Project objectives

Prevention and risk reduction in later life can be effective and cost-effective, if well targeted. However, the older population is diverse in terms of health status and older people (especially with co-morbidities) are frequently excluded from randomised trials.  Personally relevant randomised trial evidence is therefore scarce on the efficacy of many primary and secondary preventive interventions for the major public health challenges in ‘typical’ groups of older people.

The overall aim of this work package is to help improve health related quality of life for older people by better targeting effective health care delivered preventive interventions in later life.

Objectives

The objectives of the work package are to:

• Stratify the ageing population into coherent prognosis based case group for personalising intervention, avoiding crude ‘ageist’ subdivisions. These groupings should preferably be implementable in GP electronic clinical data, to support translation into practice.
• Assemble and where necessary systematically review existing trial evidence on the efficacy of key interventions in later life, with an initial focus on ‘metabolic syndrome’ interventions.
• Evaluate the overall and case group specific effectiveness of current primary care delivered interventions for hypertension, hypercholesterolemia and hyperglycaemia, using quasi-experimental methods.
• Estimate frequency of recorded harms, and proportions of such adverse events attributable to the interventions of interest.
• Explore possible effect modifiers, including co-morbidity and socio-economic status.
• Provide a population model of targeting these prevention strategies, including estimating cost-effectiveness within prognostic groups (led by Dr Praveen Thokala in Sheffield).

 

To achieve the above, we plan to use large-scale epidemiological and clinical datasets including the Clinical Practice Research Datalink (CPRD general practice and linked hospital activity and mortality datasets), the MRC CFAS and ELSA studies.

 

Changes to project objectives

The overall focus on cardiovascular disease (CVD) or metabolic syndrome risks and interventions in older people remained the same, After the initial planned steps it became clear that identifying coherent prognosis based sub-groups of the elderly explained some major claimed risk CVD paradoxes that have undermined public health action – especially the claimed beneficial effects of being overweight or obese in later life. Clarifying risk paradoxes in later life therefore became a major theme of our outputs, with a series of analyses showing that the claimed obesity paradox is due to the inappropriate inclusion in the control group of smokers, people with diseases causing weight loss, and mismeasurement of central adiposity in later life.

 We completed quasi-experimental modelling of statin effects and adverse events in secondary prevention in older groups (with a published paper). However, application of the difference in difference ‘prior event rate ratio PERR’ and other quasi-experimental methods (especially propensity scoring) to primary CVD prevention with statins proved unfeasible, as it was clear that uncontrollable confounding remained present. Similarly for blood pressure, we showed that outcomes by attained blood pressure in older subjects differed from those in younger groups, and that there are substantial falls in blood pressure during the last 15 years of life  (one paper published, one in review): these effects probably explain the paradoxical reported associations, but it again proved unfeasible to reliably model treatment effects directly due to evidence of uncontrolled confounding and lack of like-for-like control patients with untreated hypertension in older groups. The project has led to successful applications of the PERR method in proton pump inhibitor effects in later life – funded by a follow-on RfPB project, with three papers, one published.

Brief summary

Resources used in our analysis

Clinical practice research datalink (CPRD)

The Clinical Practice Research Datalink (CPRD) is the English National Health Service (NHS) observational data service for research, covering 674 UK primary care practices. Individuals in CPRD selected for our analysis, have their primary care electronic medical records linked to Hospital Episode Statistics (HES) data for admissions, and the UK government’s Office for National Statistics (ONS) for death certificate data. Registration with primary care is nearly complete for the older population in England: data are similar to the UK population in age and sex distribution and comparable for ethnicity and body mass index. In addition, CPRD has good ascertainment for estimating prevalence of major diagnoses. We obtained data on approximately 1 million people aged 60 and over, for the analyses.

UK Biobank

We extended the analysis of the obesity risk paradox in later life with one analysis using the new UK Biobank data, the only source of largescale measures of central adiposity on an older group.

