Hypoglycemia in Older Adults: Time Trends and Treatment Differences in Patients Aged ≥75 Years With Type 2 Diabetes

Technology Use and Diabetes Management Across Elder Age Groups in Type 1 Diabetes and Latent Auto-Immune Diabetes of the Adult (LADA), a BETTER Registry Cross-Sectional Analysis

OBJECTIVES

Real-world data on diabetes management among a heterogenous aging population remain limited. This study aims to provide an overview of technology use and factors associated to its use, diabetes management and psychosocial aspects experienced by adults aged 50 and over living with type 1 diabetes (T1D) or latent autoimmune diabetes in adults (LADA).

METHODS

This cross-sectional study analyzed data from the Canadian BETTER registry, mostly based on self-reported outcomes from individuals living with T1D or LADA. Comparative analyses were conducted across three age groups: 50-59, 60-69, and ≥70.

RESULTS

Participants (n=674) were predominantly Caucasian (97-98% across groups) and residing in Quebec, Canada (71-79%). Insulin pump use was similar across age groups (36-39%, p=0.822), while continuous glucose monitoring (CGM) was lower among those aged ≥70 years (85% for both 50-59 and 60-69 vs 73% for ≥70 years, p=0.020). Among other factors, having private insurance and living outside of Quebec were positively associated with both insulin pump and CGM use. A high proportion (80-86%) of participants achieved an HbA1c ≤8% across all groups. Level 2 hypoglycemia events in the last month were more frequent among participants aged 50-59 years compared to those aged ≥70 years (6.9 vs 3.4, p=0.001). Level 3 hypoglycemia, social and professional support were similar between groups. Interestingly, diabetes-related distress was lower in older age groups.

CONCLUSIONS

Most individuals in this cohort adopted technology use but in lower proportion among the group aged ≥70. Overall, diabetes management was good and similar between age groups.

Initiating an Insulin Safety Campaign to reduce the incidence of glycemic harm events for hospitalized adults 65 and older

BACKGROUND

During calendar years 2021 through 2023, our health system admitted 200,837 persons 18 years and older with diabetes, of which 61% (n = 123,393) were 65 years and older with orders for insulin administration. The incidence of diabetes among hospitalized persons 65 and older continues to increase in the United States, with 24 million adults 65 and older with diabetes reported in 2020. Insulin, a high-risk medication, has the potential for adverse drug events, which can cause significant harm to patients, potentially resulting in death. With the 2023 initiation of voluntary electronic clinical quality measures reporting for severe glycemic harm events from the Centers for Medicare Services, the study team saw an opportunity to evaluate and standardize insulin-related practices across the system.

METHODS

We implemented an Insulin Safety Campaign (ISC), to review, evaluate, and standardize insulin-related processes across our health system. The primary goal was to reduce severe glycemic harm events system-wide. Insulin-related practices were reviewed for best practice alignment and standardized. Outcomes were measured according to the Centers for Medicare and Medicaid Services' electronic clinical quality measures reporting guidelines.

RESULTS

Comparing pre-and post-implementation results, all five medical centers achieved statistically significant reductions in sever hyper- and hypoglycemic harm events.

CONCLUSIONS

Through a collaborative effort, we were able to identify, address, and reduce insulin-related process variabilities through standardization, reducing the percentage of severe glycemic harm events and improving blood glucose management in our hospitalized persons 65 and older.

Diabetes mellitus in older persons with neurocognitive disorder: overtreatment prevalence and associated structural brain MRI findings

BACKGROUND

Tight diabetes control is often applied in older persons with neurocognitive disorder resulting in increased hypoglycemic episodes but little is known about the pattern of brain injury in these overtreated patients. This study aims to: (a) quantify the prevalence of diabetes overtreatment in cognitively impaired older adults in a clinical population followed in an academic memory clinic (b) identify risk factors contributing to overtreatment; and (c) explore the association between diabetes overtreatment and specific brain region volume changes.

METHODS

Retrospective study of older patients with type 2 diabetes and cognitive impairment who were diagnosed in a memory clinic from 2013 to 2020. Patients were classified into vulnerable and dependent according to their health profile. Overtreatment was defined when glycated hemoglobin was under 7% for vulnerable and 7.6% for dependent patients. Characteristics associated to overtreatment were examined in multivariable analysis. Grey matter volume in defined brain regions was measured from MRI using voxel-based morphometry and compared in patients over- vs. adequately treated.

