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Nursing Home Residents at Risk for Overtreatment of Diabetes

(Reuters Health) – Many nursing home residents with diabetes may be treated to intensive glycemic targets even though such aggressive management may have limited benefit, a new study suggests.

Researchers examined data on 15,034 adults with diabetes residing in nursing homes in Ontario, Canada, who were treated with one or more antihyperglycemic medications. The analysis focused on how often treatment did not follow recommendations from the American Geriatrics Society to avoid targeting HbA1c below 7.5% with high-risk agents (agents other than metformin) due to the risk of hypoglycemia and mortality.

Overall, participants’ mean HbA1c was 7.3%, and 7,592 (50.5%) had mean HbA1c of 7% or less.

Adults who had severe cognitive impairment using the validated Cognitive Performance Scale had lower mean HbA1c (7.1%) than those with mild/moderate (7.3%) or intact/borderline cognitive impairment (7.3%).

Among the nursing home residents (n=7,479) being treated with high-risk agents, significantly more individuals with severe cognitive impairment (44.7%) than with mild/moderate (39.3%) or intact/borderline (38.4%) cognition were treated to HbA1c levels of 7% or lower, researchers report in JAMA Internal Medicine.

“The take-home message here is that older adults with frailty, cognitive impairment, limited life expectancy will not benefit from intensive glycemic control, and more importantly are at risk of harm because of these treatments,” said lead study author Dr. Iliana Carolina Lega, an assistant professor at the University of Toronto and endocrinologist at Women’s College Hospital.

“As a result, clinicians who take care of older patients should carefully reexamine glycemic targets for these patients and think carefully before prescribing or renewing diabetes medications, especially in the setting of A1c values less than 7%,” Dr. Lega said by email.

Some limitations of the study include the lack of data on patient or family preferences regarding diabetes treatment, as well as the lack of data on clinicians’ recommended treatment regimen and clinicians’ perspectives on the optimal treatment outcomes.

Even so, the results highlight that more intensive control and treatment with higher risk medications are more likely among patients who are sicker, frailer, and vulnerable to adverse drug events, said Dr. Kasia Lipska, an endocrinologist and associate professor at Yale School of Medicine in New Haven, Connecticut, who wasn’t involved in the study.

“We measure proportion of patients with poor glycemic control for quality measurement, but we don’t do the same for A1c levels that are too low,” Dr. Lipska said by email. “I think it’s a real blind spot in our diabetes care.”

SOURCE: JAMA Internal Medicine, online March 1, 2021.

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