Methods – by paper prepared and / or published:

P1: Obesity in Older People With and Without Conditions Associated with Weight Loss: Follow-up of 955,000 Primary Care Patients

We used de-identified electronic health records from the Clinical Practice Research Datalink (CPRD) which were linked to the Hospital Episode Statistics (HES) and the Office for National Statistics (available for English patients only). We included all registered patients with a BMI record since 1^st January 2000. We used the earliest recorded BMI within each age group 60-64; 65-69; 70-74; 75-84; ≥85 years. We used the WHO BMI classifications after excluding outlier BMI values (<14.0 and >56.5). Furthermore, we revised the BMI groupings following an analysis of the continuous association between BMI and mortality. We empirically identified major conditions associated with measured weight loss. Additionally, we plotted the hazards for mortality for two year follow-up periods to guide how many years of follow-up to exclude to minimise reverse causality. We used this to categorise persons as ‘healthier agers’ – never smokers without the major conditions associated with weight loss (recent cancer, dementia, heart failure, or a measure of multimorbidity) and who survived the first 3.9 years of follow-up. We used Cox proportional hazards model to estimate the association between the BMI categories and mortality. We also used spline models to plot the continuous BMI associations with mortality. We used competing risks models to estimate the association between the BMI categories and incident coronary heart disease and diabetes. Models were adjusted for age, gender, alcohol use, smoking, calendar years, and socio-economic status.

P2: The association between BMI and dementia: the impact of the numbers of years of follow-up excluded

We used a similar methodological approach as detailed above (P1). We focussed our analysis on ‘healthier agers’ aged 65 to 74 years. We used competing risks models to estimate the association between the BMI categories and incident dementia.

P3: Comparison of established measures of body fat distribution, components of body composition to BMI for mortality prediction for ‘healthier agers’ within the seventh decade of life using the UK Biobank  

The UK Biobank recruited adults aged 40 to 69 years during 2006 to 2010 across England, Scotland and Wales. We used the UK Biobank to compare measures of body fat distribution (waist-circumference, waist-to-hip ratio, and waist-to-height ratio), components of body composition (body fat percentage, fat mass index, fat free mass index, and skeletal mass index) to BMI for mortality prediction for ‘healthier agers’ within the seventh decade of life (never smokers without cancer, dementia, heart failure, and who survived the first 1.9 years of follow-up). We categorised these measures into sex-specific tertiles. We used Cox proportional hazards models to estimate the association between the measures and mortality. Models were adjusted for age, gender, alcohol use, smoking history, and educational attainment. Mortality model fit was assessed using the Akaike information criterion.

P4: Central adiposity and the overweight risk paradox in aging: follow-up of 130,473 UK Biobank participants

We used the UK Biobank to combine measures of central adiposity and BMI for mortality and coronary heart disease prediction. We used the ‘healthier agers’ as detailed in P3 who had a BMI in the range 18.5 to <35.0. Waist-to-hip ratio was categorised into sex-specific tertiles. We used Cox proportional hazards models for mortality and competing risks models for incident coronary heart disease.  Models were adjusted as detailed in P3.

P5: Outcomes of Treated Hypertension at Age 80 and Older: Cohort Analysis of 79,376 Individuals

Here we published on outcomes in 80 plus year olds, because during the project another team published very similar analyses that included the younger group. We used de-identified electronic health records from the Clinical Practice Research Datalink (CPRD) which were linked to the Hospital Episode Statistics (HES) and the Office for National Statistics (available for English patients only) to estimate outcomes according to attained blood pressure (BP) in the oldest adults treated for hypertension in routine family practice. The analysis focused on individuals aged 80 and older taking antihypertensive medication and free of dementia, cancer, coronary heart disease, stroke, heart failure, and end-stage renal failure at baseline. We used survival analysis, adjusted for sex, age at beginning of follow-up, quintile of 2010 English Index of Multiple Deprivation for England, and smoking status, followed individuals for 11.9 years. The outcomes were all-cause mortality, cardiovascular events (ischemic stroke, myocardial infarction (MI), heart failure), and fragility fractures.

P6: Blood pressure declines in the 20 years before death: repeat clinical measures in 46,634 individuals 

In pilot work we identified late life blood pressure declines that could explain why there have been paradoxical risk estimates for older groups.  We analysed the population based Clinical Practice Research Datalink primary care and linked hospital admission electronic medical records from England, using retrospective cohort approaches with generalized linear mixed effect modelling. The analysis focussed on 46,634 individuals, dying at age ≥60 years, from 2010-2014 and with BP measures over 20 years.  We investigated associations between specific conditions and overall cumulative burden of disease, with SBP trajectories. Lastly with compared trajectories from individuals who died with those surviving for at least 9 years. 

