Diabetes overtreatment common in nursing homes, with little medication deintensification
Type 2 diabetes overtreatment among nursing home residents is common, with few residents having their medication regimens appropriately deintensified, according to results published in the Journal of the American Geriatric Society.
“Upon nursing home admission, the admitting clinician assesses the appropriateness of each medication in context of the whole person, which includes laboratory results, vital signs, treatment goals, comorbidities and functional status,” Lauren I. Lederle, MD, from the division of geriatrics at the University of California, San Francisco, and the Geriatrics and Extended Care Service and the Veterans Affairs Quality Scholars Fellowship at San Francisco VA Medical Center, and colleagues wrote. “Since nursing home admission represents a time when clinicians review medications in light of the new nursing home resident’s goals of treatment, nursing home admission is an especially important time to examine changes in glucose-lowering medications and deprescribing.”
The cohort study included 7,422 residents with type 2 diabetes from Veterans Affairs nursing homes enrolled from 2013 to 2019. All participants were aged 65 years and older with a nursing home length of stay of 30 days or more and an HbA1c result recorded during their stay. Overtreatment was defined as HbA1c less than 6.5% with any insulin use. Potential overtreatment was defined as HbA1c less than 7.5% with any insulin use or HbA1c less than 6.5% on any glucose-lowering medications in addition to metformin.
The primary outcome was nursing home residents with continued glycemic overtreatment without deintensification 14 days after the index HbA1c.
Overall, 17% of nursing home residents with type 2 diabetes met the criteria for overtreatment, and 23% met the criteria for potential overtreatment. Among those overtreated, 27% had medication regimens deintensified at baseline, with 73% continuing to be overtreated; among those who were potentially overtreated, 19% had medication regimens deintensified at baseline, with 81% continuing to potentially be overtreated.
Researchers observed long-acting insulin use (OR = 1.37; 95% CI, 1.14-1.65) and hyperglycemia of 300 mg/dL or more before index HbA1c (OR = 1.35; 95% CI, 1.1-1.66) as factors associated with increased odds for continued overtreatment. In contrast, severe functional impairment was associated with decreased odds for continued overtreatment (OR = 0.72; 95% CI, 0.56-0.95).
No association was observed for decreased odds of overtreatment and hypoglycemia.
“Based on our study results, it will be important to develop deprescribing initiatives in nursing homes at time of admission that use behavior change principles to overcome prescribing inertia in overtreated residents,” the researchers wrote. “Our results suggests that these initiatives should target nursing home residents at high risk for harms from overtreatment, including those with a history of hypoglycemia, high levels of functional dependence or cognitive impairment.”