Preventing cardiovascular disease in older adults: One size does not fit all

NUTRITION

Samieri et al,⁵⁶ in an observational study of 10,670 nurses, found that those adhering to Mediterranean-style diets during midlife had 46% increased odds of healthy aging.

The PREDIMED study (Primary Prevention of Cardiovascular Disease With a Mediterranean Diet)⁵⁷ in adults ages 55 to 80 showed the Mediterranean diet supplemented with olive oil and nuts reduced the incidence of major cardiovascular disease.

Leon-Munoz et al.⁵⁸ A prospective study of 1,815 community-dwelling older adults followed for 3.5 years in Spain demonstrated that adhering to a Mediterranean diet was associated with a lower incidence of frailty (P = .002) and a lower risk of slow gait speed (OR 0.53, 95% CI 0.35–0.79). Interestingly, this study also found a protective association between fish and fruit consumption and frailty.

Our recommendations. A well-balanced, diverse diet rich in whole grains, fruits, vegetables, nuts, fish, and healthy fats (polyunsaturated fatty acids), with a moderate amount of lean meats, is recommended to prevent heart disease. However, poor dental health may limit the ability of older individuals to adhere to such diets, and modifications may be needed. Additionally, age-related changes in taste and smell may contribute to poor nutrition and unintended weight loss.⁵⁹ Involving a nutritionist and social worker in the patient care team should be considered especially as poor nutrition may be a sign of cognitive impairment, functional decline, and frailty.

SPECIAL CONSIDERATIONS

Special considerations when managing cardiovascular risk in the older adult include polypharmacy, multimorbidity, quality of life, and the patient’s personal preferences.

Polypharmacy, defined as taking more than 5 medications, is associated with an increased risk of adverse drug events, falls, fractures, decreased adherence, and “prescribing cascade”— prescribing more drugs to treat side effects of the first drug (eg, adding hypertensive medications to treat hypertension induced by nonsteroidal anti-inflammatory drugs).⁶⁰ This is particularly important when considering adding additional medications. If a statin will be the 20th pill, it may be less beneficial and more likely to lead to additional adverse effects than if it is the fifth medication.

Patient preferences are critically important, particularly when adding or removing medications. Interventions should include a detailed medication review for appropriate prescribing and deprescribing, referral to a pharmacist, and engaging the patient’s support system.

Multimorbidity. Many older individuals have multiple chronic illnesses. The interaction of multiple conditions must be considered in creating a comprehensive plan, including prognosis, patient preference, available evidence, treatment interactions, and risks and benefits.

Quality of life. Outlook on life and choices made regarding prolongation vs quality of life may be different for the older patient than the younger patient.

Personal preferences. Although interventions such as high-intensity statins for a robust 85-year-old may be appropriate, the individual can choose to forgo any treatment. It is important to explore the patient’s goals of care and advanced directives as part of shared decision-making when building a patient-centered prevention plan.⁶¹

ONE SIZE DOES NOT FIT ALL

The heterogeneity of aging rules out a one-size-fits-all recommendation for cardiovascular disease prevention and management of cardiovascular risk factors in older adults.

There is significant overlap between cardiovascular risk status and frailty.

Incorporating frailty into the creation of a cardiovascular risk prescription can aid in the development of an individualized care plan for the prevention of cardiovascular disease in the aging population.