P7: Ageing outcomes with ideal cardiovascular risk: Evidence from 421,000 subjects in two cohorts

We used two cohorts Clinical Practice Research Datalink (CPRD) primary care electronic medical records with linked hospital admission data, plus the UK Biobank (UKB) cohort. The analysis focused on individuals aged 60 to 69 years (CPRD n=239,591; UKB n=181,820). We identified groups with near ideal, intermediate and high cardiovascular risk using a risk scoring system similar to Life’s Simple 7 and estimated outcomes by cardiovascular risk status during a follow-up period of ≤10 years (for both cohorts). A large number of outcomes were considered including all-cause mortality and cardiovascular outcomes but also incident cancer, depression and (hospital diagnosed) dementia. CPRD only: Incident Rockwood definition frailty (multi-morbidity). UKB: baseline Fried definition frailty.

P8: Safety and Effectiveness of Statins for Prevention of Recurrent Myocardial Infarction in 12 156 Typical Older Patients: A Quasi-Experimental Study

We used primary care electronic medical records from the UK Clinical Practice Research Datalink. Sub-hazard ratios (competing risk of death) for myocardial infarction recurrence (primary end point), falls, fractures, ischemic stroke, and dementia, and hazard ratios (Cox) for all-cause mortality were used to compare older (60+) statin users and 1:1 propensity-score-matched controls (n = 12,156). Participants were followed-up for 10 years.

Results (including findings in relation to the objectives):

P1

We firstly showed that the group mean BMI declines progressively for 14 years before death.  In all groups, patients within the BMI Obese-1 (30.0-34.9) range had reduced mortality risks relative to those within the conventional BMI Normal range.  However, after excluding the specific confounders (smokers and those with conditions associated with weight loss) and follow-up less than 4 years, the BMI morality risk curves for the 60 to 64 years and 65 to 69 years age groups were U-shaped. The nadir was within the BMI range 23.0-26.9 with steeply rising mortality risks above this range.  In older age groups, mortality nadirs were at modestly higher BMIs (all <30) and risk slopes at higher BMIs were less marked, becoming nonsignificant at age 85 and older. Incidence of diabetes was raised for those within the BMI Obese-1 range at all ages and for coronary heart disease to age 84 years.

P2

We firstly showed that the proportion of patients within the BMI Obese range declined for 14 years before incident dementia. For those aged 65 to 69 years, patients within the BMI Obese range had reduced risks for incident dementia relative to those within the BMI 23.0-26.9 range. Dementia risks remained reduced for those within the BMI Obese range after excluding the first 3.9 and 5.9 years, respectively. However, after excluding the first 9.9 years of follow-up there was increased risks for dementia for those within the BMI Obese range.

P3

We showed that measures of fat distribution substantially improved the mortality model fit compared to the BMI mortality model. The model which contained waist-to-hip ratio measures achieved the lowest AIC value (best model). Persons within the higher tertile of the fat distribution measures (and BMI) had increased mortality risks compared to those within the lower tertile. 

P4

We firstly showed that persons within the BMI Overweight (25.0-29.9) range had similar mortality risks compared to those within the conventional BMI Normal range. However, persons within the BMI Normal range with higher WHR had elevated mortality risks compared to those within the BMI Normal range with lower WHR. Persons within the BMI Overweight (and Obese-1) range with higher WHR had increased risks for mortality and incident coronary heart disease compared to those with the BMI Normal range with lower WHR. 

P5

We found all-cause mortality and risk of cardiovascular disease rose with increasing SBP above 145 to 154 mmHg, and a linear increasing risk of myocardial infarction. However, we also found increase mortality rates over 11.9 years of follow-up in those with SBP of less than 135 mmHg. This presents a J-shaped association with mortality which highlights the need for work to establish whether unplanned SBP of less than 135 mmHg in older adults with hypertension may be a useful clinical sign of poorer prognosis requiring overall clinical review of care.

P6

We found Systolic (SBP) and diastolic (DBP) pressures peaked 18 to 14 years before death, after which pressures declined progressively. Declines in SBP from peak values ranged from -11.1 mm Hg for those dying aged 60 to 69 years, to -23.9 mm Hg at 90 plus: we found over 6% of subjects had SBP declines of >-10 mm Hg. BP declines appeared linear from ten to three years before death, with steeper declines in the last two years of life. SBP declines were present with and without treated hypertension, heart failure, atrial fibrillation or stroke, although steeper with these conditions. These BP declines are not simply attributable to age, treatment of hypertension or better survival without hypertension. Late life BP declines may have implications for risk estimation, treatment monitoring and trial design.

