By Andre Davies, M.D., Board Certified in Internal Medicine & Geriatrics
Heart health is a critical concern for individuals of all ages, but it becomes increasingly important as we age. Geriatric patients are more susceptible to cardiovascular diseases due to age-related changes. Physicians promote a mixture of lifestyle modifications, diet changes, and medications to improve cardiovascular outcomes. One of the most utilized medication classes are cholesterol lowering agents.
Statins are one type of cholesterol lowering medications, and they are most often a first line option for therapy. For certain patients who have elevated levels of cholesterol, or who have other risk factors like type 2 diabetes, for example, taking a statin can reduce their risk of having poor health outcomes related to heart disease or stroke. Many patients begin screening tests for high cholesterol at the age of 40 at their annual physical exam, and there are clear guidelines on when patients should begin taking a statin.
A common question I’m asked in clinic by patients is, “when can I stop taking my statin”? By the time the patient has come to the appointment, they are already tuned into the conversation about indefinite statin treatment: they have digested articles from the internet, they have listened to specials on the topic in the media, and sometimes they know of a friend whose doctor recently stopped their statin. The answer, of course, is “it’s complicated.”
While the benefits of statins for patients between the ages of 40 and 75 are well established, they are less clear for patients with ages above 75. Many of the earlier studies that looked at the risk- lowering- effects of statins do not include patients older than 75. As a result, it can be challenging to translate the findings for adults with advanced ages. Additionally, the guidelines are not always clear on what to do with those over 75 when it comes to starting and stopping statins. Research also shows that many primary care physicians are uncomfortable with stopping medications like statins.
As a board-certified geriatrician, re-evaluating a patient’s medication list and identifying medications eligible for deprescribing is a critical and routine part of my practice. The concept of deprescribing is to review medications that may no longer be helping, or may even be harmful, and discontinuing them. Many of my patients, by the time they are in their late 70s and 80s, have accrued a long list of medications and supplements, some of which may have been started decades ago. I try to evaluate the patient as a whole. I take into account their medical history, as well as their specific health goals, and then I partner with them to make decisions on deprescribing.
For many of my patients, continuing to take their statin makes sense. Research has demonstrated benefits in continuing to take statins for patients with known cardiovascular disease, a stroke history, or a history of type 2 diabetes, for instance, and so it is an easy decision to make. For other patients, who are taking a statin for primary prevention, they may still have a cardiovascular or stroke risk lowering benefit, even between the ages of 75-85. There are screening tests, like CT calcium scores, that we sometimes do in the clinic to help stratify these patients into different risk categories, and these tests may help us make better informed decisions about deprescribing.
But even in these cases, the conversation can become complex. These same patients may be most at risk for frailty syndrome, declining health, and shortened life expectancy. They may struggle with polypharmacy issues, cognitive impairment, or intolerance to statins. In these situations, there are little to no guidelines, and I work closely with my patients to make a tailored decision on whether to deprescribe the statin.
Making a tailored plan means listening closely to your patient. In the geriatric’s world, we have a philosophy called the 5 M’s, and it is a framework for thinking about the whole patient. They stand for assessing the patient’s Mind, Mobility, Medications, Medical issues, and importantly, what Matters Most to the patient. What are their goals? What is their functional status? I try to mesh their goals with their personal medical history in order to help them decide what to do with their statin. Luckily, there are ongoing trials looking at statins in the elderly, which will hopefully help to streamline answer to whether to stop statins or not. But until then, the issue remains a complex answer, which requires connecting the dots between your personal medical history, your specific goals, and a little art of medicine.
As a board-certified Geriatrician & Internal Medicine physician, my goal is to promote heart health and provide comprehensive care to all my patients. By focusing on prevention, early detection, medication management, comprehensive care, and promoting a good quality of life, we can help patients maintain optimal heart health. It is through a collaborative and patient-centered approach that we can make a significant impact on the cardiovascular well-being of our older population.
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Naples, FL 34102
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Naples, FL 34109
www.gulfshoreconciergemedicine.com