RESULTS

Among 161 patients included (median age 76.8 years, range 60.8-93.3 years, 32.9% women), 29.8% were considered as adequately treated, 54.0% as overtreated, and 16.2% as undertreated. In multivariable analyses, no association was observed between diabetes overtreatment and age or the severity of cognitive impairment. Among patients with neuroimaging data (N = 71), associations between overtreatment and grey matter loss were observed in several brain regions. Specifically, significant reductions in grey matter were found in the caudate (adj β coeff: -0.217, 95%CI: [-0.416 to -0.018], p = .033), the precentral gyri (adj βcoeff:-0.277, 95%CI: [-0.482 to -0.073], p = .009), the superior frontal gyri (adj βcoeff: -0.244, 95%CI: [-0.458 to -0.030], p = .026), the calcarine cortex (adj βcoeff:-0.193, 95%CI: [-0.386 to -0.001], p = .049), the superior occipital gyri (adj βcoeff: -0.291, 95%CI: [-0.521 to -0.061], p = .014) and the inferior occipital gyri (adj βcoeff: -0.236, 95%CI: [-0.456 to - 0.015], p = .036).

CONCLUSION

A significant proportion of older patients with diabetes and neurocognitive disorder were subjected to excessively intensive treatment. The association identified with volume loss in several specific brain regions highlights the need to further investigate the potential cerebral damages associated with overtreatment and related hypoglycemia in larger sample.

Impact of Type 2 Diabetes and Glycated Hemoglobin Levels Within the Recommended Target Range on Mortality in Older Adults With Cognitive Impairment Receiving Care at a Memory Clinic: NCGG-STORIES

OBJECTIVE

To determine the impact of type 2 diabetes and glycated hemoglobin (HbA1c) levels within the recommended target range according to the Japan Diabetes Society/Japan Geriatrics Society Joint Committee on mortality in older adults with cognitive impairment.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included 1,528 and 468 patients aged ≥65 years without and with type 2 diabetes, respectively, who were visiting a memory clinic. The 468 patients with type 2 diabetes were divided into three groups (within, above, and below the target range) based on their HbA1c levels, cognitive function, ability to perform activities of daily living, and medications associated with a high risk of hypoglycemia. The impact of diabetes and HbA1c levels on mortality was evaluated using Cox proportional hazards models.

RESULTS

Over a median follow-up period of 3.8 years, 353 patients (17.7%) died. Compared with individuals without type 2 diabetes, HbA1c levels above (hazard ratio [HR] 1.70, 95% CI 1.08-2.69) and below (HR 2.15, 95% CI 1.33-3.48) the target range were associated with a higher risk of death; however, HbA1c levels within the target range were not (HR 1.02, 95% CI 0.77-1.36).

CONCLUSIONS

HbA1c levels above and below the target range were associated with a higher risk of mortality, whereas patients with HbA1c levels within the target range did not exhibit a higher risk of mortality than individuals without type 2 diabetes. These results provide empirical support for the current target ranges among older adults with cognitive impairment.

Medication Prescribing for Type 2 Diabetes in the US Long-Term Care Setting: Observational Study

OBJECTIVES

To characterize prescribing of glucose-lowering medication annually and to quantify the annual frequency of hypoglycemia among residents in long-term care (LTC) facilities with type 2 diabetes mellitus (T2DM).

DESIGN

Serial cross-sectional study using a deidentified real-world database comprising electronic health records from LTC facilities.

SETTING AND PARTICIPANTS

Individuals eligible for this study were ≥65 years old with T2DM and recorded stay of ≥100 days at an LTC facility in the United States in any of 5 study years (2016-2020), excluding individuals receiving palliative or hospice care.

METHODS

Drug orders (prescriptions) for glucose-lowering medications for each LTC resident with T2DM in each calendar year were summarized by administration route (oral or injectable) and by drug class as ever-prescribed (ie, multiple prescriptions were included once), overall and stratified by age subgroup, <3 vs ≥3 comorbidities, and obesity status. We calculated the annual percentage of patients ever prescribed glucose-lowering medication each year, overall and by medication category, who experienced ≥1 hypoglycemic events.