P7

Only a small proportion (2.4%) of the primary care population had ideal risk scores (26% in UKB volunteers). All-cause mortality was substantially lower with ideal risks. There were similar reductions in risk of heart failure, respiratory conditions, anaemia, depression and pressure ulcers. The smaller, but significant reductions in risk between ideal vs intermediate groups suggest a dose response trend. Interestingly, in individuals with ideal risk scores only 0.5% developed moderate to severe frailty compared for 5.4% in the high group, with 3 out of 4 cases in incident frailty attributed to high or intermediate cardiovascular risk.  In the UK biobank, individuals in the ideal group showed a reduction in the risk of dementia. Individuals in their 60’s with ideal cardiovascular risks present better outcomes in later life, for a variety of conditions, and mostly avoid incident frailty in a 10 year period. This result support that most of incident frailty could be avoided if all individuals had ideal cardiovascular risk.

P8

Mean age was 76.5±9.2 years; 45.5% were women. Statins were associated with near significant reduction in myocardial infarction recurrence (sub-hazard ratio = 0.84, 0.69-1.02, p = .073), with a protective effect in the 60-79 age group (0.73, 0.57-0.94) but a nonsignificant result in the 80+ group (1.06, 0.78-1.44; age interaction p = .094). No significant associations were found for stroke or dementia. Data suggest an increased risk of falls (1.36, 1.17-1.60) and fractures (1.33, 1.04-1.69) in the first 2 years of treatment, particularly in the 80+ group. Treatment was associated with lower all-cause mortality. Statin use was associated with health care cost savings in the 60-79 group but higher costs in the 80+ group.

Conclusions:

Our main conclusions are:

• That the claimed obesity risk paradox in later life (i.e. being overweight or obese is associated with equal or better outcomes compared to normal BMI) is deeply misleading. It is true only if smokers and people with diseases causing weight loss are included. It is also driven in part by mismeasurement due to the BMI formula, which ignores central adiposity and does not account for the muscle loss seen in later life. Overall, for ageing well, it is clear that having a normal BMI and waist circumference is associated with substantially better outcomes than seen in older groups with more adiposity.

• Some have claimed that being obese may be protective for dementia, but on taking account of the biasing factors noted above, especially reserve causation, we showed that this is not true, and being obese is associated with an increased risk of being diagnosed with dementia.

• That the reported paradoxical risk estimates from higher blood pressures in later life may be confounded by substantial falls in pressures for approximately 15 years before death. This work is apparently the first report of long term trends in BP toward the end of life. It has potential major implications for BP management toward the end of life and is the focus of a NIHR clinical PhD studentship, which resulted from the SPHR work.

• Estimates of statin effectiveness for the prevention of recurrent myocardial infarction in patients aged 60-79 years were similar to trial results, but more evidence is needed in the older group. There may be an excess of falls and fractures in very old patients, which deserves further investigation.

• In groups of 60 to 69 year olds with near ideal cardiovascular risk factors, ageing well outcomes over 10 years are dramatically better than in groups with less ideal risks.This finding counters claims that CVD risk factors are not predictive in later life. Given the success in decreasing overall mortality in older groups demonstrated in RCTs of blood pressure and cholesterol control, it is likely that comprehensive CVD risk reduction could achieve major gains toward ageing well.  Unfortunately less than 3% of the general older population in CPRD (representative of England) had near ideal CVD risks.

 

Plain English summary

In this project we aimed to improve evidence on cardiovascular risk factors in later life, to help people age well. Some scientists have claimed these heart disease risk factors are not predictive in later life: for example there has been substantial publicity about how being overweight or obese in old age may even be beneficial.  We used very large databases of electronic medical records and data from study volunteers, to clarify this evidence.

Our main conclusions are:

• That the claimed obesity risk paradox in later life (i.e. being overweight or obese is associated with equal or better outcomes compared to normal BMI) is deeply misleading. It is true only if smokers and people with diseases causing weight loss are included, but this biases the results. It is also driven in part by mismeasurement due to the BMI formula, which ignores adiposity in the stomach area, and does not account for the muscle loss seen in later life. Overall, for ageing well, it is clear that having a normal BMI and waist circumference is associated with substantially better outcomes compared to older groups with more adiposity.

