New research will help “dial back” diabetes overtreatment in long-term care

CIHR funding to Lisa McCarthy will support research to reduce intensity of diabetes management for long-term care residents

People with diabetes are often told to tightly control their blood sugar levels, but for one population this approach may actually be harmful. Long-term care residents with diabetes, who are often older adults with frailty, often have their blood sugar levels tightly controlled through medication and restrictive diets, but these treatments may put them at risk of medical complications and lower quality of life. Newly funded research led by Lisa McCarthy, associate professor – status and clinician scientist at U of T’s Leslie Dan Faculty of Pharmacy, aims to address overtreatment of diabetes in this population and help long-term care staff, residents and families make better decisions around diabetes management.

“We ultimately want to make sure that people can get the care that they need – no less, no more – while reducing the risk of harms,” says McCarthy, also a clinician-scientist at Trillium Health Partners in Mississauga.

More than 25 per cent of residents in long-term care homes have diabetes. Clinical practice guidelines from organizations including Diabetes Canada recommend that blood sugar levels in frail older adults do not need to be as tightly controlled as in younger people. Yet, previous research led by her colleague Dr. Iliana Lega, an endocrinologist at Women’s College Hospital and assistant professor at U of T’s Temerty Faculty of Medicine, has found that more than half of long-term care residents with diabetes have overly controlled blood sugar.

“We ultimately want to make sure that people can get the care that they need – no less, no more – while reducing the risk of harms”

“There are many different reasons that overtreatment is a problem, including causing low blood sugar, which is also known as hypoglycemia, which can have a number of consequences associated with falls, fractures, and confusion,” says McCarthy. “Overtreatment also unwisely uses financial resources and people’s time. We’re also overly restricting people’s diets, which can affect joy in people’s lives.”

McCarthy is a lead with deprescribing.org, a team that creates guidelines and tools to support medication management and deprescribing, particularly for older adults, with the aim of reducing medication-related harms. In her newest research project, called the “DIAL study,” she has partnered with experts in diabetes and long-term care, including Dr. Lega and Dr. Wade Thompson from the University of British Columbia, to find ways to “deintensify” diabetes management, which could include deprescribing medication or reducing blood sugar monitoring and restrictive diets.

McCarthy recently received a four-year, $677,000 grant from the Canadian Institutes of Health Research (CIHR) to support the research, as well as a $50,000 CIHR Mid-Career Award in Research and Aging, recognizing the application’s top ranking in the grant competition.

Research team will work closely with long-term care residents and families

The research team will first use provincial data to examine the benefits and harms of reducing intensity of diabetes management in Ontario’s long-term care homes and understand how often this takes place.

A key part of the study is gathering the perspectives of long-term care residents and families to ensure that any strategy to dial back diabetes management is informed by their perspectives and addresses their concerns.

“Long-term care residents with diabetes and their families have likely heard for years that blood sugar needs to be tightly controlled, and now we’re saying that maybe we can ease off. That’s a major paradigm shift for them, and they may be resistant to that change,” says McCarthy. “Decisions related to care need input from residents and their families for them to hold. An important part of this work is figuring out how to talk to and work with residents and their families.”

With this groundwork in place, they will then develop an intervention to help support long-term care staff, residents, and families deintensify diabetes management. The research team has partnered with several stakeholders, including three long-term care homes, to help develop and pilot the intervention.

McCarthy hopes that the research will support staff in long-term care to have these conversations and ultimately improve safety and care of residents of long-term care.

“We have tools and guidelines to help make deprescribing part of the culture of long-term care, and now we need to bring them together with experts, residents and families to turn it into an intervention,” says McCarthy. “By understanding more about the problem, and working with residents, caregivers and care teams to design it, we hope that we will develop an intervention that will be sustainable and improve care and quality of life.”