits have been shown in older patients such that exercise should be part of a preventive regimen. Preventive therapy in the very old means considering not only medical issues of co-morbidities, polypharmacy, and altered risk-benefit relationship of medications but also adjusting goals and approaches across the older agespan in keeping with informed patient preferences.

Figure 1

Life expectancy estimates for older persons are shown by sex, co-morbidity, and functional status. Average life expectancy is represented by the solid black line. Data based on co-morbid status and for heart failure are from a sample of the Medicare population recently reported by Cho, et al. (3) Low/medium co-morbidity conditions were history of M.I., ulcer, acute M.I., rheumatologic disease, peripheral artery disease, diabetes, paralysis, cerebrovascular disease; high co-morbidity conditions were chronic obstructive pulmonary disease, heart failure, moderate/severe liver disease, chronic renal failure, dementia, cirrhosis/chronic hepatitis, AIDS). The shaded area represents the range of co-morbid conditions (no co-morbid conditions are represented by the green solid line; medium to low co-morbidity by the orange line, to high co-morbid health status represented by the solid red line. Heart failure data are represented by the solid blue line. Data based on functional status, are from the Established Populations for Epidemiologic Studies of the Elderly as reported by Keeler, et al. (4) ADL= activities of daily living bathing and showering, dressing, Eating/feeding (including chewing and swallowing), Functional mobility (moving from one place to another while performing activities), personal hygiene and grooming (including brushing/combing/styling hair) and toilet hygiene; mobility impaired was defined as inability to walk half a mile and/or walk up a flight of stairs without help. Total independent status is represented by the green dashed line, mobility impairment by the brown dashed line, and ADL impairment by the red dashed line. Life expectancy declines as age increases but varies by sex, co-morbidities and functional status. Life expectancy is shortest in those with heart failure and in those with impairment in ADLs and longest in those without co-morbidities who function independently.