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Do No Harm: Rethinking Diabetes, Hypertension in Frail Older Adults

Effectively managing chronic conditions like diabetes and hypertension can greatly improve quality of life, reduce complications, and extend longevity for older adults. However, when treatment becomes overly aggressive, it can do more harm than good. Every day, thousands of vulnerable older adults in the United States are harmed by intensive management of these conditions—resulting in dangerously low blood sugar or blood pressure, emergency visits, hospitalizations, disability, or even death. These harms are preventable and often stem from well-intentioned but excessive medical care.

Despite clear guidelines promoting cautious, individualized care—especially for frail older adults and nursing home residents—these complications remain alarmingly common.

Joseph G. Ouslander, MD, a professor of geriatric medicine at Florida Atlantic University’s Charles E. Schmidt College of Medicine, and his collaborator have published a paper in the Journal of the American Geriatrics Society calling for urgent change in how health care providers are supported and held accountable. They argue that physicians, nurse practitioners, and physician assistants prescribing diabetes and hypertension medications should be actively encouraged—not merely expected—to avoid overtreatment through carefully designed quality measures.

“These preventable complications, including dangerously low blood sugar and blood pressure, often result from well-intended medical care that overlooks a patients’ age, health status, or life expectancy,” says Ouslander, senior author. “We need better approaches that reward appropriate, personalized care. These measures should prioritize safe, evidence-based, personalized care rather than rigid targets that can cause harm.”

Ouslander and Michael Wasserman, MD, coauthor and geriatrician with the California Association of Long-Term Care, emphasize that clinical guidelines are crucial in preventing treatment-related harms like low blood sugar and blood pressure in older adults. For diabetes, major organizations such as the American Diabetes Association recommend more relaxed blood sugar targets (and higher HbA1c levels) for older adults with poor health or multiple conditions to minimize hypoglycemia risk. Yet, many vulnerable older adults continue to be overtreated. Updated long term care guidelines also caution against overly strict diets, sliding-scale insulin, and medications that raise the risk of hypoglycemia.

For high blood pressure, several guidelines recommend moderate targets (systolic 130 to 150) even for those over age 80. However, since most clinical trials exclude frail or nursing home residents, the researchers advocate for a personalized approach that carefully balances each patient’s risks, benefits, and goals.

The researchers reference the well-known SPRINT trial, which demonstrated that aggressive blood pressure control can reduce hypertension-related risks. Yet, the trial excluded nearly all medically vulnerable older adults—such as those in nursing homes or with diabetes, dementia, prior strokes, or serious illnesses—meaning its results may not be applicable to those most vulnerable to harm from intensive treatment.

In their review, Ouslander and Wasserman offer several general and specific recommendations for strategies that they believe have the potential to reduce the incidence of medically caused hypoglycemia and hypotension and related complications in vulnerable older adults.

Among their key recommendations:

• Test new treatments: Study newer medications and technologies that may be safer and more effective for older adults.
• Prioritize quality improvement: Support programs that enhance diabetes and hypertension care in clinics and nursing homes.
• Use data to target risks: Leverage health records and claims data to identify and address causes of hypoglycemia and hypotension.
• Document individualized care plans: Clearly record shared decision-making tailored to patient health, preferences, and life expectancy.
• Foster cross-disciplinary collaboration: Engage researchers, policymakers, and clinicians to develop practical and affordable safety strategies.
• Develop new quality metrics: Track medication overuse and adverse events, sharing data to incentivize safer care.
• Conduct more research: Prioritize clinical trials and real-world studies to find the best strategies for vulnerable older adults.

“To truly protect vulnerable older adults from preventable harm, we must rethink how we manage chronic conditions like diabetes and hypertension,” Ouslander says. “This means moving beyond one-size-fits-all targets to evidence-based, personalized treatment plans shaped by shared decision-making, supported by appropriate technology, and backed by policies prioritizing patient safety over rigid metrics. It’s not just a clinical challenge—it’s a moral imperative that requires collaboration to develop smarter, safer, and more person-centered care that reduces hospitalizations, improves outcomes, and honors the dignity of those most at risk.”

— Source: Florida Atlantic University