Are elderly people with diabetes being overtreated?
A new study suggests that's so: Older, sicker patients tend to be the ones most likely to still be using insulin to manage their blood sugar, despite guidelines that suggest it's often safer to lower diabetes treatment intensity with age.
Significant side effect
The study found that nearly 20% of people with type 2 diabetes older than 75 were still using insulin treatment. And almost 30% of people with diabetes over 75 in poor health were taking insulin.
One of the most significant side effects of insulin is low blood sugar (hypoglycaemia). This can leave you feeling shaky, sweaty, irritable, confused and dizzy. It can also cause an irregular heartbeat, and may lead to fainting. At its most serious, hypoglycaemia can cause death, though this happens rarely, according to the American Diabetes Association.
Major health organisations – including the American Diabetes Association, the US Department of Veterans Affairs and the American Geriatrics Society – recommend that healthy older patients can maintain tighter blood sugar control. But for patients in poor health, with shorter life expectancies, these groups suggest less aggressive lowering of blood sugar levels.
"It seems a little counterintuitive after you spend decades working hard to control your blood sugar to think about not doing that," said study author Dr Richard Grant.
"But, as with most things in medicine, there's a risk-benefit ratio, and for most years, there's a much bigger benefit than risk to taking insulin. But as life expectancy decreases, tight blood sugar control provides less benefit than risk," Grant said. He's a research scientist in the division of research at Kaiser Permanente of Northern California, in Oakland.
Stepping down treatment
Grant said patients are often concerned if doctors bring up the idea of treating their diabetes less aggressively. "It's not abandoning care, it's maybe taking half a step back to reduce the risk from treatment," he explained.
The findings were published online in JAMA Internal Medicine.
Another study published previously in the same journal found that patients don't always follow the guidelines for stepping down their treatment. The study – led by Dr Nancy Schoenborn at Johns Hopkins University School of Medicine in Baltimore – found that 60% of people surveyed didn't agree with the guidelines and thought the longer you live with diabetes, the more aggressive your treatment should be.
These findings suggest that patients need better information about why doctors are recommending certain treatments plans over others, Schoenborn said in a university news release. Reducing treatment levels can lower the risk of side effects and improve quality of life, she said.
Grant's study included almost 22 000 people with type 2 diabetes. Their health was followed for up to four years, beginning at age 75.
Their health was defined as good if they had fewer than two additional medical conditions, or had two additional conditions but stayed physically active. Intermediate health was defined as having more than two additional conditions or having two additional conditions and no weekly exercise. People in poor health had end-stage lung, heart or kidney disease, or dementia or advanced cancer.
Reassessing one's goals
People in poor health had double the risk of being treated with insulin compared to those in good health. Those in intermediate health had an 85% higher risk of being treated with insulin than those in good health, the findings showed.
Those most likely to continue using insulin throughout the four-year study were those in poor health. People in good health were least likely to stay on insulin.
Grant said, "It's very important for doctors to reassess the goals and treatment of older patients from time to time."
Dr Joel Zonszein, director of the clinical diabetes centre at Montefiore Medical Center in New York City, said, "We have to start thinking a bit more about how we treat elderly patients and the impact of treatment on their quality of life."
Zonszein said preventing low blood sugar levels (hypoglycaemia) is even more important in older patients, and that there are newer types of insulin and other medications that can be used that have less risk of causing hypoglycaemia.
The bottom line, according to the experts, is to maintain an ongoing conversation with your doctor. Anytime your health status changes, talk with your doctor about the benefits and risks of all the treatments you're taking.
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