More Medicine May Not Be Better Medicine for Older Patients

Seniors being treated with medicine for levels of blood sugar and hypertension may be able to take less medicine without losing any benefits, new research shows.

A new study published in JAMA Internal Medicine suggests doctors and patients should work together to backpedal such treatment more often. The reason: In people in their 70s and older, very low blood pressures and sugar levels can actually raise the risk of dizzy spells, confusion, falls and even death. The consequences can be dangerous.

In recent years, experts have started to suggest that doctors ease up on how aggressively they treat such patients for high blood pressure or diabetes — especially if they have other conditions that limit their life expectancy.

To see if such efforts to encourage doctors to de-intensify treatment are working, a team of researchers from the University of Michigan Medical School and VA Ann Arbor Healthcare System studied the issue from two sides: patient records and a survey of primary care providers. They focused on patients over 70 with diabetes who had their blood sugar and pressure well under control using medication.

In all, only one in four of nearly 400,000 older patients who could have been eligible to ease up on their multiple blood pressure or blood sugar medicines actually had their dosage changed. Even those with the lowest readings, or the fewest years left to live, had only a slightly greater chance as other patients of having their treatment de-intensified.

Meanwhile, only about half of the nearly 600 doctors, nurse practitioners and physician assistants surveyed said they would de-intensify the treatment of a hypothetical 77-year-old man with diabetes and ultra-low sugar levels that put him at risk of a low-sugar crisis called hypoglycemia.

According to a news release from the Health System of the University of Michigan, many providers said they worried that decreasing medications for a patient like this might lead to harm, and that decreasing medications might make their clinical “report cards” look worse. Some even worried about their legal liability.

“As physicians, we want to make sure patients get the care they need, but we should also avoid care that might harm them,” says Eve Kerr, M.D., MPH, an author on both studies and director of the VA Center for Clinical Management Research. “If something is not likely to benefit them, but is likely to cause other problems, then we should pull back,” she adds. “We were surprised to find that this is not yet happening despite guidelines to aid providers in determining who qualifies for de-intensification.”

In both cases, the researchers looked at care in the VA system – which is actively trying to encourage de-intensification of blood sugar-reducing treatment in its oldest patients nationwide.


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