LETTER TO THE EDITOR

Comment on: ‘‘Recommendations to Prescribe in Complex OlderAdults: Results of the CRIteria to Assess Appropriate MedicationUse Among Elderly Complex Patients (CRIME) Project’’

Gulistan Bahat

� Springer International Publishing Switzerland 2014

I read the article by Onder et al. on ‘‘Recommendations to

Prescribe in Complex Older Adults: Results of the CRIteria

to Assess Appropriate Medication Use Among Elderly

Complex Patients (CRIME) Project’’ with great interest

[1].

Onder et al., aimed at producing recommendations to

guide pharmacologic prescription in older complex patients

with a limited life expectancy, functional and cognitive

impairment, and geriatric syndromes. As they noted, the

occurrence of several geriatric conditions may influence

the efficacy and limit the use of drugs prescribed to treat

chronic conditions and hence question the appropriateness

of treatment. However, currently, the assessment of these

geriatric conditions is rarely incorporated into clinical trials

and treatment guidelines [1].

They successfully filled this huge gap in geriatric

medicine and developed a total of 19 new recommenda-

tions for the treatment of five common chronic conditions

(diabetes mellitus, hypertension, congestive heart failure,

atrial fibrillation, and coronary heart disease) in such

geriatric complex patients, based on the results of their

literature search and expert consensus.

In their Recommendation 4 for the treatment of diabetes,

they stated that ‘‘Use of statins in older adults with limited

life expectancy (\2 years) or advanced dementia is not

recommended’’. For the corresponding rationale, among

other statements, they denoted that the benefits of statin use

decreases with increasing age. While I totally agree and

appreciate this recommendation, I would offer a comment

on the rationale of the statement that benefits of statin use

decrease with increasing age.

In assessing the potential value of hypolipidemic ther-

apy in the elderly, it is critical to distinguish between rel-

ative risk and attributable or absolute risk [2]. The relative

risk is the ratio of disease prevalence in one population

without the risk factor to the risk in another population

possessing the risk factor. The attributable risk is the

absolute difference in disease prevalence between the two

groups. The relative risk is a good measure of the strength

of an association in assessing causality while the attribut-

able risk is a more useful clinical measurement. It estimates

how much elevated cholesterol levels contribute to coro-

nary heart disease. It also estimates how much the risk

might be reduced if the hypercholesterolemia were cor-

rected [3]. Because coronary heart disease morbidity and

mortality rates increase with age, the attributable risk of

high total cholesterol is greater in the elderly even though

the relative risk decreases with age. This increase in

absolute risk in the elderly suggests that the benefit from

cholesterol-lowering therapy should be greater than in

younger individuals. This point, although not widely

appreciated, has important implications for treating

hypercholesterolemia in the elderly [2].

I conclude that while being totally of the same opinion

for this recommendation in older adults with limited life

expectancy or advanced dementia, the higher benefit from

cholesterol-lowering therapy in the elderly, owing to their

higher absolute risk of high cholesterol for coronary heart

disease, should be considered while treating our other

elderly patients.

G. Bahat (&)

Department of Internal Medicine, Division of Geriatrics,

Istanbul Medical School, Istanbul University,

Capa, 34390 Istanbul, Turkey

e-mail: gbahatozturk@yahoo.com

Drugs Aging

DOI 10.1007/s40266-014-0161-9

Acknowledgments There is no source of funding for the present

communication. The author has no conflicts of interest or financial or

other contractual agreements that might cause conflicts of interest.

References

1. Onder G, Landi F, Fusco D, Corsonello A, Tosato M, Battaglia M,

Mastropaolo S, Settanni S, Antocicco M, Lattanzio F. Recom-

mendations to prescribe in complex older adults: results of the

crıteria to assess appropriate medication use among elderly complex

patients (CRIME) project. Drugs Aging. 2014;31(1):33–45.

2. Rosenson RS. Treatment of dyslipidemia in the older adult. In:

UpToDate. http://www.uptodate.com/contents/treatment-of-dyslipid

emia-in-the-older-adult?source=preview&anchor=H1&selectedTitle

=1*150#H1. Accessed 16 December 2013.

3. Gordon DJ, Rifkind BM. Treating high blood cholesterol in the

older patient. Am J Cardiol. 1989;63:48H–52H.

G. Bahat