In the realm of geriatric medicine, the management of chronic illnesses such as diabetes mellitus and hypertension is traditionally viewed as a critical path toward enhancing the quality of life and longevity for older adults. Yet, emerging evidence and expert analysis reveal a disturbing paradox: the overly aggressive treatment of these conditions may inadvertently inflict serious harm upon the very population it aims to protect. This phenomenon, known as iatrogenic harm, underscores how well-intentioned yet excessive medical interventions can precipitate life-threatening complications such as severe hypoglycemia and hypotension, particularly among vulnerable older adults who often possess complex medical profiles.
Chronic diseases like diabetes and hypertension disproportionately affect the elderly, compounded by the presence of multimorbidity, polypharmacy, and altered physiological responses due to aging. While tight glycemic and blood pressure control have been widely advocated in younger, healthier populations, their application to frail older adults demands circumspection. The physiological reserve in this demographic is diminished, rendering them susceptible to adverse drug reactions and fluctuations in cardiovascular and metabolic parameters. Consequently, the risks of inducing iatrogenic hypoglycemia or hypotension become notably heightened, frequently culminating in hospital admissions, disability, or even mortality.
Despite the propagation of clinical guidelines urging individualized, patient-centered care that favors moderate treatment targets, current clinical practice demonstrates a persistent pattern of overtreatment. For instance, the longstanding paradigm of rigorous HbA1c targets below 7% for all diabetic patients is increasingly being challenged in older adults with limited life expectancy or multiple comorbidities. Recognizing this, major health organizations now advocate for relaxed glycemic thresholds—sometimes tolerating higher HbA1c levels to mitigate hypoglycemia risk, a condition that can precipitate seizures, falls, cognitive decline, and cardiovascular events. Nevertheless, many older adults continue to receive intensive regimens, including sliding scale insulins and strict dietary restrictions, which are ill-fitted to their unique clinical needs.
Parallel concerns arise in the management of hypertension, where the aggressive pursuit of systolic blood pressure below 130 mmHg, although advantageous in reducing stroke and cardiac events in midlife, may prove detrimental to frail seniors. Clinical trials such as the SPRINT study have illuminated the benefits of intensive blood pressure control but largely excluded the most vulnerable cohorts: nursing home residents, individuals with dementia, or those burdened with multiple chronic conditions. This exclusion breeds uncertainty about the applicability of these findings to older adults who may experience symptomatic hypotension, syncope, or renal impairment from aggressive treatment protocols.
A critical issue exacerbating overtreatment is the reliance on rigid clinical targets and quantitative quality metrics that inadequately consider the nuances of aging physiology and individual patient preferences. Healthcare providers face pressures from institutional benchmarks and performance measures that can inadvertently incentivize uniform treatment goals, sowing the seeds for potential harm. Thus, there is an urgent need to recalibrate these quality measures to better reflect personalized, evidence-based, and safety-oriented care frameworks that prioritize patient autonomy and quality of life.
In their recent expert commentary published in the Journal of the American Geriatrics Society, Dr. Joseph G. Ouslander of Florida Atlantic University and Dr. Michael Wasserman of the California Association of Long-Term Care illuminate a strategic path forward. Their analysis advocates for a paradigm shift where prescribers of diabetes and hypertension medications are actively encouraged—not merely advised—to avoid overtreatment through the implementation of thoughtfully designed quality indicators. These indicators would reward the tailoring of therapeutic intensity in alignment with patient-specific characteristics such as frailty, cognitive status, and residual life expectancy.
To mitigate the incidence of iatrogenic hypoglycemia and hypotension, Drs. Ouslander and Wasserman emphasize the importance of integrating advanced pharmacological developments and emerging technologies into the care continuum. Novel antidiabetic agents with more favorable safety profiles, including GLP-1 receptor agonists and SGLT2 inhibitors, promise efficacious glycemic control with reduced hypoglycemia risk. Similarly, ambulatory blood pressure monitoring and clinical decision support systems can augment the clinician’s ability to discern real-time risks, enabling dynamic treatment adjustments that better reflect physiological variability.
The authors also highlight the potential of leveraging large-scale health data and electronic medical records to identify patterns of overtreatment and adverse events. Such data-driven approaches can inform quality improvement initiatives within clinics and nursing homes, targeting the root causes of hypoglycemic and hypotensive episodes. Crucially, documenting individualized care plans through shared decision-making processes becomes fundamental, ensuring that therapeutic goals resonate with patients’ values, preferences, and holistic health contexts rather than adhering to inflexible numerical thresholds.
Cross-disciplinary collaboration emerges as another linchpin in reimagining safer chronic disease management for older adults. By fostering partnerships among clinicians, researchers, policymakers, and patient advocates, the healthcare system can develop pragmatic, scalable, and cost-effective safety strategies. This collaborative ethos seeks not only to fortify clinical guidelines but to embed them within health policy frameworks and reimbursement models that favor patient-centered care and incentivize minimization of preventable harms.
Further, advancing clinical research specifically targeting vulnerable older populations is paramount. This includes prioritizing randomized controlled trials and pragmatic real-world studies that encompass frail elders, nursing home residents, and individuals with complex multimorbidity—groups historically underrepresented in pivotal hypertension and diabetes studies. Expanding evidence in these cohorts will better inform clinicians on optimal treatment thresholds, medication selection, and monitoring strategies, contributing to a robust, geriatric-tailored evidence base.
Ultimately, this evolving perspective underscores that managing chronic diseases in older adults transcends a solely biomedical exercise. It demands an ethical commitment to “do no harm,” recognizing the fine line between therapeutic benefit and iatrogenic risk. Personalized treatment plans underscored by shared decision-making, empowered by cutting-edge technologies, and supported by adaptive quality metrics represent the fulcrum upon which safer and more humane healthcare rests for the aging population.
Dr. Ouslander articulates this vision poignantly: “Protecting vulnerable older adults from preventable harm is not merely a clinical challenge but a moral imperative. We must shift from one-size-fits-all treatment targets to individualized care regimens that honor patients’ dignity, reduce hospitalizations, and improve outcomes.” This call to action is timely and necessary as the demographic tide swells with an increasing number of older adults living with complex chronic illnesses. The healthcare community must heed it, embracing innovation, empathy, and rigor to ensure that the promise of chronic illness management in geriatric care is realized without unintended and preventable consequences.
Subject of Research: People
Article Title: Strategies to Reduce Iatrogenic Hypoglycemia and Hypotension in Vulnerable Older Adults
News Publication Date: 13-Aug-2025
Web References:
- https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.70038
- https://www.fau.edu/medicine/directory/joseph-ouslander/
- https://www.fau.edu/medicine/
- https://www.fau.edu/
References:
Ouslander, J.G., & Wasserman, M. (2025). Strategies to Reduce Iatrogenic Hypoglycemia and Hypotension in Vulnerable Older Adults. Journal of the American Geriatrics Society. DOI: 10.1111/jgs.70038
Image Credits: Alex Dolce, Florida Atlantic University
Keywords: Geriatrics, Hypertension, Hypotension, Diabetes, Hypoglycemia, Emergency rooms, Nursing homes, Quality control, Clinical medicine, Medical treatments, Medications, Antidiabetics, Drug therapy, Insulin, Health care, Hospitals, Human health, Gerontology
