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).
Design
Systematic review.
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.
Keywords
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Article info
Publication history
Published online: May 15, 2021
Footnotes
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.
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