In summary, those who appear to benefit most from screening are high-risk populations—for example, those individuals who already have marked hypercholesterolemia or who have other risk factors that place them at high risk (e.g., smokers, hypertensives, etc.). Those for whom screening offers morbidity reductions (even if mortality and life expectancy are not affected) include persons who have a family history of hypercholesterolemia, who are not being treated with lipid-altering medications, or who have secondary hyperlipoproteinemias arising from diabetes or other causes.35

There is little doubt that initial reductions in serum cholesterol can be accomplished by dietary means. The problem is that long-term adherence to dietary regimens is difficult to achieve, and without sustained counseling, serum cholesterol levels are likely to drift upward again.10,25,89 It may be, however, that the elderly are more likely to comply with dietary regimens than younger adults and that the appeal of avoiding medications may further increase adherence to dietary treatment strategies by the aging.

It is important to note that the relationship between serum cholesterol levels and cardiovascular risk changes with age. Thus, in asymptomatic elderly persons, the association between serum cholesterol levels and later risk for mortality from coronary artery disease is in fact weaker than that in younger adults. Moreover, low cholesterol values in the elderly (e.g., below 150 mg/dl) appear to be associated with excess mortality, independent of cancer incidence.31 Although there is no clear cause-and-effect relationship, the association of low cholesterol levels with mortality has raised concern in the minds of some experts about the advisability of oversensitizing aging adults to the importance of low serum cholesterol levels. Finally, the treatment of hypercholesterolemic patients in elderly age groups may not reduce mortality rates to those of untreated patients with lower cholesterol levels. All of these questions should be settled by additional research.

The reasons for the differing associations among serum cholesterol, morbidity, and mortality in aging individuals are still unknown. In part, the differences may be due to genetically high HDL cholesterol levels among some of the surviving elderly.1,93 The menopause also leads to increases in serum cholesterol in females. Current recommendations are to screen for serum cholesterol in asymptomatic adult men at least every five years and more frequently in symptomatic men. At least one group still regards screening in such asymptomatic adults as optional for women and the elderly.35 Others suggest that screening is warranted for all individuals on the five-year schedule. Various intervention studies have shown that, in younger individuals



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