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Department of Medicine, Divisions of 1 Geriatrics
2 Cardiology, Westchester Medical Center/New York Medical College, Valhalla.
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Abstract |
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Methods. In an academic nursing home, we investigated the prevalence of use of lipid-lowering drugs in persons, mean age 77 ± 9 years (40% men and 60% women), with a serum LDL cholesterol 
100 mg/dl associated with the aforementioned ailments before and after a 5-month educational program on the treatment of dyslipidemia was given to physicians and nurse practitioners.
Results. After the educational program, the prevalence of use of lipid-lowering drugs to treat the targeted elderly population increased (p <.001) in persons with CAD from 29% (18 of 63 persons) to 70% (44 of 63 persons), in persons with symptomatic PAD from 28% (5 of 18 persons) to 79% (15 of 19 persons), in persons with prior stroke from 24% (11 of 45 persons) to 64% (28 of 44 persons), and in diabetics from 26% (14 of 53 persons) to 67% (35 of 52 persons).
Conclusion. A 5-month educational program on dyslipidemia treatment given to physicians and nurse practitioners in an academic nursing home improved the prevalence of use of lipid-lowering drugs in persons with increased serum LDL cholesterol associated with CAD, symptomatic PAD, prior stroke, and diabetes mellitus.
ELDERLY persons with an increased serum low-density lipoprotein (LDL) cholesterol associated with coronary artery disease (CAD), peripheral arterial disease (PAD), prior stroke, and diabetes mellitus should be treated with lipid-lowering drug therapy (1–4). We previously reported that, in an academic nursing home, lipid-lowering drug therapy was used in only 16 of 77 persons (21%) with CAD who had no contraindications to lipid-lowering drugs (5). In that study, serum LDL cholesterol was measured in only 22 of the 61 persons (36%) with CAD not treated with statins and was increased in 14 of these 22 persons (64%).
After the results of that study were available, one of the investigators (Aronow) discussed the results with the two geriatrics fellows, four staff physicians, and three nurse practitioners taking care of the patients in the academic nursing home. Aronow also discussed the evidence for obtaining serum lipids in all elderly persons with CAD, PAD, prior stroke, and diabetes mellitus and for treating these persons with dyslipidemia with lipid-lowering drugs in the absence of contraindications to these drugs.
Two months later, one of the geriatrics fellows (Ghosh) and Aronow found that all persons with CAD, PAD, prior stroke, and diabetes mellitus in the nursing home had measurements of serum total cholesterol, serum LDL cholesterol, serum high-density lipoprotein cholesterol, and triglycerides, but that the utilization of lipid-lowering drug therapy was low in these four subgroups. Aronow then began an educational program focusing on why elderly persons with dyslipidemia associated with CAD, PAD, prior stroke, and diabetes mellitus should be treated with lipid-lowering drugs in the absence of contraindications to these drugs. This article reports the prevalence of use of lipid-lowering drugs in elderly persons with an increased serum LDL cholesterol associated with these ailments in an academic nursing home before and 5 months after an educational program on the treatment of dyslipidemia.
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Methods |
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100 mg/dl associated with either documented CAD, symptomatic PAD, prior stroke, or diabetes mellitus. Patients were excluded from this study if they had a limited life expectancy, comorbidities contraindicating the use of lipid-lowering drugs, or were younger than 59 years of age. Dementia was not a contraindication. None of the patients in this study were on medications increasing the incidence of myopathy in patients treated with lipid-lowering drugs. CAD was diagnosed if the person had either prior coronary revascularization, coronary angiographic evidence of significant CAD, documented myocardial infarction, or typical angina pectoris. Symptomatic PAD and prior stroke were diagnosed as previously described (6). Diabetes mellitus was diagnosed according to the American Diabetes Association's new criteria (7).
Aronow discussed the results of the initial chart review with the two geriatrics fellows, the four staff physicians, and the three nurse practitioners taking care of the patients, and he gave a 1-hour lecture on another day on the treatment of elderly persons with dyslipidemia. The 80-slide lecture on the treatment of dyslipidemia in the elderly included epidemiologic data on the association of serum lipids with vascular disease in the elderly; randomized, controlled data on the use of statins to reduce mortality, coronary events, stroke, PAD, and congestive heart failure in elderly persons with cardiovascular disease; randomized, controlled data on the use of statins to reduce cardiovascular mortality and morbidity in elderly persons without cardiovascular disease; observational, prospective data from nursing home patients showing the reduction by statins of coronary events, stroke, and congestive heart failure in patients with prior CAD, mean age 81 years, the reduction by statins of coronary events in patients with symptomatic PAD, mean age 80 years, and reduction by statins of coronary events and stroke in patients with diabetes mellitus and CAD, mean age 79 years; mechanisms of actions of statins in reducing coronary events and stroke; American College of Cardiology/American Heart Association guidelines for treating dyslipidemia in patients with atherosclerotic vascular disease; recommendations made by the Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (NCEP III); and the like.
