Are older patients with diabetes still being overtreated in French long-term care homes?

Prevalence and characteristics of older adults with type 2 diabetes mellitus living in French Caribbean nursing homes: results from the baseline KASEHPAD study

BACKGROUND

The management of older adults with type 2 diabetes mellitus (T2DM) has not been previously assessed in nursing homes within the Caribbean region.

AIMS

To investigate the prevalence of T2DM among residents of French Caribbean nursing homes and to characterize their health and functional status.

METHODS

This cross-sectional study is based on baseline screening data from the KASEHPAD (Karukera Study of Ageing in Nursing Homes) cohort. Clinical characteristics and standard geriatric parameters were systematically collected and analyzed. Hemoglobin A1c (HbA1c) levels of older adults with diabetes were retrospectively extracted from patient records.

RESULTS

A total of 332 participants aged 60 years or older were recruited from six nursing homes between September 2020 and November 2022. The prevalence of T2DM among residents was 28.3% (95% CI: 23.5-33.2). Among older adults with T2DM, 85.1% had hypertension, 17.1% had heart failure, and 24.1% had a history of stroke. The mean HbA1c level was 7.32 ± 1.5%. Of the 35 individuals (42.7%) with HbA1c < 7%, 19 (54.3%) were receiving antidiabetic medications. Multivariate analysis identified HbA1c as the sole factor significantly associated with antidiabetic medication use (OR: 1.76, 95% CI: 1.12-3.04).

DISCUSSION

Older adults with T2DM residing in French Caribbean nursing homes exhibit a high prevalence of cardiovascular risk factors and are at risk of overtreatment. The management of T2DM in this population appears to be driven primarily by blood glucose levels.

CONCLUSION

As the prevalence of older adults with T2DM is expected to rise in the Caribbean region, this trend will present significant challenges in delivering tailored care within future nursing home settings.

Overtreatment of older people with type 2 diabetes-a high impact frequent occurrence in need of a new definition

BACKGROUND

Diabetes overtreatment is a frequent and major issue in older people with type 2 diabetes but its definition is often inconsistent and may be misleading. This critical review has aimed at examining the definitions of diabetes overtreatment in older people used in research studies.

METHODS

Studies addressing diabetes overtreatment in people aged 65 or older were identified by searching the PubMed database according to an extensive search equation.

RESULTS

Twenty-two research studies providing a definition of diabetes overtreatment in people aged were found. Overall, 12 different definitions of diabetes overtreatment were used. All studies defined overtreatment according to a HbA_1c threshold (varying from <42 mmol/mol [<6.0%] to <64 mmol/mol [<8%]). Amongst them, 2 definitions had no consideration about glucose-lowering (GL) treatment, 6 required the prescribing of ≥1 GL agent(s), and 4 the prescribing of ≥1 GL agent(s) inducing the high risk of hypoglycaemia (i.e., sulfonylurea(s) or insulin(s)). Only 4 definitions (four studies) were individualised, using varying HbA_1c thresholds according to patients' age or health status.

CONCLUSIONS

Definitions of diabetes overtreatment are heterogeneous across research studies, which is confusing. A standardised definition, based on the individual risk of hypoglycaemia and/or its complications must be promoted in order to bring clarity and greater insight into this field, as well as to improve the quality of management of diabetes in older patients.

Ten-Year Prospective Follow-Up of Institutionalized Patients With Diabetes in a Long-Term Care Home

Clinical practice recommendations advise individualizing diabetes treatment for elderly people, especially those living in long-term care facilities. Elderly patients face one of two main risks: either excessive treatment leading to hypoglycemia or insufficient treatment leading to progression of complications and excess mortality. This article describes a 10-year prospective observational study of people with diabetes in a long-term care home to determine the effect of routine glucose monitoring and monthly evaluation by a diabetes specialist with a goal of improving A1C. Its findings suggest that minimal glucose monitoring and monthly medical follow-up can optimize patient outcomes and help to maintain quality of life without over-medicalization of older people with diabetes in institutional settings.

Making progress: but a way to go-the age and ageing care-home collection

Care homes enable people with advanced physical and cognitive impairment to live well with 24-h support from staff. They are a feature of care systems in most countries. They have proved pivotal to the coronavirus disease 2019 (COVID-19) response. We searched Age and Ageing for care-home articles published since 2015. From these we collated 42 into the Age and Ageing care-home collection. This collection draws together important papers that show how Age and Ageing is helping to shape and grow care-home research. The  collection outlines the technical issues that researchers face by grouping together important feasibility trials conducted in the sector. It looks at the challenges of measuring quality of life and working with routine data in care homes. It brings together observational studies considering loneliness, functional dependency, stroke outcomes, prescribing and acute deterioration. Health services research in care homes is represented by two studies that demonstrate realist evaluation as a way to make sense of service innovations. Papers are included that consider: non-pharmacological strategies for residents with dementia, end-of-life care, sexuality and intimacy and the care-home workforce. Given the importance of the COVID-19 pandemic in care homes, all of the care home COVID-19 papers published in Age and Ageing to date are included. Finally, a group of papers that present innovative approaches to research in care homes, each of which give voice to residents and/or staff, are collated and presented as a way of moving towards a more resident and care home centred research agenda.

