Diabetes Overtreatment, Hypoglycemia Common in Nursing Homes

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Diabetes Overtreatment, Hypoglycemia Common in Nursing Homes

Overtreatment of diabetes that may lead to hypoglycemia (low blood glucose) is common among nursing home residents, who may often benefit from less intensive diabetes treatments, according to a new study published in the Journal of the American Geriatrics Society.

Doctors who treat people with diabetes tend to pay a lot of attention to measures of blood glucose control such as A1C (a measure of long-term blood glucose control) — and for good reason. Better glucose control is linked, in the long run, to a lower risk for complications of diabetes like cardiovascular disease, kidney disease, and vision problems. But some treatments that lower blood glucose levels — including insulin and the oral drugs known as sulfonylureas (which include glipizide, glyburide, and glimepiride) — can also lead to hypoglycemia in certain contexts. Studies have shown that intensive blood glucose control tends to raise the risk for severe hypoglycemia, as measured by emergency room visits and hospital admissions. Even when hypoglycemia isn’t severe, it can be a very distressing experience — yet there is evidence that doctors don’t discuss this risk, or strategies to avoid hypoglycemia, with patients as much as they should. Hypoglycemia is also linked to greater frailty and functional decline in older adults, so to may be especially important to avoid it in this age group.

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Few adjustments made for nursing home patients with overtreatment

For the latest study, researchers were interested in looking at how common diabetes overtreatment might be among nursing home residents. The study participants were 7,422 residents of Veterans Affairs nursing homes who had lived there for at least 30 days, were at least 65 years old, and had type 2 diabetes. Based on previous research looking at the relationship between insulin, A1C, and hypoglycemia in older adults, the researchers defined overtreatment as an A1C level below 6.5% with any insulin use. They also defined potential overtreatment as an A1C level below 7.5% with any insulin use, or an A1C level below 6.5% with any glucose-lowering medication other than metformin alone.

The researchers found that among the study participants, 17% met the criteria for overtreatment, and 23% met the criteria for potential overtreatment. Unfortunately, only a small proportion of these participants appeared to have their diabetes treatments scaled back as a result of overtreatment — 27% of those with overtreatment, and 19% of those with potential overtreatment. In other words, 73% of participants with diabetes overtreatment and 81% of those with potential overtreatment didn’t show any signs of having their treatments reexamined.

The researchers found several factors that were linked to continued overtreatment of diabetes. Participants who took long-acting insulin were 37% more likely to experience continued overtreatment, and those who had very high blood glucose of 300 mg/dl or higher before their A1C test were 35% more likely to experience continued overtreatment. On the other hand, participants with severe functional impairment were 28% less likely to experience continued overtreatment. But shockingly, episodes of hypoglycemia were not linked to a lower risk for continued overtreatment — meaning that providers apparently weren’t taking this into account.

“Many [nursing home] residents who are unlikely to benefit from tight glycemic control and are at high risk of hypoglycemia continue to receive insulin and other medications that increase hypoglycemia risk even after [A1C] results suggest overtreatment,” the researchers concluded. “In addition to hypoglycemia risk, factors such as cognitive and functional impairment should be considered when identifying patients for treatment deintensification.”

Want to learn more about hypoglycemia? Read “Understanding Hypoglycemia,” “What Is Hypoglycemia? Symptoms and Treatments,” and “Best Ways to Treat Low Blood Sugar.”

Quinn Phillips

Quinn Phillips

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A freelance health writer and editor based in Wisconsin, Phillips has a degree from Harvard University. He is a former Editorial Assistant for Diabetes Self-Management and has years of experience covering diabetes and related health conditions. Phillips writes on a variety of topics, but is especially interested in the intersection of health and public policy.

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