During the 5-month period, Aronow distributed articles on the treatment of dyslipidemia in elderly persons to the staff physicians, geriatrics fellows, and nurse practitioners, and he made appropriate comments to them when indicated on the treatment of dyslipidemia during weekly geriatric conferences and at his monthly lecture to the Division of Geriatrics. The articles distributed to the staff prescribing lipid-lowering medications included the NCEP III guidelines, as well as research papers and review articles on the treatment of elderly persons with dyslipidemia residing in the community and in the nursing home.
After 5 months of this educational program, the utilization of lipid-lowering drug therapy was again assessed by chart review by Ghosh.
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Results |
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Discussion |
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Observational data have also shown that the use of statins is associated with a lower prevalence of vascular dementia and Alzheimer's disease and with a beneficial effect on the progression of cognitive impairment in older persons (19). However, prospective, randomized, double blind, placebo-controlled trials have to be performed to investigate the effect of statins on the development and progression of vascular dementia and of Alzheimer's disease.
In the Heart Protection Study, 20,536 adults up to age 80 years with CAD, other occlusive arterial disease, or diabetes mellitus were randomized to simvastatin 40 mg daily or double-blind placebo and followed for a mean of 5 years (20). All-cause mortality, coronary events, stroke, and coronary and noncoronary revascularization were significantly reduced by simvastatin, regardless of age and initial serum lipids (20).
On the basis of the available data, NCEP III recommends lowering the serum LDL cholesterol to <100 mg/dl in persons with CAD, other clinical forms of atherosclerotic vascular disease, diabetes mellitus, and the metabolic syndrome, and in persons with two or more risk factors that confer a 10-year risk for CAD of >20% (2). These guidelines also recommend no age restriction for treatment of elderly persons with lipid-lowering drug therapy if they have CAD or are at higher risk for CAD because of multiple risk factors or advanced subclinical atherosclerosis (2). Despite these guidelines, lipid-lowering drugs are underutilized in elderly persons with CAD (21–23). Although all of the persons treating patients with dyslipidemia in the nursing home in this study were familiar with the NCEP III guidelines, they were not following them prior to the educational program on treating dyslipidemia in the elderly.
Conclusions
The present study showed that an educational program on treating dyslipidemia in the elderly can lead physicians and nurse practitioners to obtain serum lipids in elderly persons with CAD, PAD, prior stroke, and diabetes mellitus. After 5 months of such an educational program, the prevalence of treatment of increased serum LDL cholesterol in elderly persons in this nursing home increased from 29% to 70% in elderly persons with CAD, from 28% to 79% in elderly persons with significant PAD, from 24% to 64% in elderly persons with prior stroke, and from 26% to 67% in elderly diabetics. The investigators in this study concluded that the reason for increased compliance after the educational program was actual incorporation and agreement on new knowledge and treatment paradigms. These data favor incorporating such a program into the curriculum for all fellows in geriatrics.
However, one limitation of this study was that it was nonrandomized. Whether the use of nurses as case managers after an educational program on treating dyslipidemia in the elderly will improve appropriate utilization of lipid-lowering drugs has to be investigated in a nursing home setting. Whether an educational program on treating dyslipidemia in the elderly would be effective in a nonclosed nursing home setting also has to be investigated.
Physician education through the use of journal articles, lectures, and audits with physician feedback has to be intensified to provide better medical care to elderly persons with CAD, significant PAD, prior stroke and diabetes mellitus with dyslipidemia through the use of optimal doses of drugs found to be effective and safe by evidence-based studies.
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Acknowledgments |
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Received June 18, 2002
Accepted July 12, 2002
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References |
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125 mg/dL treated with statins versus no lipid-lowering drug. Am J Cardiol.. 2002;89:67-69.[Medline]
125 mg/dl treated with statins versus no lipid-lowering drug. Am J Cardiol.. 2002;90:789-791.[Medline]
125 mg/dl treated with statins versus no lipid-lowering drug. J Gerontol Med Sci.. 2002;57A:M333-M335. 125 mg/dl treated with statins versus no lipid-lowering drug. Am J Cardiol.. 2002;90:147-149.[Medline]
125 mg/dl treated with statins. J Gerontol Med Sci.. 2002;57A:M747-M750.This article has been cited by other articles:
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  J. Afilalo, G. Duque, R. Steele, J. W. Jukema, A. J.M. de Craen, and M. J. Eisenberg Statins for secondary prevention in elderly patients: a hierarchical bayesian meta-analysis. J. Am. Coll. Cardiol., January 1, 2008; 51(1): 37 - 45. [Abstract] [Full Text] [PDF]
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 S. S Tomlinson and K. K Mangione Potential Adverse Effects of Statins on Muscle Physical Therapy, May 1, 2005; 85(5): 459 - 465. [Full Text] [PDF]
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