Frequent and severe hypoglycaemia detected with continuous glucose monitoring in older institutionalised patients with diabetes

BACKGROUND

Little is known about the prevalence of hypoglycaemia in older people with diabetes. However, the HbA1c goal is ≥8% for institutionalised patients with treatments that can cause hypoglycaemia.

PURPOSE

We aimed to assess the prevalence of hypoglycaemia with continuous glucose monitoring and to evaluate the link with HbA1C in older institutionalised patients with diabetes taking potentially hypoglycaemia-inducing drugs.

DESIGN

Prospective, multicentre study carried out in six geriatric care centres in the Côte d'Or region of France between January 2019 and July 2020.

SETTINGS, SUBJECTS AND METHODS

A FreeStyle Libre Pro® (FSLP) was worn for up to 14 days in blinded mode in 42 patients taking at least one potentially hypoglycaemia-inducing antidiabetic drug.

RESULTS

Two hundred and forty-two hypoglycaemic events were detected in 79% (n = 33) of patients wearing the FSLP. One or more hypoglycaemic event was detected in 100% of patients with HbA1C < 7% and in 79% of patients with HbA1C ≥ 8% (P = 0.02). The time spent in hypoglycaemia was higher in patients with HbA1C < 7% than those with HbA1C ≥ 8% (P = 0.015). Time spent <54 mg/dl was detected in 45% of patients.

CONCLUSIONS

We report a very high prevalence of hypoglycaemia, with a significant proportion of severe hypoglycaemia, in older institutionalised patients with diabetes taking potentially hypoglycaemia-inducing drugs. Having HbA1C < 7% exposes patients to a higher risk of hypoglycaemia, but this risk remains also high in patients with HbA1C ≥ 8%. In this population, continuous glucose monitoring could be considered an effective tool to detect hypoglycemia, which is associated with increased risk of cardiovascular events, falling, fractures, cognitive impairment and mortality.

Potential Overtreatment and Undertreatment of Type 2 Diabetes Mellitus in Long-Term Care Facilities: A Systematic Review

OBJECTIVE

To investigate the prevalence, outcomes, and factors associated with potential glycemic overtreatment and undertreatment of type 2 diabetes mellitus (T2DM) in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

Residents with T2DM and aged ≥60 years living in LTCFs.

MEASURES

Articles published between January 2000 and September 2020 were retrieved following a systematic search of MEDLINE, EMBASE, Cochrane Library, CINAHL plus, and gray literature. Inclusion criteria were the reporting of (1) potential overtreatment and undertreatment quantitatively defined (implicitly or explicitly) based on hemoglobin A1c (HbA1c) and/or blood glucose; (2) prevalence, outcomes, and associated factors of potential glycemic overtreatment and undertreatment; and (3) the study involved residents of LTCFs.

RESULTS

Fifteen studies were included. Prevalence of potential overtreatment (5%-86%, n = 15 studies) and undertreatment (1.4%-35%, n = 8 studies) varied widely among facilities and geographical locations, and according to definitions used. Prevalence of potential overtreatment was 16%-74% when defined as treatment with a glucose-lowering medication in a resident with ≥1 hypoglycemia risk factor or serious comorbidity, together with a HbA1c <7% (n = 10 studies). Potential undertreatment was commonly defined as residents on glucose-lowering medication having HbA1c >8.5% and the prevalence 1.4%-14.8% (n = 6 studies). No studies prospectively measured resident health outcomes from overtreatment and undertreatment. Potential overtreatment was positively associated with use of oral glucose-lowering medications, dementia diagnosis or dementia severity, and/or need for assistance with activities of daily living (n = 2 studies). Negative association was found between potential overtreatment and use of insulin/combined insulin and oral glucose-lowering medication. No studies reported factors associated with potential undertreatment.

CONCLUSIONS AND IMPLICATIONS

The prevalence of potential glycemic overtreatment and undertreatment varied widely among residents with T2DM depending on the definition(s) used in each study. Longitudinal studies examining associations between glycemic management and health outcomes, and the use of consensus definitions of overtreatment and undertreatment are required to establish findings about actual glycemic overtreatment and undertreatment in LTCFs.