Diabetes Control Too Tight for Some Older Adults

January 15, 2015

Maintaining tight glycemic control in older diabetic adults who are in poor health can do far more harm than good, according to results of a new study.

A substantial proportion of older adults with diabetes mellitus (DM) who are in poor health may be treated to too tight glycemic levels with insulin and sulfonylureas, according to a new study.

“Our findings suggest that a substantial proportion of older adults with diabetes were potentially overtreated. In older adults with multiple serious comorbidities and functional limitations, the harms of intensive glycemic control likely exceed the benefits,” state the authors led by Kasia J. Lipska, MD, MHS, of the Section of Endocrinology, Department of Internal Medicine, at Yale University School of Medicine, New Haven, Conn.

Older patients may derive less benefit from tight glycemic control and may be more susceptible to hypoglycemia, which has been associated with poor outcomes, such as increased mortality, cardiovascular disease, falls and accidents, dementia, and low health-related quality of life, the researchers noted.

Dr Lipska and colleagues analyzed data on 1288 adults, aged 65 years and older, with DM from the National Health and Nutrition Examination Survey from 2001 through 2010. The patients were divided into 3 groups based on health status:

   * Very complex/poor: difficulty with 2 more activities of daily living or being dependent on dialysis
   * Complex/intermediate: difficulty with 2 or more instrumental activities of daily living or having 3 or more chronic conditions
  * Relatively healthy: if none of the other conditions were present).

Very complex/poor

Difficulty with 2 more activities of daily living or being dependent on dialysis

Complex/intermdiate

Difficulty with 2 or more instrumental activities of daily living or having 3 or more chronic conditions

Relatively healthy

If none of the other conditions were present - See more at: http://www.consultantlive.com/diabetes-type-2/diabetes-control-too-tight-some-older-adults#sthash.XPVuh487.dpuf

Tight glycemic control was an HbA1c level less than 7%.

Of the 1288 older adults with DM, half were relatively healthy, slightly more than one-quarter had complex/intermediate health, and less than one-quarter had very complex/poor health.

Overall, 62% of the adults had an HbA1c level less than 7% and this proportion did not differ across health status categories (63% were relatively healthy, 63% had complex/intermediate health and 56% had very complex/poor health). Of the adults with an HbA1c level less than 7%, 55% were treated with either insulin or sulfonylureas and this proportion was similar across health status categories (51% were relatively healthy, 59% had complex/intermediate health and 60% had very complex/poor health).

[[{"type":"media","view_mode":"media_crop","fid":"31017","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_4574376923840","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3275","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin-right: 2px; margin-left: 2px; float: right;","title":" ","typeof":"foaf:Image"}}]]In addition, more than one-third of the patients with very complex/poor health and nearly half of those with complex/intermediate health had HbA1c levels of less than 6.5%. This corresponds to 1.8 million persons. The researchers estimate that about 1 million adults with complex or very complex medical problems were treated with insulin or sulfonylureas to achieve tight glycemic targets.

"Using a nationally representative sample of US adults, we showed that nearly two-thirds of older adults with diabetes who have complex/intermediate or very complex/poor health attained tight glycemic control. 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,” the researchers concluded. “Recognition of both the harms and benefits of glycemic control is critical for patients and physicians and other healthcare professionals to make informed decisions about glucose-lowering treatment."

The researchers published their results online on January 12, 2015, in JAMA Internal Medicine.

References:

Kasia J. Lipska KJ, Ross JS, Miao Y, et al.  Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. Published online January 12, 2015. doi:10.1001/jamainternmed.2014.7345