Tight glycemic control can do more harm to elderly patients

Diabetes management typically focuses on treatments to lower glucose levels, but a new report shows that tight glycemic control may actually be causing problems in older adults with diabetes.

Hypoglycemia can cause a host of problems, particularly in older adults who may already struggle with vision, balance, and confusion problems. Particularly in those with other health problems, and other medications that may also contribute to hypoglycemia, tight glycemic control could be less beneficial than in younger, healthier populations.

Younger adults with diabetes are taught to aim for hemoglobin A1c (HbA1c) levels between 6% and 7%, but older adults with other health problems are more susceptible to hypoglycemia and may face negative consequences with tight glycemic control, the report notes.

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The study explains that recent studies have found that hypoglycemia is a particular threat for older adults, and that glucose-lowering medications resulting in hypoglycemia played a role in a quarter of emergency hospitalizations for adverse drug events in one study. Other recent studies revealed that hospital admissions for hypoglycemia surpass those for hyperglycemia, and hypoglycemia is the dominant complication of diabetes for most older adults.

“Aiming for a hemoglobin A1c below 7 increases the risk for hypoglycemia, and older adults are especially susceptible to this risk,” Kasia Joanna Lipska, MD, MHS, assistant professor of endocrinology at the Yale School of Medicine tells Medical Economics. “As a result, many guidelines suggest that treatment should be more cautious for these vulnerable elders and that aiming for ‘tight’ blood sugar control may not be worth the risk.”

Lipska says her study found that the overtreatment of older adults with diabetes is quite common. Despite recommendations more than a decade ago from the American Geriatrics Society and Veteran Affairs, a more cautious approach in lowering glucose levels in the elderly-especially those with additional health issues-has not been put into practice.

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Before implementing a plan to pursue tight glycemic control in an older patient with other health problems, Lipska recommends assessing the benefits and harms of any treatment regimen, an exploring how tight control can be achieved safely.

Of the nearly 1,3000 older adults studied, Lipska found that more than half of older adults with diabetes had A1c levels below 7%, even in cases where additional complex health problems were present.

In another recent study on diabetes overtreatment, researchers found that only 27% of patients who experienced dangerously low blood glucose levels had their medication regimens changed as a result. The study determined that one-third of physicians maintained their patient’s medication regimens because they thought they could benefit from exceeding guideline goals, while a quarter reported being worried about malpractice lawsuits from reducing treatment. Half of those polled were concerned that lowering medications for patients who have exceeded goals would lower scores on various performance measures, according to the report, and 20% worried that patients would be upset about a medication reduction after conditioning them on the importance of taking their medications.

Researchers recommend personalizing treatment plans and glycemic control goals in older populations with comorbidities rather than standardizing goals not tailored to the patient’s individual needs.