• Some have claimed that being obese is not a risk factor for dementia, but on taking account of the biasing factors noted above, we showed that this is not true, and being obese is associated with a substantially increased chance of being diagnosed with dementia.

• That the reported paradoxical risk estimates from higher blood pressures in later life may be confounded by substantial falls in pressures for approximately 15 years before death. This work is apparently the first report of long term trends in BP toward the end of life. It has potential major implications for BP management toward the end of life but more work is needed to clarify how care should be modified.

• In groups of 60 to 69 year olds with near ideal cardiovascular risk factors, ageing well outcomes over 10 years are dramatically better than in groups with less ideal risks.

This finding counters claims that CVD risk factors are not predictive in later life. The finding also provides an indication of the very large extent to which ageing outcomes could be improved in the older population. Unfortunately less than 3% of the general older population in CPRD (representative of England) had near ideal CVD risks.

Dissemination

Published articles

1. Bowman K, Atkins JL, Delgado J, Kos K, Kuchel GA, Ble A, Ferrucci L, Melzer D. Central adiposity and the overweight risk paradox in aging: follow-up of 130,473 UK Biobank participants. Am J Clin Nutr. 2017 May 31. pii: ajcn147157. doi: 10.3945/ajcn.116.147157. [Epub ahead of print] PMID: 28566307 DOI: 10.3945/ajcn.116.147157 

2. Delgado J, Masoli JA, Bowman K, Strain WD, Kuchel GA, Walters K, Lafortune L, Brayne C, Melzer D, Ble A; As part of the Ageing Well Programme of the NIHR School for Public Health Research, England.. Outcomes of Treated Hypertension at Age 80 and Older: Cohort Analysis of 79,376 Individuals. J Am Geriatr Soc. 2016 Dec 30 DOI: 10.1111/jgs.14712 

3. Atkins JL, Pilling LC, Ble A, Dutta A, Harries LW, Murray A, Brayne C, Robine JM, Kuchel GA, Ferrucci L, Melzer D. Longer-Lived Parents and Cardiovascular Outcomes: 8-Year Follow-Up In 186,000 U.K. Biobank Participants. J Am Coll Cardiol. 2016 Aug 23;68(8):874-5 DOI: 10.1016/j.jacc.2016.05.072 

4. Bowman K, Delgado J, Henley WE, Masoli JA, Kos K, Brayne C, Thokala P, Lafortune L, Kuchel GA, Ble A, Melzer D; as part of the Ageing Well Programme of the NIHR School for Public Health Research, England. Obesity in Older People With and Without Conditions Associated With Weight Loss: Follow-up of 955,000 Primary Care Patients. J Gerontol A Biol Sci Med Sci. 2017 Feb;72(2):203-209 DOI: 10.1093/gerona/glw147 

5. Ble A, Hughes P, Delgado J, Masoli J, Bowman K, Zirk-Sadowski J, Mujica Mota R, Henley W, Melzer D. Safety and effectiveness of statins for prevention of recurrent myocardial infarction in 12,156 typical older patients: a quasi-experimental study. The Journal of Gerontology Series A: Biological Sciences and Medical Sciences 2016. DOI: 10.1093/gerona/glw082 

6. Ble A, Masoli JAH, Barry H, Winder RE, Tavakoly B, Henley WE, Kuchel GA, Valderas JM, Melzer D, Richards SH. Any versus long-term prescribing of high risk medications in older people using 2012 Beers Criteria: results from three cross-sectional samples of primary care records for 2003/4, 2007/8 and 2011/12. BMC Geriatrics 2015, 15:146 DOI:10.1186/s12877-015-0143-8 

7. Melzer D, Tavakoly B, Winder R, Masoli JAH, Henley WE, Ble A, Richards SH. Much more medicine for the oldest old: Trends in UK electronic clinical records. Age & Ageing. 2014 Aug 7. DOI:10.1093/ageing/afu113 (AB is supported by NIHR SPHR) Conference presentationsDelgado J. Ageing without cardiovascular risk. NIHR SPHR Annual Scientific Meeting. London, 23 Mar 2017.

Conference Posters

1. Lafortune L, Xu K, Wood A, Melzer D, Brayne C, Mant J. Risk factor associations with cardiovascular outcomes in later life. Public Health England Annual Conference. Warwick, 13-14 Sep 2016.

