Guideline-Recommended Diabetes Treatment: Are Older Patients on the Same Page as Physicians?

Current guidelines for the treatment of type 2 diabetes in older adults recommend considering factors such as diabetes duration and life expectancy in order to individualize treatment and determine whether therapies should be intensified or deintensified.

However, when it comes to these treatment decisions, many older adults with type 2 diabetes may not be on the same page as their physicians, according to a new study. The findings suggest that these perceptions “may present substantial barriers to appropriate treatment goals and care,” the researchers wrote.

The study was a cross-sectional national online survey of 818 US adults aged 65 years or older with type 2 diabetes. Specifically, the researchers assessed 7 factors in treatment decisions and participants’ perceptions of how these factors would impact treatment intensity. Factors included diabetes duration, established diabetes complications, comorbidities, life expectancy, risk of adverse effects, cost, and treatment effort.

Ultimately, the researchers found that patients viewed these 7 factors as important when adding pharmacologic therapies to their treatment regimens, but less important when removing therapies from their regimens. In fact, many participants believed that longer disease duration, more established complications, and more comorbidities warranted more aggressive diabetes treatment, despite guidelines that recommend the opposite.

Endocrinology Consultant discussed these findings and their implications further with lead study author Nancy Li Schoenborn, MD, from Johns Hopkins University School of Medicine.

Endocrinology Consultant: What prompted you to conduct this study?

Dr Schoenborn: My general research has largely focused on patient preferences; especially how older adults understand treatment guidelines and how this may serve as a facilitator or barrier to the implementation of recommended care. This is an area in which there is little available evidence and knowledge gaps still exist. It is largely recognized that individualized diabetes care is needed in older adults, but a large amount of literature suggests that this practice may not yet be where it needs to be. Understanding of treatment guidelines among patients was one potential contributing factor that, to my knowledge, had not been assessed until now.

This topic has also resonated with me personally in my practice caring for older adult patients. In my experience, I did not think that my patients realized why there is a need to individualize care and why we would not necessarily want to treat diabetes aggressively in every case.

Endo Con: Were these findings anticipated, or did some of them come as a surprise?

Dr Schoenborn: Some of the findings were expected, and some were a surprise. It was not too surprising to see that some of the guideline recommendations were not intuitively apparent to patients. When it comes to treating patients with multiple complications of diabetes, I can definitely understand why they would think more aggressive treatment is needed to control their illness, even though this is the opposite of what treatment guidelines recommend.

However, what came as a surprise to me was the clear difference we observed regarding how the patient valued different factors in the decision to add another pharmacologic therapy vs the decision to discontinue a pharmacologic therapy. Patients placed significantly less importance on these factors when it came to discontinuing a therapy compared with adding a therapy, and this trend was very clear. I think this observation really begs the question, what factors matter to them when it comes to discontinuing a therapy? I think the findings from this study really lay the groundwork for a future study.

Endo Con: As you mentioned, one of the key findings from your study was that many older adults do not place high importance on factors recommended by guidelines to individualize diabetes treatment, especially when deciding to stop use of diabetes medications. What consequences can this have?

Dr Schoenborn: Although we did not examine this in our paper, I would imagine that some guideline-recommended treatment decisions may seem confusing or even counterintuitive to patients, such as pursuing less aggressive treatment in patients with multiple complications. As a physician, I can imagine how this might be confusing to patients and may create misperceptions that this treatment decision is part of giving up on the treatment of their illness. I think these types of treatment decisions really highlight the need for us to elicit patients’ thoughts about the treatment decisions we make and seeing what questions they may have. If they are totally on board, that’s great. If they are hesitant, it is important to ask what questions they have and to discuss their perceptions of these treatment decisions.

Endo Con: How can these findings inform clinical practice?

Dr Schoenborn: It is important for clinicians to be aware of how many older adults may perceive treatment decisions and how to frame discussions with patients. I know for myself, if I discuss a treatment decision with a patient that I know they are in favor of, I may not need to spend as much time discussing the pros and cons of the decision with them. For patients who may be hesitant to these changes, I would prepare to spend more time focusing on their concerns and reiterating that these treatment decisions are not necessarily permanent, that I will continue to monitor them, and that ceasing a medication does not mean that they are receiving ‘less care.’ I think preemptively providing reassurance and deliberately eliciting their thoughts and concerns is important, especially when treatment decisions are time-sensitive.

—Christina Vogt

Reference:
Schoenborn NL, Crossnohere NL, Bridges JFP, Pollack CE, Pilla SJ, Boyd CM. Patient perceptions of diabetes guideline frameworks for individualizing glycemic targets [Published online September 16, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.3806.