OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7‐day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90‐day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0‐7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50‐.66). Compared with non‐sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31‐1.88), except for basal insulin (aRR = .59; 95% CI = .52‐.66). The only resident factor associated with increased likelihood of deintensification was documented end‐of‐life status (aRR = 1.12; 95% CI = 1.01‐1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75‐.96), obesity (aRR = .88; 95% CI = .78‐.99), and peripheral vascular disease (aRR = .90; 95% CI = .81‐.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one‐half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736–745, 2020

BACKGROUND/OBJECTIVES Clinical practice guidelines support using acetylcholinesterase inhibitors (AChEIs) and memantine to treat dementia, but conflicting evidence of effectiveness and frequent side effects limit use in practice. We examined racial/ethnic differences in initiation and time to discontinuation of antidementia medication in Medicare beneficiaries. DESIGN Retrospective cohort study. SETTING Secondary analysis of 2009/2010 enrollment, claims, and Part D prescription data for a 10% national sample of U.S. Medicare fee-for-service enrollees. PARTICIPANTS Beneficiaries aged 65+ with Alzheimer's Disease or Related Disorder (ADRD) prior to 2009 and no fills for antidementia medications in the first half of 2009 (n=84,043). MEASUREMENTS Initiation was defined as having ≥1 fill for antidementia medication in the second half of 2009, and discontinuation as a gap in coverage of ≥30 days during one year after initiation. Covariate selection was guided by the Andersen Behavioral Model. RESULTS Overall, 3,481 (4.1%) of previous non-users initiated antidementia medication in the second half of 2009. Of those initiating one drug class (AChEIs or memantine), 9% later added the other class and 2% switched classes. Among initiators, 23% discontinued within one month and 62% discontinued within one year. Hispanic beneficiaries were more likely than White beneficiaries to initiate (adjusted odds ratio [OR]=1.25, 95% CI=1.10-1.41). Black and White beneficiaries did not differ in likelihood of initiation. Hispanic and Black beneficiaries discontinued at a faster rate than White beneficiaries (adjusted hazard ratio [HR]=1.56, 95% CI=1.34-1.82 and HR=1.25, 95% CI=1.08-1.44, respectively). CONCLUSION Relative to White beneficiaries, initiation of antidementia medications was no different in Black beneficiaries and more likely in Hispanic beneficiaries. However, Black and Hispanic beneficiaries discontinued at a faster rate. More research into reasons explaining these differences is needed.

U.S. Department of Veterans Affairs.