Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes

Abstract

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

Rates, determinants and success of implementing deprescribing in people with type 2 diabetes: A scoping review

“…None of the articles included for full‐text screening, however, were excluded for this reason. A recent study observed that end‐of‐life status may increase the likelihood of deprescribing glucose‐lowering medications in nursing homes 50 . Finally, the quality of many of the included studies was poor.…”

“…A recent study observed that end-of-life status may increase the likelihood of deprescribing glucose-lowering medications in nursing homes. 50 Finally, the quality of many of the included studies was poor. When interpreting the results, this was taken into account.…”

Identifying the need for simplification of type 2 diabetes mellitus treatment in residents of aged-care facilities: a meta-analysis and systematic review of the literature

“…Niznik et al, 2020 10 Umpierrez et al, 2018 11 McCracken et al, 2017 12 Retornaz et al, 2017 13 Walfridsson et al, 2016 14 Dharmarajan et al, 2016 15 Bo et al, 2015 16 To explore predictors for diabetes treatment deintensification…”

Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit

“…In a study published in JAGS of 6960 veterans residing in Veterans Administration Community Living Centers (NHs) with limited life expectance and/or advanced dementia, over 40% were potentially overtreated with hypoglycemic agents (hemoglobin [Hgb] A1C < 7.5%). 15 Less than half of these overtreated patients had deintensification of hypoglycemic treatment over the course of 90 days. In another recent study of 5,471 VA NH residents older than 65 years with type 2 diabetes, 14% met the authorsʼ criteria for overtreatment (Hgb A1C < 6.5% while on insulin).…”

“…Recurrent episodes of hypoglycemia can result in strokes, worsening cognitive impairment, and many other complications. In a study published in JAGS of 6960 veterans residing in Veterans Administration Community Living Centers (NHs) with limited life expectance and/or advanced dementia, over 40% were potentially overtreated with hypoglycemic agents (hemoglobin [Hgb] A1C < 7.5%) . Less than half of these overtreated patients had deintensification of hypoglycemic treatment over the course of 90 days.…”