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Doctors should cut back on some medications given seniors, two JAMA studies suggest

Too much, too late: Overtreatment for blood pressure and blood sugar can be dangerous for some

pill bottles with sortersOct. 26, 2015 - The medical treatment of senior citizen is often a little more complicated due to the uncertain consequences of old age. The decision on a surgery, a drug dosage or other procedure has to consider the patients age.

A senior who takes medicine to get their blood sugar or blood pressure down – or both – knows their doctor prescribed it to help them.

But what if stopping, or at least cutting back on, such drugs could help even more?

 

In some older people, that may be the safer route. But two new studies published in JAMA Internal Medicine suggest doctors and patients should work together to backpedal such treatment more often.

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.

Dialing back

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. 

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.

Could more seniors dial back on some of their medications with a doctor's help?

“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. 

Kerr and her colleagues, based at the VA CCMR and the U-M Institute for Healthcare Policy and Innovation, note that their study data come from just before the VA’s efforts to reduce overtreatment started. They’re already doing follow-up studies to see if things change over time, and to study how often de-intensification happens in the non-VA senior population. 

But in the meantime, they note, older patients with diabetes and high blood pressure – and the adult children who often assist with their care – should talk to their care teams about whether de-intensification is right for them.

Long-term gain, short-term pain

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. 

Invited Commentary

For many years vascular disease prevention strategies have been focused on reducing undertreatment, often using a “one-size-fits-all” approach to increase patient adherence, writes Enrico Mossellow, MD, PhD, in an invited commentary – Targeting Vascular Risk Factors in Older Adults.

“The paradigm of this approach has been the proposal of a polypill targeting multiple vascular risk factors, a standard treatment aimed at maximizing vascular protection,” he says.

“Conversely, during recent years an increasing emphasis has been placed on the issue of potential overtreatment, frequently resulting from the same treatment approach in all patients despite significant individual differences in comorbidity and life expectancy.

“In type 2 diabetes mellitus (T2DM), data from randomized clinical trials1 have shown uncertain or negative benefit-risk trade-offs associated with aggressive treatment of hypertension and hyperglycemia.

“These results, added to the well-known exclusion of elderly individuals with multiple morbidities from nearly all clinical trials, have informed recent guidelines, which now recommend more moderate targets for treatment of T2DM and hypertension in older participants, especially those considered frail or affected by important comorbidities.”

“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.” 

It can be hard for an older person to recognize the signs of too-low blood sugar, such as confusion and combativeness, or of too-low blood pressure, such as dizziness. Meanwhile, keeping up with taking multiple medications, and checking blood sugar daily or even more often, can be a struggle for the oldest patients. De-intensifying their treatment can often be a relief. 

NOTES:

In addition to Sussman and Kerr, the medical records study’s authors include senior author Timothy Hofer, M.D., M.S., Sameer Saini, M.D., MS, Rob Holleman, MPH, Mandi Klamerus, MPH, Lillian Min, M.D., and Sandeep Vijan, M.D., M.S. In addition to Caverly and Kerr, the survey research was conducted by Angela Fagerlin, Ph.D., Brian Zikmund-Fisher, Ph.D., Susan Kirsh, M.D., MPH, Jeffrey Kullgren, M.D., M.S., MPH and Katherine Prenovost, Ph.D. Funding for the work came from the Veterans Health Administration.

REFERENCES:

JAMA Internal Medicine, doi:10.1001/jamainternmed.2015.5110 and doi:10.1001/jamainternmed.2015.5950. There is also accompanying commentary.

 

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