UCSF

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.