Potential diabetes overtreatment among older adults with type 2 diabetes mellitus (T2DM) in Taiwan

Several clinical practice guidelines have recommended relaxing hemoglobin A1c (HbA1c) goals for older adults with type 2 diabetes mellitus (T2DM) and multiple comorbidities as the benefits of intensive glycemic control decline with age and the risks of adverse events such as hypoglycemia increase. However, there has not been an adequate assessment of this phenomenon and the factors associated with potential diabetes overtreatment, leading to uncertainty in identifying older adults who may be potentially overtreated. This dissertation addresses the gaps in care management for older diabetic adults. The first paper examined the prevalence of potential diabetes overtreatment with various HbA1c thresholds among older diabetic adults aged 65 and older. The potential overtreatment rates ranged from 25% to 45%, with HbA1c levels at less than 6.5% and 7.0%. Increasing age was associated with potential diabetes overtreatment. The second paper assessed severe hypoglycemia events requiring medical assistance as another indicator of potential diabetes overtreatment. Approximately 3% of the older adults in the study population had a severe hypoglycemia event requiring medical assistance, identified through primary diagnosis codes and glucose solution treatment in the ED or hospitalization. Insulin, glinide, sulfonylurea, and dementia were strongly associated with severe hypoglycemia. The third paper evaluated the treatment deintensification rate in the outpatient clinic following the severe hypoglycemia event. Only a third of the patients who had a history of severe hypoglycemia had their diabetes treatment deintensified. Revisits to the ED or hospitalization for recurrent hypoglycemia were lower for the group of patients who had their treatment deintensified. A reduction in the average HbA1c level six months after the severe hypoglycemia event was also observed regardless of deintensification status. These findings suggest a gap in care management for older diabetic adults. Potential overtreatment of diabetes in older diabetic adults is an under-recognized concern. There is a need to change the clinical practice to reflect the complexity and dynamic nature of older adults with diabetes. An approach to targeting higher-risk patients such as those who have experienced a severe hypoglycemia event for treatment deintensification may be an ideal first step to addressing the issue of potential overtreatment