Diabetes overtreatment common in nursing homes, with little medication deintensification
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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.”
Perspective
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Kathy W. Warwick, RDN, LDN, CDCES
Caring for older adults with diabetes in the post-acute long-term care setting has become more challenging over the past few years because residents are typically much older with many comorbidities at the time of admission. Polypharmacy is common in this population as medications have been added throughout midlife, but few have been eliminated even though kidney or liver function may have declined and there are diminishing benefits from tight glycemic control.
Reliance on sliding scale insulin protocols for management of diabetes remains common despite decades of evidence that resulting glycemic control is poor and frequent fingerstick glucose testing contributes to decreased quality of life.
For several years, the American Diabetes Association has encouraged a more holistic view of appropriate glycemic goals for the elderly considering several factors, such as existing complications, cognitive impairment, life expectancy and risk for hypoglycemia. Preventing hypoglycemia has become the primary objective related to the increased risk for falls and hypoglycemia unawareness in this population. Avoiding extreme hyperglycemia is also important for decreasing the incidence of infections, dehydration and poor wound healing.
Residents and their families often have differing opinions when it comes to setting glycemic goals. As a consultant dietitian, I often have family members insist that “mama can’t have any bread” or “she shouldn’t be served a slice of cake” at our monthly birthday celebrations. This affects perceived quality of life in a population that is often depressed with decreased or inconsistent food intake and weight loss. The American Medical Director’s Association has advocated for serving a “regular” well-balanced diet for those elderly living with diabetes in long-term care as opposed to restrictive therapeutic diets.
Medication deintensification efforts need to be a part of the admission process and should be undertaken by a multidisciplinary care team along with family members involved in the resident’s care. Whenever possible, the resident should be included and have input for care planning and goal setting. Diabetes management could also be part of a long-term care facility’s quality improvement program.
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