Older Adults Need Better Treatment of Cardiovascular Risk Factors

Source: Tufts University
June 20, 2002 (Reviewed: June 29, 2004)

Health professionals need no reminder that cardiovascular disease is the number one killer in the USA and in many other countries of the world, despite the fact that we know quite a bit about how to control the risk factors associated with it. There remains a major gap between what we know about how to control risk factors and our success in bringing those risk factors under control. The extent of the gap, especially among those with type 2 diabetes, was quantified in a recent analysis of data from a large population of older adults. The results are published in the Journal of the American Geriatrics Society.

Measuring risk factors

University of Washington researchers conducted a secondary analysis of data from a population-based, prospective cohort study of risk factors for cardiovascular disease in a group of 5,888 community-dwelling people aged 65 and older. They wanted to determine the prevalence of cardiovascular risk factor control in people with and without diabetes.

The analysis took into account medical and personal history data, including presence of disease, medication use, smoking status, weight, and physical activity. Measurements of fasting plasma glucose, serum cholesterol and its sub-fractions, and systolic and diastolic blood pressure were also factored in.

Classifying disease status

Participants were classified as having diabetes if they reported using insulin or oral hypoglycemic agents or had a serum glucose level of 126 mg/dL or greater after a minimum 8-hour fast. They were classified as hypertensive if they reported using antihypertensive medication and self-reported a history of hypertension or if their blood pressure was 140/90 mm Hg or greater. Dyslipidemia was defined by the use of lipid-lowering agents, or by an LDL cholesterol measurement of >/= 190 mg/dL (in the presence of less than 2 other risk factors) or >/= 160 mg/dL (in the presence of 2 or more other risk factors) for people without diabetes, and by an LDL measurement of >/= 130 mg/dL (without macrovascular disease) or > 100 mg/dL (with macrovascular disease) for people with diabetes.

The results: sub-optimal risk factor management

Among study participants, 579 (17%) were classified as having diabetes. Of those with diabetes, only 12% achieved American Diabetes Association-recommended fasting glucose levels of less than 110 mg/dL.

Among those with hypertension, a larger proportion of diabetic than non-diabetic participants (89% vs. 75%, p<0.01) was treated with antihypertensive agents, but a smaller proportion of diabetic participants achieved recommended blood pressure levels (</= 129/85 mm Hg for diabetics and </= 139/89 mm Hg for non-diabetics) (27% vs 48%, p<0.01).

Diabetic dyslipidemic participants were less likely to receive lipid-lowering therapy (26% vs. 55%, p<0.01) and achieved recommended LDL levels less often (8% vs. 54%, p<0.01) than non-diabetic participants.

Practical implications

There are several potential reasons for these findings. With regard to the achievement of fasting glucose levels of less than 110 mg/dL, the researchers suggest that physicians may not view this treatment goal as practical in older people, because of the risks of treatment-induced hypoglycemia. And patient compliance with treatment may also play a role in achieving any or all of the risk factor management goals.

Given the burden that cardiovascular disease puts on public health systems, it is clear that practitioners should make every possible effort to improve risk factor control, particularly in older patients. The researchers emphasize that their study is only intended to demonstrate the adequacy of cardiovascular risk-factor control and to identify opportunities to improve care - not to criticize clinicians, for whom managing multiple risk factors in an older population is becoming an increasing challenge.

Source

• Glucose, blood pressure, and lipid control in older people with and without diabetes mellitus: The Cardiovascular Health Study. NL. Smith, PJ. Savage, SR. Heckbert,  et al., Journal of the American Geriatrics Society, 2002, vol. 50, pp. 416--423

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