Published in Cardiology

Expert Opinion / My Approach · July 19, 2016

MY APPROACH to the Patient With Memory Loss Who Needs a Statin

Written by

 

 Karol E Watson MD, PhD, FACC 

Written by

 

 Tamer Sallam MD, PhD

Statins are among the most powerful cholesterol-lowering medications, and they are also associated with the greatest cardiovascular risk reduction. For these reasons, the 2013 ACC–AHA cholesterol guidelines recommend statin therapy for patients at elevated cardiovascular risk. When we encounter such a patient, our approach is to prescribe moderate- or high-intensity statin therapy by the guidelines. But what if the patient has memory loss? If a patient's major threat to life is an atherosclerotic cardiovascular disease (ASCVD), a statin is still indicated. It may, in fact, protect the patient from further cognitive decline due to the vascular protective benefits. Also, it may protect the patient from stroke and vascular dementia, the second most common cause of dementia. In addition, ASCVD risk reduction benefits may be seen within the first 2 years of beginning statin therapy. Therefore, if the patient has a reasonable quality of life and at least a 2-year life expectancy, statin therapy is appropriate. But what if a patient develops memory problems while on statin therapy? Muscular symptoms are well-known statin side effects, but recently memory problems have been attributed to some to statins (whether correctly or incorrectly).

In 2012, after receiving reports that some statin users experienced short-term memory lapses, the FDA released an advisory saying that it had investigated "... reports of cognitive impairment from statin use for several years...." The symptoms, they said, were nonspecific and described as unfocused thinking. The FDA concluded that these "...symptoms were not serious and were reversible within a few weeks after the patient stopped using the statin."

But do statins really cause memory impairment? Mild memory loss is commonly seen in clinical practice. Most cases are due to normal aging, but progressive and significant memory loss may signal a more serious condition such as dementia. The statin clinical trials have been inconsistent about cognition. Statins have been associated with better cognition in observational trials, but the only randomized controlled trial of statin therapy performed exclusively in older individuals, the PROSPER trial, conducted neurocognitive testing and found no differences between groups (neither harm nor benefit). More intriguingly, results of a recent analysis of 482,543 statin users and 26,484 users of other lipid-lowering agents, showed the same percentage in each group reporting short-term memory loss after beginning therapy. So why might patients who are newly prescribed statin therapy report more memory problems? There is a well-known "detection bias,” whereby people are more likely to recognize health problems when they start a new medication. Also, memory problems are common. We often forget where we put our keys or forget an acquaintance's name; however, patients may be more likely to blame memory problems on a new drug. Also, when patients are prescribed a new medication, they are likely to see a clinician more often, which can also add to detection bias.

So, our approach to the patient with memory problems who need a statin is this: before prescribing a statin, and as part of comprehensive lifestyle assessment, we take a brief history of muscular symptoms and memory symptoms. Common questions we ask are: Do you exercise regularly? Do you have muscle or joint pain? How often do you take any pain relievers for this pain? In regard to cognition, we ask about common memory complaints such as minor forgetfulness or word-finding difficulties. We may ask: Do you ever have minor absent-mindedness such as forgetting where you put your keys or why you went into a certain room? Do you ever find a certain word “on the tip of your tongue” but are unable to find the word? Do you ever forget the name of an acquaintance? The purpose of such questions is to create a baseline for comparison should future symptoms arise. If the patient does complain of symptoms that he/she is certain are attributable to the statin, we hold the statin to see if there is clear symptom resolution. If there is, we usually rechallenge the patient with a different statin, a different dose of the same statin, or a different dosing schedule. We often go to the lowest dose of our statin of choice and give alternate-day dosing. This is a strategy that has been tested for statin-intolerant patients using atorvastatin and rosuvastatin. Once we find a dose/dosing schedule that the patient can tolerate, we reinforce adherence. Formal cognitive testing is not usually necessary. Ultimately, whether the patient has cognitive impairment or not, before initiating statin therapy we recommend a clinician–patient discussion as outlined in the 2013 ACC–AHA cholesterol guidelines to discuss the potential for ASCVD risk reduction, possible adverse effects, potential drug–drug interactions and patient preferences.