Diabetes Overtreatment Common in Nursing Homes as White House Focuses Efforts on Unnecessary Meds

While the Biden administration’s overprescription reform in nursing homes focuses mostly on antipsychotics, research has found that other disease treatments – including medication for type 2 diabetes – are overprescribed as well.

About 40% of nursing home residents with type 2 diabetes were either overtreated or potentially overtreated, according to results published in the Journal of the American Geriatric Society last month.

The study concluded overtreatment of diabetes in nursing home residents was common. Authors pointed to “prescribing inertia” – between 73% and 81% of residents continued to be overtreated or potentially overtreated after blood tests were conducted.

Residents that had their medication regimens appropriately deintensified were in the minority.

Only 46% of residents had their medication reduced in the nursing home setting, the study found.

As part of the administration’s nursing home reforms, the Centers for Medicare & Medicaid Services (CMS) will launch a new effort to identify inappropriate use of antipsychotic medications specifically, according to a White House fact sheet published in late February.

Overtreatment has been linked to an increased risk in mortality, severe hypoglycemia, cognitive impairment, and falls, authors noted. About 44% of 30-day-stay or longer residents had hypoglycemia post-admission.

“We propose that NH residents with an episode of hypoglycemia should be required to undergo a medication review to determine whether GLMs should be deintensified,” authors said.

Drs. Lauren Lederle and Michael Steinman, as well as Bocheng Jing, Brain Nguyen and Sei Lee were authors on the study.

“Many NH residents who are unlikely to benefit from tight glycemic control and are at high risk of hypoglycemia continue to receive insulin and other medications that increase hypoglycemia risk even after HbA1c results suggest overtreatment,” the authors wrote. “In addition to hypoglycemia risk, factors such as cognitive and functional impairment should be considered when identifying patients for treatment deintensification.”

The American Diabetes Association, American Geriatrics Society and Veterans Affairs all recommend less aggressive glycemic treatment for frail older adults, according to the study.

In 2021, the American Diabetes Association even put new emphasis on deintensification and deprescribing among diabetes patients – “tight glycemic control” was found to have no benefit in this population, authors noted.

Physician groups like Theoria Medical and GAPS Health have been working to deescalate the number of medications and doses upon admission to the nursing home setting regardless of diagnosis, and again prior to release to the home or hospice.

“There’s no one in their [sixth to tenth] decade of life who should be on 20-plus medications,” said Dr. Jerry Wilborn, co-founder and CEO of GAPS. “We’re actively managing the medication regimen, but the key word is optimizing because we make sure that the patients are on the medications they should be on based on their clinical journey.”

GAPS has seen a 20-30% reduction in re-hospitalizations as a result of medication management and optimization, WIlborn told Skilled Nursing News.

Study authors said successful interventions include engaging and educating multiple stakeholders, including patients, their families, pharmacists, nurses and physicians.

About 7,422 residents from Veterans Affairs nursing homes participated in the diabetes study from 2013 to 2019; all were aged 65 or older and experienced a nursing home stay of 30 days or more, the study said.

Residents overtreated for type 2 diabetes had HbA1c blood tests at 6.5% or lower; potential overtreatment was considered to be less than 7.5% with any insulin use.