RESULTS

Among 71,200 to 120,861 LTC residents with T2DM included each year from 2016 to 2020, 68% to 73% (depending on the year) were prescribed ≥1 glucose-lowering medications, including oral agents for 59% to 62% and injectable agents for 70% to 71%. Metformin was the most commonly prescribed oral agent, followed by sulfonylureas and dipeptidyl peptidase 4 inhibitors; basal plus prandial insulin was the most commonly prescribed injectable regimen. Prescribing patterns remained relatively consistent from 2016 to 2020, both overall and by patient subgroup. During each study year, 35% of LTC residents with T2DM experienced level 1 hypoglycemia (glucose ≥54 to <70 mg/dL), including 10% to 12% of those prescribed only oral agents and ≥44% of those prescribed injectable agents. Overall, 24% to 25% experienced level 2 hypoglycemia (glucose concentration <54 mg/dL).

CONCLUSIONS AND IMPLICATIONS

Study findings suggest that opportunities exist for improving diabetes management for LTC residents with T2DM.

Trends of Antidiabetic and Cardiovascular Diseases Medication Prescriptions in Type 2 Diabetes between 2005 and 2017-A German Longitudinal Study Based on Claims Data

BACKGROUND

With an attempt to understand possible mechanisms behind the severity-dependent development of type 2 diabetes (T2D) comorbidities, this study examines the trends of antidiabetic and cardiovascular diseases (CVD) medication prescriptions in individuals with T2D.

METHODS

The study is based on claims data from a statutory health insurance provider in Lower Saxony, Germany. The period prevalence of antidiabetic and CVD medication prescriptions was examined for the periods 2005-2007, 2010-2012, and 2015-2017 in 240,241, 295,868, and 308,134 individuals with T2D, respectively. (Ordered) logistic regression analyses were applied to examine the effect of time period on the number and prevalence of prescribed medications. Analyses were stratified by gender and three age groups.

RESULTS

The number of prescribed medications per person has increased significantly for all examined subgroups. For the two younger age groups, insulin prescriptions decreased but those of non-insulin medications increased, while both increased significantly over time for the age group of 65+ years. Except for glycosides and antiarrhythmic medications, the predicted probabilities for CVD medications increased over the examined periods, with lipid-lowering agents demonstrating the highest increase.

CONCLUSIONS

Results point towards an increase in medication prescriptions in T2D, which is in line with the evidence of the increase in most comorbidities indicating morbidity expansion. The increase in CVD medication prescriptions, especially lipid-lowering agents, could explain the specific development of severe and less severe T2D comorbidities observed in this population.

Time trends (2012-2020) in glycated hemoglobin and adherence to the glycemic targets recommended for elderly patients by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee among memory clinic patients with diabetes mellitus

AIMS/INTRODUCTION

To investigate the changes in the glycated hemoglobin (HbA1c) levels and the relative status of the glycemic control related to the new glycemic targets recommended by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee in 2016 in patients with diabetes mellitus visiting a memory clinic from 2012 to 2020.

MATERIALS AND METHODS

This cross-sectional study included 1,436 patients aged ≥65 years with diabetes. Patients were categorized into three categories as follows: category I, intact cognitive function and activities of daily living (ADL); category II, mild cognitive deficits or impaired instrumental ADL; and category III, moderate to severe cognitive impairment or impaired basic ADL. Trends in HbA1c levels, glycemic control status (optimally/poorly/excessively controlled) and proportion of individuals receiving drugs potentially associated with severe hypoglycemia among all patients and categories (I, II or III) from 2012 to 2020 were examined using linear, logistic and multinominal logistic regression models adjusted for confounding factors.

RESULTS

Between 2012 and 2020, the HbA1c levels, as well as the proportion of patients with poor glycemic control, increased, whereas the proportion of patients with excessive glycemic control and those receiving drugs potentially associated with severe hypoglycemia decreased.

CONCLUSIONS

Increased levels of HbA1c and decreased proportions of individuals under excessive glycemic control might reflect recent treatment strategies that avoid hypoglycemia in older patients. Given the adverse complications associated with hyperglycemia, more flexible and individualized glycemic targets based on comprehensive assessments, including vascular complications and comorbidities, might be necessary.