Effect of De-intensifying Diabetes Medications on Negative Events in Older Veteran Nursing Home Residents

Objective: Guidelines advocate against tight glycemic control in older nursing home (NH) residents with advanced dementia (AD) and/or limited life expectancy (LLE). We evaluated the effect of de-intensifying diabetes medications on all-cause emergency department (ED) visits, hospitalizations, and death in NH residents with LLE/AD and tight glycemic control.

Research Design and Methods: We conducted a national retrospective cohort study of 2,082 newly admitted non-hospice Veteran NH residents with LLE/AD potentially overtreated for diabetes (HbA1c ≤7.5% and ≥1 diabetes medication) in fiscal years 2009-2015. Diabetes treatment de-intensification (dose decrease or discontinuation of a non-insulin agent or stopping insulin sustained ≥7 days) was identified within 30 days following HbA1c measurement. To adjust for confounding, entropy weights were used to balance covariates between NH residents who de-intensified vs. continued medications. We used the Aalen-Johansen estimator to calculate the 60-day cumulative incidence and risk ratios (RR) for ED or hospital visits and deaths. 

Results: Diabetes medications were de-intensified for 27%. In the subsequent 60 days, 28.5% of all residents were transferred to the ED or acute hospital setting for any cause and 3.9% died. After entropy weighting, de-intensifying was not associated with 60-day all-cause ED visits or hospitalizations (RR = 0.99 [0.84, 1.18]) or 60-day mortality (RR = 1.52 [0.89-2.81]). 

Conclusion: Among NH residents with LLE/AD who may be inappropriately overtreated with tight glycemic control, de-intensification of diabetes medications was not associated with increased risk of 60-day all-cause ED visits, hospitalization, or death in NH residents with LLE/AD.