Identifying the need for simplification of type 2 diabetes mellitus treatment in residents of aged-care facilities: a meta-analysis and systematic review of the literature


  • Lowri Hughes Thomas Cardiff University School of Medicine, Cardiff University, Cardiff, UK.
  • Philip MS Evans Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK.
  • Atul Kalhan Department of Diabetes and Endocrinology, Royal Glamorgan Hospital, Llantrisant, UK.



type 2 diabetes mellitus, aged-care facilities, frailty, dementia


Background: The management of type 2 diabetes mellitus (T2DM) in frail older adults is made challenging by the impact of physical and cognitive decline on self-monitoring of blood glucose (BG), administration of medications, especially injectable therapies, and risk of hypoglycaemia.

Aims and objectives: (1) To revisit the prevalence of hypoglycaemia in adults with T2DM living in aged-care facilities; (2) to evaluate the impact of simplification of T2DM treatment on quality of life (QOL), morbidity and mortality in this population; and (3) to identify higher risk older adults in whom simplification of therapy will be most appropriate.

Methods: MEDLINE was searched using the following concept areas: aged-care facilities, T2DM, anti-diabetic therapies, morbidity, mortality and QOL. Results (and additional literature identified by citation checking) were screened and assessed against pre-defined eligibility criteria. Standardised structures for extracting, appraising and reporting the literature were used.

Results: Hypoglycaemia is common in adults with T2DM in aged-care facilities. Glycated haemoglobin (HbA1c) needs to be interpreted cautiously in this cohort, with additional capillary BG monitoring needed to identify individuals at risk of hypo- or hyperglycaemia. Simplification of T2DM treatment can reduce morbidity and mortality in frail older adults.

Conclusion: In residents of aged-care facilities, simplification of T2DM treatment can help deliver optimal individualised patient-centred care and improve QOL.


Gojka R. WHO Global report on diabetes: a summary. Int J Noncommun Dis 2016;1(1):3–8.

Diabetes UK. How many people are at risk of type 2 diabetes? London: The British Diabetic Association. 2019. Available at: (accessed 6 May 2020).

Diabetes UK. Diabetes in the UK 2010: Key statistics on diabetes. 2010. Available at: (accessed 5 May 2020).

Sinclair AJ, Gadsby R, Abdelhafiz AH, Kennedy M. Failing to meet the needs of generations of care home residents with diabetes: a review of the literature and a call for action. Diabet Med 2018;35(9):1144–56.

Dunning T, Sinclair A, Colagiuri S. New IDF guideline for managing type 2 diabetes in older people. Diabetes Res Clin Pract 2014;103(3):538–40.

American Diabetes Association. 12. Older Adults: Standards of Medical Care in Diabetes—2020. Diabetes Care 2020;43(Suppl 1):S152–S162.

Ryan R, Synnot A, Prictor M, Hill S. Data extraction template for included studies. 2016. Available at: (accessed 30 April 2020).

Critical Appraisal Skills Programme. CASP Checklists. 2018. Available at: (accessed 30 April 2020).

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta- analyses: the PRISMA statement. BMJ 2009;339:b2535.

Niznik JD, Hunnicutt JN, Zhao X, et al. Deintensification of diabetes medications among Veterans at the end of life in VA nursing homes. J Am Geriatr Soc 2020;68(4):736–45.

Umpierrez GE, Cardona S, Chachkhiani D, et al. A randomized controlled study comparing a DPP4 inhibitor (linagliptin) and basal insulin (glargine) in patients with type 2 diabetes in long-term care and skilled nursing facilities: Linagliptin-LTC Trial. J Am Med Dir Assoc 2018;19(5):399–404.e3.

McCracken R, McCormack J, McGregor MJ, et al. Associations between polypharmacy and treatment intensity for hypertension and diabetes: a cross-sectional study of nursing home patients in British Columbia, Canada. BMJ Open 2017;7(8):e017430.

Retornaz F, Grino M, Mari L, Oliver C. Assessment of glycemic control in nursing home residents with diabetes. J Nutr Health Aging 2017; 21(4):457–63.

Walfridsson A, Sehlberg M, Gillespie U, et al. Diabetes treatment and hypoglycaemic episodes in elderly patients at nursing homes in Uppsala County. Uppsala J Med Sci 2016;121(3):179–83.

Dharmarajan TS, Mahajan D, Zambrano A, et al. Sliding scale insulin vs basal-bolus insulin therapy in long-term care: a 21-day randomized controlled trial comparing efficacy, safety and feasibility. J Am Med Dir Assoc 2016; 17(3):206–13.

Bo M, Gallo S, Zanocchi M, et al. Prevalence, clinical correlates, and use of glucose-lowering drugs among older patients with type 2 diabetes living in long-term care facilities. J Diabetes Res 2015;2015:174316.

Neumark A-SN, Brudin L, Neumark T. Adherence to national diabetes guidelines through monitoring quality indicators—A comparison of three types of care for the elderly with special emphasis on HbA1c. Primary Care Diabetes 2015;9(4):253–60.

Abbatecola AM, Bo M, Barbagallo M, et al. Severe hypoglycemia is associated with antidiabetic oral treatment compared with insulin analogs in nursing home patients with type 2 diabetes and dementia: results from the DIMORA Study. J Am Med Dir Assoc 2015;16(4):349.e7–e12.

Andreassen LM, Sandberg S, Kristensen GBB, et al. Nursing home patients with diabetes: prevalence, drug treatment and glycemic control. Diabetes Res Clin Pract 2014;105(1):102–09.

Bouillet B, Vaillant G, Petit JM, et al. Are elderly patients with diabetes being overtreated in French long-term-care homes? Diabetes Metab 2010; 36(4):272–7.

Sjöblom P, Anderstengblad U-B, Löfgren C, et al. Can diabetes medication be reduced in elderly patients? An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control. Diabetes Res Clin Pract 2008;82(2):197–202.

Meyers RM, Broton JC, Woo-Rippe KW, et al. Variability in glycosylated hemoglobin values in diabetic patients living in long-term care facilities. J Am Med Dir Assoc 2007;8(8):511–14.

Gill EA, Corwin PA, Mangin DA, Sutherland MG. Diabetes care in rest homes in Christchurch, New Zealand. Diabet Med 2006;23(11):1252–6.

Pham M, Pinganaud G, Richard-Harston S, et al. Prospective audit of diabetes care and outcomes in a group of geriatric French care homes. Diabetes Metab 2003;29(3):251–8.

Wolffenbuttel BHR, van Vliet S, Knols AJF, et al. Clinical characteristics and management of diabetic patients residing in a nursing home. Diabetes Res Clin Pract 1991;13(3):199–206.

Davis KL, Wei W, Meyers JL, et al. Use of basal insulin and the associated clinical outcomes among elderly nursing home residents with type 2 diabetes mellitus: a retrospective chart review study. Clin Interv Aging 2014;9:1815–22.

Newton CA, Adeel S, Sadeghi-Yarandi S, et al. Prevalence, quality of care, and complications in long term care residents with diabetes: a multicenter observational study. J Am Med Dir Assoc 2013;14(11):842–6.

Hurley L, O'Donnell M, O'Caoimh R, Dinneen SF. Investigating the management of diabetes in nursing homes using a mixed methods approach. Diabetes Res Clin Pract 2017;127:156–62.

Barnhart C, McClymont K, Smith AK, et al. "Everyone else gets ice cream here more often than I do--It burns me up"-perspectives on diabetes care from nursing home residents and their doctors. BMC Geriatrics 2016;16:28.