Overtreatment of Diabetes Leading to Hypoglycemia in Nursing Home Residents with Diabetes

Lauren Lederle, MD

A new study of older adults with diabetes is providing insight into the risk of hypoglycemia from glycemic overtreatment among nursing home residents in the US.

An analysis of data from more than 7000 patients in Veterans Affairs nursing homes, results provide insight into factors associated with increased risk of overtreatment and suggest nearly 1-in-5 patients met criteria for overtreatment and an additional 23% met criteria for potential overtreatment.

“I hope this work lays the foundation for future projects that promote appropriate deintensification of glucose lowering medications in nursing home residents,” said lead investigator Lauren Lederle, MD, of the San Francisco VA Medical Center, in a statement.

Together with colleagues from the University of San Francisco and the San Francisco Virginia Medical Center, Lederle and a team of investigators designed the current study with the intent of developing a more thorough understanding of incidence of overtreatment and deintensification practices in nursing home residents with diabetes. To do so, investigators created a cohort study using data from VA nursing homes admitted from 2013-2019 over 65 years of age with a diagnosis of type 2 diabetes, which was defined using HbA1c or ICD codes.

Including all adults aged 65 years or older with type 2 diabetes and a length of stay of 30 days or more, investigators identified 7422 individuals for inclusion in their analyses. This cohort had a mean age of 74.6 (SD, 7.9) years, 98.4% were male, and a mean HbA1c of 7.1 (SD, 1.4).

Overtreatment was defined as an HbA1c less than 6.5% with any insulin use and potential overtreatment was defined as an HbA1c less than 7.5% with any insulin use or HbA1c less than 6.5% on any glucose-lowering medication other than metformin alone.

Of the 7422 residents included, 17% met the criteria for overtreatment and an additional 23% met criteria for potential overtreatment. In analyses assessing treatment strategies among patients with overtreatment or potential overtreatment, deintensification of medication regimens was observed among 27% of those meeting criteria and 19% among those meeting criteria for potential overtreatment.

Further analysis suggested use of long-acting insulin (OR, 1.37 [95% CI, 1.14-1.65]) and hyperglycemia (OR, 1.35 [95% CI, 1.10-1.66]), defined as 300 mg/dL or greater, before index HbA1c were associated with increased likelihood of continued overtreatment. Additionally, results indicated severe functional impairment was associated with decreased odds of continued overtreatment (OR, 0.72 [95% CI, 0.56-0.95]), but hypoglycemia was not associated with decreased of overtreatment.

“We found that overtreatment of T2DM is common in VA nursing homes residents and that a minority of NH residents have their medication regimens appropriately deintensified. 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,” wrote investigators.

This study, “Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes,” was published in the Journal of the American Geriatrics Society.