Nursing Home Residents With Diabetes at High Risk of Overtreatment

By Marilynn Larkin

April 01, 2022

NEW YORK (Reuters Health) - Overtreatment of diabetes is common among nursing home residents and appropriate deintensification is rare, a cohort study shows.

"Prescribing inertia is strong," Dr. Lauren Lederle of the University of California, San Francisco and the San Francisco VA told Reuters Health by email. "Most residents continued to be overtreated two weeks after laboratory testing (hemoglobin A1c test) confirmed overtreatment."

"There are many possible explanations for our findings and many barriers to deintensification of treatment for diabetes," she said. "First, the definition of 'overtreatment' for diabetes is population- specific and not clearly agreed upon. A consensus definition of overtreatment for nursing home patients would assist clinicians in identifying overtreatment and taking action."

"Second, patients and clinicians may overestimate the benefits of treatment and overtreatment," she noted. "While many younger patients should receive more aggressive treatment to avoid long-term complications of diabetes, for older patients, especially those in nursing homes, the benefits of aggressive treatment have not been established."

"Third," she added, "patients and clinicians may underestimate the harms and burdens of treatment and overtreatment, which include hypoglycemia, more frequent fingerstick monitoring and more frequent insulin injections."

As reported in the Journal of the American Geriatrics Society, Dr. Lederle and colleagues studied data on 7,422 veterans (mean age, 75; 98%, men) with type 2 diabetes who were living in a nursing home for at least 30 days.

Overtreatment was defined 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.

Glycemic deintensification was determined by comparing baseline and follow-up period GLM regimens. The baseline regimen was the GLM regimen on the day before the index HbA1c.

A follow-up GLM regimen was considered deintensified if a medication was discontinued or decreased, whereas a follow-up GLM regimen was considered intensified if a GLM was started or increased.

The primary outcome was continued glycemic overtreatment without deintensification 14 days after HbA1c.

Seventeen percent of residents met criteria for overtreatment and 23% met criteria for potential overtreatment.

Among residents overtreated and potentially overtreated at baseline, only 27% and 19%, respectively, had medication regimens deintensified; the rest continued to be overtreated.

Long-acting insulin use and hyperglycemia of at least 300 mg/dL before the index HbA1c were associated with increased odds of continued overtreatment (odds ratios: 1.37 and 1.35, respectively).

Severe functional impairment (Minimum Data Set-Activities of Daily Living score, 19 or greater) was associated with decreased odds of continued overtreatment (OR, 0.72).

Hypoglycemia was not associated with decreased odds of overtreatment.

The authors conclude, "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 residents most likely to benefit from deintensification."

Dr. John Rowe, Julius B. Richmond Professor of Health Policy and Aging at the Columbia Aging Center, Mailman School of Public Health in New York City, told Reuters Health by email that he "strongly agrees" with the findings.

Residents may be overtreated, he said, because of "a lack of sophistication about signs and symptoms of hypoglycemia in older persons, especially those that are frail or cognitively impaired. Hypoglycemia may be mistaken for delirium or just slight worsening of pre-existing conditions."

"The most troubling finding," he said, "was that hypoglycemia was not predictive of de-prescribing!"

"Evidence such as (this) can lead to adoption of routine deprescribing initiatives similar to how evidence led to reductions in use of restraints in older persons in nursing homes in the past," he noted.

"When managing diabetes in frail or cognitively impaired older persons, be mindful they may often not eat because of anorexia or physical inability to feed themselves and that hypoglycemia may not be detected, so it is important to err on the side of maintaining higher rather than lower levels of blood sugar and HbA1c," Dr. Rowe concluded.

SOURCE: Journal of the American Geriatrics Society, online March 23, 2022.