Some Older Patients Are Treated Not Wisely, but Too Much

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By Paula Span

older patientsOver many years, the 77-year-old patient has managed to control hisType 2 diabetes. Thanks in part to daily doses of a drug that reduces blood sugar, his glucose level is a very low 6.5 percent.

Like a lot of older people, he copes with multiple medical conditions, including high blood pressure and severe kidney disease. But with four prescription drugs, plus Tylenol forlower back pain, he’s doing reasonably well.

Oh, and he’s a hypothetical example, concocted by researchers at the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System. They sent this fictional case study to primary-care professionals at Veterans Affairs medical centers across the country and asked a series of questions about the man’s treatment.

The researchers believed their nearly 600 respondents — mostly physicians, but also nurse practitioners and physician assistants — would recognize that such a patient risked developing dangerously low blood sugar, called hypoglycemia. But no. About half these professionals said they wouldn’t worry about potential harm from the man’s rigorous treatment regimen.

Evidence is accumulating that older adults with diabetes, hypertension and other conditions should be treated less aggressively than they commonly are. “Deintensification,” the Michigan researchers have named this approach.

As this and another related recent study have shown, not for the first time, getting that message out to practicing physicians has proved difficult.

“In our health care system, we are all more scared of failing to do something than of doing too much,” said Dr. Jeremy Sussman, a primary care physician and research scientist at the Ann Arbor hospital.

Under current guidelines, most older patients with diabetes don’t have to get their blood sugar to rock bottom; a 7.5 or 8 percent blood glucose level (measured as HbA1c, an average of several recent readings) produces the same benefits as very low glucose. Blood pressure readings, too, should be allowed to rise as patients age — up to 150 millimeters of mercury for systolic pressure. The previous goal was to keep it below 140.

There are good reasons to be less vigilant. In older people with diabetes, for instance, maintaining very low blood sugar — often called “tight control” — can do more harm than good. “People can feel fatigued and weak, get cold sweats, feel like they’re going to pass out,” said Dr. Tanner Caverly, lead author of the Michigan survey, published in JAMA Internal Medicine. Thefainting and falls that may result can have devastating consequences.

Further, a widely cited study called Accord, published in 2008 in The New England Journal of Medicine, found that intensive therapy to reduce blood glucose actually resulted in higher mortality.

Yet a large national study by Dr. Sussman and his colleagues, published last month in JAMA Internal Medicine, reveals how rarely deintensification occurs among patients over age 70.

Reviewing Veterans Affairs data on more than 211,000 patients, the researchers found that fewer than 19 percent of those with very low blood pressure had scaled back their medications. Only 27 percent of those with very low blood sugar had done so.

“There’s been a huge effort to ensure that fewer people are undertreated,” Dr. Sussman said. “Now, maybe we’ve crossed the line and too many people are overtreated.”

Examples of both extremes are easy to find.

Among older adults, substantial proportions still don’t take advantage of vaccines, among the simplest of health protections. A third of those over age 65 didn’t get flu shots last season, according to data from the Centers for Disease Control and Prevention. More than 40 percent haven’t been vaccinated against pneumonia, and fewer than a quarter have gotten the shingles vaccine.

But older Americans receive too many colonoscopies and too many mammograms. Last year, a study found that more than half of nursing home residents with advanced dementia, a terminal disease, were receiving drugs of questionable value; about a fifth took statins to lower cholesterol.

Overtreatment, however, rarely brings the sort of hand-wringing that undertreatment does. You might think it would be welcome news that older diabetics can do well with lower doses of medication, and that in some cases they might be able to stop taking glucose-lowering drugs altogether.

Tight control takes great effort, and it makes sense for young and middle-aged people with diabetes. The benefits accrue slowly, over years, so younger patients are more apt to receive them. The young have stronger bones and better balance, so they are less likely to be injured in the falls that too-low blood sugar can cause.

Older, frailer people with lower life expectancy and many additional health problems face different trade-offs.

“As you get older, the benefits go down and the risks go up,” said Dr. Sei Lee, a geriatrician at the University of California, San Francisco, who has written about the subject for years. “What was good for you at 55 might be bad for you at 75.”

As a member of the American Geriatrics Society’s Choosing Wisely panel, Dr. Lee helped draft its recommendation that a 7 to 7.5 percent blood glucose reading is a reasonable goal for healthy seniors. For those with additional health problems and life expectancies of less than 10 years, the panel suggested a 7.5 to 8 percent goal, rising to 8 to 9 percent for those with many medical conditions and few years ahead.

Given all that, it’s disappointing that more primary care providers in the new Veterans Affairs study never thought to tell our fictional 77-year-old that he could afford to let his blood glucose rise a bit, and maybe eat a cookie once in a while. But sometimes patients themselves resist, especially if they have been dutifully monitoring their disease for years.

Dr. Sussman recalled a veteran, about 80, who took pride in the way he’d managed his illness, testing his blood several times a day, injecting insulin, keeping his glucose below 7. He had lost weight with age, however, so Dr. Sussman suggested he stop insulin shots and begin taking the diabetes drug metformin, which comes in pill form.

The man gave it a try. “But he and his wife never lost their discomfort with doing less than they had been,” Dr. Sussman said. The patient went back to the injections.

At least his doctor had pointed out the option and explained the likely benefits. In the new Veterans Affairs study, nearly 30 percent of respondents said they lacked the time to discuss the risks and benefits. About a quarter said they feared that reducing the fictional patient’s medications could make them vulnerable to a lawsuit.

More than 40 percent worried that higher blood glucose would violate their institutions’ performance measures, the report cards doctors get — even though the Department of Veterans Affairs has never specified a target below 7 percent for these patients.

Just the contrary: The department last year announced a National Hypoglycemic Safety Initiative, changing its approach to diabetes management to avoid intensive treatment when it’s not warranted.

Still, older adults who haven’t reassessed their diabetes or blood pressure regimens for years probably should be asking their doctors if they can or should make changes. The doctors, for now, might not raise the subject themselves.

“It’s one thing to find out about something new and exciting and do it,” Dr. Sussman reflected. “It’s harder, emotionally, to look at something you’ve done for a long time and think, maybe this isn’t so good. And stop.”

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