2. Ble A, Hughes P, Delgado J, Masoli J, Bowman K, Zirk-Sadowski J, Mujica Mota R, Henley W, Melzer D. Preventing myocardial infarction: do statins work in older people?  NIHR SPHR Annual Scientific Meeting. Newcastle-upon-Tyne, 10 Mar 2016

3. Delgado J, Masoli J, Bowman K, Strain D, Kuchel G, Walters K, Lafortune L, Brayne C, Melzer D, Ble A. Preventing CVD in the oldest old: Outcomes with antihypertensive treatment. NIHR SPHR Annual Scientific Meeting. Newcastle-upon-Tyne, 10 Mar 2016

4. Bowman K, Delgado J, Henley W, Masoli J, Kos K, Brayne C, Thokala P, Lafortune L, Kuchel GA, Ble A, Melzer D. Is obesity really protective in older people? Evidence from Electronic Medical Records of Over 955,000 Primary Care Older UK Patients. NIHR SPHR Annual Scientific Meeting. Newcastle-upon-Tyne, 10 Mar 2016

5. Bowman KH, Delgado J, Masoli JAH, Pilling LC, Ble A, Henley WE, Melzer D. The Obesity Paradox and Advancing Age: Evidence from Electronic Medical Records of Over 900,000 Primary Care Older UK Patients. BGS Autumn Meeting. Brighton, 14 – 16 Oct 2015.

6. Bowman K. Obesity Risks in Older People. Cardiovascular Research Network. 8 Sep 2015. (presentation) Melzer D. Are lean or obese older people more likely to age well? British Society for Research on Ageing Annual Scientific Meeting. London, 1 – 2 Jul, 2015.

Conference presentations

1. Delgado J. Ageing without cardiovascular risk. NIHR SPHR Annual Scientific Meeting. London, 23 Mar 2017. 
2. Melzer D, Delgado J, Masoli JA, Kuchel GA. Outcomes of treated hypertension in 79,376 patients aged 80 years and older: Linked records based cohort analysis. The American Geriatrics Society Annual Scientific Meeting. Long Beach California, 19 – 21 May 2016. 
3. Ble A. Statins, recurrence of myocardial infarction, and disabling conditions in the elderly. Gerontological Society of America Annual Meeting. Orlando, 18 Nov, 2015. 
4. Melzer D. Using big data to improve the evidence for preventing cardiovascular disease in older patients. Gerontological Society of America Annual Meeting. Orlando, 18 Nov, 2015. 
5. Bowman K. Chronic kidney disease as a risk factor for cardiovascular events or mortality. Gerontological Society of America Annual Meeting. Orlando, 18 Nov, 2015. 
6. Delgado J. The effectiveness of statins in preventing the onset of dementia and Parkinson's disease. Gerontological Society of America Annual Meeting. Orlando, 18 Nov, 2015. 
7. Melzer D. Health care quality for an active later life. King’s Fund Conference: Making health and care services fit for an ageing population. London. 22 Oct 2013.

Non-academic dissemination

1. Lafortune L. Feedback from Research: the challenge of obesity in older people. "Improving Practice in Physical Health", Cambridgeshire & Peterborough NHS Foundation Trust. Peterborough, 26 Feb 2016. (presentation) 
2. Ble A. Evaluation medication use in the elderly. Meeting with geriatricians of the Royal Devon and Exeter Hospital Trust. Exeter, 4 Mar 2016.
3. Melzer D. Personalising preventive interventions in later life.  Reducing Avoidable Mortality: Department of Health and European Observatory on Health Systems and Policies. 13 May and 28 Feb 2014 (meetings - invited talk and facilitator role re health of older women)

Public involvement

Input was valuable but there may be ‘sampling issues’ – i.e. it is sometimes unclear how representative PPI opinions provided are of the wider population of interest.

Impact

The papers are only now being published, but our results should help debunk claims that obesity and other heart disease risk factors don’t matter in old age. The results for the near ideal CVD risk group, who had spectacularly good ageing outcomes compared to groups with less ideal risk factors, should help focus energy on moving the risk distribution in the older population. At present, less than 3% of older people (60 to 69) appear from primary care records to have near ideal cardiovascular risks.

This project was funded by the National Institute for Health Research School for Public Health Research (project number SPHR-SWP-AWP-PR2).

Department of Health Disclaimer

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR School for Public Health Research, NIHR, NHS or the Department of Health.