Older Adults May Be Overtreated for Diabetes

A substantial portion of older adults with diabetes and complex medical conditions attained tight glycemic control, which may suggest overtreatment in this patient population, according to a new study published in JAMA Internal Medicine.

Despite the prevalence of diabetes in older people, optimal glucose levels are still poorly defined. For young, healthy patients, HbA1c levels of <7% or <6.5% are recommended. Currently, the American Diabetes Association (ADA) and American Geriatrics Society (AGS) agree that glycemic targets should be higher for older patients with compromised health. 

However, most patients with diabetes aged 65 and older still maintain HbA1c levels of <7%. In older patients, there are limited benefits to such tight glycemic control, and they have a high risk for complications, such as hypoglycemia, with the use of some glucose-lowering medications. Further, glucose-lowering agents have been found to be responsible for one-fourth of emergency hospitalizations for adverse drug events in older adults in the United Sates, almost all of which were for hypoglycemia. 

In light of these findings, the researchers wanted to determine if older adults with diabetes were potentially being overtreated for the condition.

The study included data from 1,288 patients aged 65 years and older with diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2010. The patients were divided into three groups based on health status. 

The first group was considered as having very complex/poor health, where patients had difficulty with ≥2 integral daily tasks or dialysis dependence. The second group was categorized as complex/intermediate, where patients had difficulty with ≥2 integral daily tasks or had ≥3 chronic conditions. The third group was composed of relatively healthy participants if they did not fit the criteria for the other groups.

Tight glycemic control was considered an HbA1c level <7%.

Using these parameters, 21.2% had very complex/poor health, 28.1% had complex/intermediate health, and 50.7% were relatively healthy. Out of all the participants, 61.5% achieved tight glycemic control; this proportion did not significantly differ based on health status. 

Of the patients with tight glycemic control, 54.9% were treated with either insulin or sulfonylureas; again, this proportion did not significantly differ based on health status.

Over 10 years, the researchers found no significant changes in the proportion of older adults with HbA1c <7%, those with HbA1c <7% and complex/intermediate or very complex/poor health, or those with HbA1c <7% who were treated with insulin or sulfonylureas despite having complex/intermediate or very complex/poor health.

In older populations with complex health problems, tight glycemic control may not be as beneficial as it is for younger patients and often carries a risk for complications. However, the results of this study indicate that the majority of those with very complex and complex health status maintained an HbA1c level of <7%, indicating potential overtreatment. 

The researchers stress that patients should discuss the risks and benefits of tight glycemic control with their health care providers in order to make an informed decision about the best treatment options for their diabetes.