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

https://doi.org/10.1016/j.jamda.2021.04.013Get rights and content

Abstract

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).

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.

Section snippets

Methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement.29 A protocol was published prospectively on PROSPERO 2019 (CRD42019120029).30

Results

Of the 6026 potentially relevant articles retrieved, 15 articles satisfied the inclusion criteria (Supplementary Figure 1). Excluded studies with reasons for exclusion are in Supplementary Table 1. Study characteristics are summarized in Table 2. Studies were conducted in the United States (n = 3),35, 36, 37 Italy (n = 3),38, 39, 40 France (n = 3),41, 42, 43 Norway (n = 1),44 Sweden (n = 1),45 Australia (n = 1),46 Canada (n = 1),47 Japan (n = 1),48 and India (n = 1).49

Discussion

This was the first systematic review to examine the prevalence, outcomes of, and factors associated with potential overtreatment and undertreatment of T2DM in the LTCF setting. Prevalence of potential glycemic overtreatment and undertreatment of T2DM (5%–86% and 1.4%–35%, respectively) varied widely due to the varying definitions of potential overtreatment and undertreatment used. The widely varying prevalence also reflect likely differences in organizational culture and medication management

Conclusion and Implications

This systematic review provides evidence of potential glycemic overtreatment and undertreatment in LTCFs. More studies reported potential overtreatment than potential undertreatment. Residents with dementia, greater ADL impairment, and lower insulin use were more likely to be potentially overtreated. The review compiled a large range of definitions used to describe potential glycemic overtreatment and undertreatment, highlighting the need for standardization. Nevertheless, these definitions may

References (75)

  • P. de Souto Barreto et al.

    Multimorbidity type, hospitalizations and emergency department visits among nursing home residents: A preliminary study

    J Nutr Health Aging

    (2014)
  • C.A. Newton et al.

    Prevalence, quality of care, and complications in long term care residents with diabetes: A multicenter observational study

    J Am Med Dir Assoc

    (2013)
  • A.M. Abbatecola et al.

    Tighter glycemic control is associated with ADL physical dependency losses in older patients using sulfonylureas or mitiglinides: Results from the DIMORA study

    Metabolism

    (2015)
  • A. Basso et al.

    Assessment of glycemic control among diabetic residents in nursing homes

    Diabetes Res Clin Pract

    (2012)
  • F. Retornaz et al.

    Assessment of glycemic control in nursing home residents with diabetes

    J Nutr Health Aging

    (2017)
  • B. Bouillet et al.

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

    Diabetes Metab J

    (2010)
  • L.M. Andreassen et al.

    Nursing home patients with diabetes: Prevalence, drug treatment and glycemic control

    Diabetes Res Clin Pract

    (2014)
  • A. Chandrakumar et al.

    Prevalence of hypoglycemia among diabetic old age home residents in South India

    Diabetes Metab Syndr

    (2016)
  • K. Khunti et al.

    Clinical inertia versus overtreatment in glycaemic management

    Lancet Diabetes Endocrinol

    (2018)
  • J.K. Sluggett et al.

    Medication management policy, practice and research in Australian residential aged care: Current and future directions

    Pharmacol Res

    (2017)
  • T. Alam et al.

    What is the proper use of hemoglobin A1c monitoring in the elderly?

    J Am Med Dir Assoc

    (2006)
  • A.H. Heald et al.

    Hypoglycaemia in the over 75s: Understanding the predisposing factors in type 2 diabetes (T2DM)

    Prim Care Diabetes

    (2018)
  • K.L. Davis et al.

    Association between different hemoglobin A1c levels and clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus

    J Am Med Dir Assoc

    (2014)
  • B. Bauduceau et al.

    Cardiovascular complications over 5 years and their association with survival in the GERODIAB cohort of elderly French patients with type 2 diabetes

    Diabetes Care

    (2018)
  • L.M. Andreassen et al.

    The potential for deprescribing in care home residents with Type 2 diabetes

    Int J Clin Pharm

    (2016)
  • I. Hjaltadóttir

    Sigurðardóttir Á. Prevalence of diabetes as well as general health status of Icelandic nursing home residents 2003–2012

    Laeknabladid

    (2015)
  • R. Simó et al.

    Cognitive impairment and dementia: A new emerging complication of type 2 diabetes—the diabetologist’s perspective

    Acta Diabetol

    (2017)
  • I. Tsuji et al.

    Predictors of nursing home placement in community-based long-term care

    J Am Geriatr Soc

    (1995)
  • L.B. Russell et al.

    Hospitalizations, nursing home admissions, and deaths attributable to diabetes

    Diabetes Care

    (2005)
  • M.S. Kirkman et al.

    Diabetes in older adults

    Diabetes Care

    (2012)
  • R.R. Kalyani et al.

    Hyperglycemia and incidence of frailty and lower extremity mobility limitations in older women

    J Am Geriatr Soc

    (2012)
  • K.J. Lipska et al.

    National trends in US hospital admissions for hyperglycemia and hypoglycemia among Medicare beneficiaries, 1999 to 2011

    JAMA Intern Med

    (2014)
  • K.J. Lipska et al.

    HbA1c and risk of severe hypoglycemia in type 2 diabetes: The Diabetes and Aging Study

    Diabetes Care

    (2013)
  • N. Shehab et al.

    US emergency department visits for outpatient adverse drug events, 2013–2014

    JAMA

    (2016)
  • A.I. Geller et al.

    National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations

    JAMA Intern Med

    (2014)
  • T.A. Dunning et al.

    The McKellar Guidelines: Helping plan care for older people with diabetes

    Aust Nurs Midwifery J

    (2016)
  • M.N. Munshi et al.

    Management of diabetes in long-term care and skilled nursing facilities: A Position Statement of the American Diabetes Association

    Diabetes Care

    (2016)
  • Cited by (14)

    • Individualizing Diabetes Care in Older Persons With Multimorbidity

      2021, Journal of the American Medical Directors Association
    View all citing articles on Scopus

    JMN has received travel grants from MSD, personal fees for independent education activities and research support from Sanofi, and research funding from Eli Lilly and Boehringer Ingelheim. MH is employed by an organization providing aged care services. JS, SW, JSB, and JKS declare no conflict of interest.

    JS is a recipient of the Cyril Tonkin Scholarship for PhD research at the Faculty of Pharmacy and Pharmaceutical Sciences, Monash University. SW is supported by an Australian Government Research Training Program Scholarship. JSB has received research grants paid to his employer from NHMRC, Dementia Australia Research Foundation, Yulgilbar Foundation, Dementia Centre for Research Collaboration, Victorian Government Department of Health and Human Services, GSK Independent Medical Education, Aged Care Quality and Safety Commission, and several aged care provider organizations. JKS is supported by a NHMRC Early Career Fellowship (grant number APP1156439). JMN is supported by a Medical Research Future Fund Next Generation Clinical Researchers Program – TRIP Fellowship (APP1168265). The funders had no role in study design, methods, data collection and analysis, decision to publish or preparation of this manuscript. All authors had final responsibility for the decision to submit for publication.

    View full text