Diabetes frequently affects adults over 65. However, the best way for this age group to manage their glucose levels has been poorly defined by experts. New research now suggests that a substantial number of older adults with diabetes are being overtreated for the disease.
The study, published in JAMA Internal Medicine, examined the glycemic control of older patients with diabetes – some with very complex and poor health – in order to assess possible overtreatment of the metabolic disorder.
For younger, healthier adults with diabetes, the American Diabetes Association (ADA) suggests that blood sugar should be controlled to achieve a hemoglobin A1c level of less than 7%. In contrast, the American Association of Clinical Endocrinologists (AACE) recommends a level below 6.5%.
“However, older persons, particularly those with complex medical problems, may derive less benefit from intensive strategies to lower glucose levels,” write the authors, “and are more susceptible to hypoglycemia and its consequences compared with younger, healthier persons.”
Hypoglycemia, whereby levels of glucose in the blood become lower than normal, is the most common complication of diabetes in older adults and can lead to emergency hospitalizations. Nearly one-fourth of adverse drug events leading to emergency hospitalizations in older adults are attributed to hypoglycemia.
The study was conducted by Dr. Kasia Lipska of the Yale School of Medicine, New Haven, CT, and co-authors. The team analyzed data for 1,288 adults aged 65 and over from the National Health and Nutrition Examination Survey (NHANES), from 2001 until 2010.
Participants were separated into three groups according to their state of health, which the authors defined as:
“Those who are relatively healthy, those with complex medical histories for whom self-care may be difficult and those with a very significant comorbid illness and functional impairments, many of whom may have limited life expectancy.”
Each participant had also previously been diagnosed with diabetes. Of the participants, 50.7% were relatively healthy, 28.1% had complex/intermediate health and 21.2% had very complex/poor health.
In total, 61.5% of the participants had tight glycemic control – a hemoglobin A1c level of less than 7% – and this ratio of patients did not vary across the different health status groups.
Specifically, 62.8% of the relatively healthy, 63% of those with complex/intermediate health and 56.4% of those with very complex/poor health had a hemoglobin A1c level that was lower than 7%.
Of these participants, 54.9% had their diabetes treated with either insulin or sulfonylureas. Again, this ratio of patients did not vary across the different health status groups.
The authors write that their findings show nearly two-thirds of older adults with diabetes and complex/intermediate or very complex/poor health attained tight glycemic control.
- Cardiovascular disease
- Dementia
- Falls and accidents
- Increased mortality
- Low health-related quality of life.
“These vulnerable adults are unlikely to experience the benefits of intensive glycemic control and instead are likely to experience harms from treatment, such as hypoglycemia and other adverse effects,” they state.
There is a possibly, note Dr. Lipska and the team, that some of the conditions used to categorize health status may have stronger associations with hypoglycemia than others. To categorize health status though, the researchers used a framework recommended by the ADA and American Geriatrics Society (AGS).
Another possible limitation of the study acknowledged by the authors is that the ADA and AGS recently recommended higher glycemic targets for older patients with multiple comorbidities, which may have reduced levels of overtreatment since 2010.
However, the authors state that other institutions have been endorsing this approach for nearly 10 years with no evidence of the endorsements leading to changes in practice.
“Recognition of both the harms and benefits of glycemic control is critical for patients and physicians and other health care professionals to make informed decisions about glucose-lowering treatment,” conclude the authors.
Recently, Medical News Today reported on a study finding that life expectancy is not reduced by intensive type 1 diabetes treatment.