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Glycemic Control and Medications in T2DM Elderly with Dementia

Older veterans with T2DM and dementia may need to decrease intensity of diabetes medications…

One study predicts that the prevalence of diabetes among adults aged ≥65 years is projected to increase dramatically by 2050. Other studies have observed that dementia affects up to 16% of diabetic patients aged ≥65 years and 24% aged ≥75 years. Some data has shown that the two conditions may share a pathophysiological link. An improvement in ambulatory care needs to be made. Reducing known risk factors for hypoglycemia, in older patients with coexisting diabetes and dementia is crucial, but to date, few efforts have been made or documented.

Since older adults with diabetes and dementia are at increased risk for hypoglycemia and other adverse events associated with tight glycemic control, they may not experience as many long term benefits. Therefore, the objective of this study was to examine risk factors for tight glycemic control in this population and use of medications associated with a high risk of hypoglycemia in the subset with tight glucose control.

This was a longitudinal, retrospective cohort study using administrative data from the VA health care system and Centers for Medicare & Medicaid Services, using claims for fiscal years (FYs) 2008–2009 included 15,880 veterans aged ≥65 years with type 2 diabetes and dementia and who were prescribed any antidiabetic medication. Researchers used outpatient VA drug dispensing records for the first 120 days of FY2009 to identify patient use of antidiabetic medication. The study utilized a multivariable regression analysis to identify any sociodemographic and clinical predictors of A1c control (tight, moderate, poor, or not monitored) and, in patients with tight control, subsequent use of medication associated with a high risk of hypoglycemia, such as sulfonylureas and insulin. ICD-9 codes were used to find subjects with Alzheimer’s Disease and Related Disorders (ADRD). Patients without an ADRD ICD-9 code who filled a VA prescription for an antidementia medication in FY2008 were also included in the study.

The researchers observed that 52% of patients had tight glycemic control defined as HbA1c <7%. Specific comorbidities, older age, and recent weight loss were associated with greater odds of tight versus moderate control, whereas Hispanic ethnicity and obesity were associated with lower odds of tight control. Out of the patients who were considered tightly controlled, 75% of them used sulfonylureas and/or insulin. Patients with higher odds were primarily male, black, or aged ≥75 years; had a hospital or nursing home stay in FY2008; or had congestive heart failure, renal failure, or peripheral vascular disease.

The authors concluded that a large number of older veterans with diabetes and dementia were said to be at high risk for hypoglycemia associated with intense diabetes treatment and may be candidates for decreasing the intensity or alteration of diabetes medications regimen.

Practice Pearls:

  • The present findings highlight the need for initiatives to support safer antidiabetic prescribing choices for patients with dementia.
  • Since clinical trials comparing various antidiabetic medications in older patients with dementia are unlikely to occur, well designed observational studies are needed to guide prescribing choices for this rapidly growing population.
  • The relationship between glycemic control levels and the progression of dementia is unknown as of right now and further studies may be needed.

Carolyn T. Thorpe, Walid F. Gellad, Sijian Zhang, et al. “Tight Glycemic Control and Use of Hypoglycemic Medications in Older Veterans With Type 2 Diabetes and Comorbid Dementia”. Diabetes Care. April 2015;38:588–595