Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes

Abstract

Background Older nursing home (NH) residents with glycemic overtreatment are at significant risk of hypoglycemia and other harms and may benefit from deintensification. However, little is known about deintensification practices in this setting. Methods We conducted a cohort study from January 1, 2013 to December 31, 2019 among Veterans Affairs (VA) NH residents. Participants were VA NH residents age ≥65 with type 2 diabetes with a NH length of stay (LOS) ≥ 30 days and an HbA1c result during their NH stay. We defined overtreatment as HbA1c <6.5 with any insulin use, and potential overtreatment as HbA1c <7.5 with any insulin use or HbA1c <6.5 on any glucose‐lowering medication (GLM) other than metformin alone. Our primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c. Results Of the 7422 included residents, 17% of residents met criteria for overtreatment and an additional 23% met criteria for potential overtreatment. Among residents overtreated and potentially overtreated at baseline, 27% and 19%, respectively had medication regimens deintensified (73% and 81%, respectively, continued to be overtreated). Long‐acting insulin use and hyperglycemia ≥300 mg/dL before index HbA1c were associated with increased odds of continued overtreatment (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.14–1.65 and OR 1.35, 95% CI 1.10–1.66, respectively). Severe functional impairment (MDS‐ADL score ≥ 19) was associated with decreased odds of continued overtreatment (OR 0.72, 95% CI 0.56–0.95). Hypoglycemia was not associated with decreased odds of overtreatment. Conclusions Overtreatment of diabetes in NH residents is common and a minority of residents have their medication regimens appropriately deintensified. Deprescribing initiatives targeting residents at high risk of harms and with low likelihood of benefit such as those with history of hypoglycemia, or high levels of cognitive or functional impairment are most likely to identify NH residents most likely to benefit from deintensification.

Rates of overtreatment and deprescribing of antihyperglycemics among long‐term care residents in British Columbia

“…[4][5][6][7][8] 8 We found higher rates of deprescribing compared to a recent study in US LTC homes, which may be explained by our longer follow-up period. 8 Limitations included missing HbA1c data for around 30% of residents with diabetes. We did not capture ethnicity, socioeconomic factors, and other factors that could affect T2DM management.…”

Individualized Approaches to Diabetes Care in Nursing Homes

“…All staff should be aware of the signs of hyperglycemia and hypoglycemia, which may be hard to spot in older patients or not be noticed at all 21 . Goals and Therapeutic Strategies Specifications: Recent research by Bouillet et al on 100 senior diabetic patients in Pakistani NHs found that 59% were using an oral anti diabetic medicine (OAD) alone, 42% were taking insulin alone, and 17% were taking both 59 . Similar results have been seen in other polls.…”

Individualized Approaches to Diabetes Care in Nursing Homes

“…All staff should be aware of the signs of hyperglycemia and hypoglycemia, which may be hard to spot in older patients or not be noticed at all 21 . Goals and Therapeutic Strategies Specifications: Recent research by Bouillet et al on 100 senior diabetic patients in Pakistani NHs found that 59% were using an oral antidiabetic medicine (OAD) alone, 42% were taking insulin alone, and 17% were taking both 59 . Similar results have been seen in other polls.…”