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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.

Jeremy Sussman, M.D., M.S., lead author of the study that used medical records, notes that the reasons why doctors prescribe medication to help people get their blood pressure and diabetes under control mostly focus on the long term.

Controlling these factors for years can help people cut their risk of problems that result from too-high blood pressure or sugar levels, like stroke, heart attack, blindness, nerve damage, amputation and kidney failure.

“Every guideline for physicians has detailed guidance for prescribing and stepping up or adding drugs to control these risk factors, and somewhere toward the end it says ‘personalize treatment for older people’,” says Sussman, an assistant professor of general internal medicine. “But nowhere do they say actually stop medication in the oldest patients to avoid hypoglycemia or too-low blood pressure.”

If a patient has been on medication for diabetes or blood pressure for many years, and is now in their late 70s or older, they may have gotten many long-term benefits from keeping their levels in control. But because their chance of a dangerous blood sugar or blood pressure dip goes up with age, the short-term risk starts to balance out any long-term gain they could still get.

“Physicians are used to thinking about when to start medications, and if a patient isn’t complaining and appears to be doing fine, stopping medications may not be first thing on their mind,” says Tanner Caverly, M.D., MPH, clinical lecturer and lead author on the survey of primary care providers. “As we get more precise evidence about the degree of benefit and harm from using these medications, it’s showing us that we need to dial back in some patients.”