Glycemic Control and Use of High-risk Antihyperglycemic Agents Among Nursing Home Residents With Diabetes in Ontario, Canada

Iliana C Lega; Michael A Campitelli; Jeremy Matlow; Yingbo Na; Nathan M Stall; Paula A Rochon; Lorraine L Lipscombe

doi:10.1001/jamainternmed.2021.0022

. 2021 Mar 1;181(7):992–994. doi: 10.1001/jamainternmed.2021.0022

Glycemic Control and Use of High-risk Antihyperglycemic Agents Among Nursing Home Residents With Diabetes in Ontario, Canada

Iliana C Lega ^1,^2,^3,^✉, Michael A Campitelli ³, Jeremy Matlow ^1,², Yingbo Na ^1,³, Nathan M Stall ^1,^2,⁴, Paula A Rochon ^1,^2,^3,⁴, Lorraine L Lipscombe ^1,^2,³

¹Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada

²Department of Medicine, University of Toronto, Toronto, Ontario, Canada

³ICES, Toronto, Ontario, Canada

⁴Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada

Accepted for Publication: January 4, 2021.

Published Online: March 1, 2021. doi:10.1001/jamainternmed.2021.0022

^✉

Corresponding Author: Iliana C. Lega, MD, Women’s College Hospital, 76 Grenville St, Toronto, ON M5S 1B2, Canada (iliana.lega@wchospital.ca).

Author Contributions: Dr Lega had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Lega, Campitelli, Matlow, Stall, Rochon, Lipscombe.

Acquisition, analysis, or interpretation of data: Lega, Campitelli, Matlow, Na, Stall, Lipscombe.

Drafting of the manuscript: Lega, Campitelli, Na.

Critical revision of the manuscript for important intellectual content: Lega, Campitelli, Matlow, Stall, Rochon, Lipscombe.

Statistical analysis: Campitelli, Na, Stall.

Obtained funding: Lega.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by a grant from the Canadian Institutes of Health Research (1018890). Additionally, this study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Role of the Funder/Sponsor: The Canadian Institutes of Health Research and ICES had no influence on the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

Additional Contributions: We thank Susan E. Bronskill, PhD, ICES (Toronto, Canada), Afshan Zahedi, MD, Women’s College Hospital (Toronto, Canada), and Catherine Yu, MD, St. Michael’s Hospital (Toronto, Canada), who were involved in the discussions of this study and the study design. We also acknowledge the assistance of Vaidehi Misra BHSc, Research Assistant, Women’s College Research Institute (Toronto, Canada) for her assistance with editing and formatting the manuscript. These individuals were not compensated for their contributions to this study. Parts of this material are based on data and information compiled and provided by: R.A.I., O.D.D., and O.D.B. We thank IMS Brogan, Inc, for use of their Drug Information Database.

Additional Information: ICES is an independent, non-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. In 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. This change acknowledges the growth and evolution of the organization’s research since its inception in 1992, while retaining the familiarity of the former acronym within the scientific community and beyond.

^✉

Corresponding author.

PMCID: PMC7922236 PMID: 33646263

Abstract

This cohort study examines levels of glycemic control among nursing home residents with diabetes and compares rates of intensive glycemic control with high-risk antihyperglycemic agents across levels of cognitive impairment.

Older adults with diabetes are commonly treated to intensive glycemic targets,¹ despite guidelines recommending a more conservative approach.² The American Geriatric Society’s Choosing Wisely statement recommends avoiding treatment to glycated hemoglobin (HbA_1c) levels lower than 7.5% with agents other than metformin because of limited benefit, and increased risks of hypoglycemia and mortality.³ Nursing home residents with cognitive impairment may be at particular risk for harm from intensive therapy, both because they are unlikely to realize long-term benefit and because they may be less able to communicate hypoglycemic symptoms. We examined levels of glycemic control among nursing home residents with diabetes and compared rates of intensive glycemic control with high-risk antihyperglycemic agents across levels of cognitive impairment.

Methods

We performed a population-based, retrospective study using Ontario administrative health databases. Data sets were linked using unique, encoded identifiers and analyzed at ICES (formerly known as the Institute for Clinical Evaluative Sciences). We identified adults aged 66 years or older living in nursing homes with a full Resident Assessment Instrument Minimum Data set version 2.0 assessment from January 1, 2016, to September 1, 2017, who had type 2 diabetes based on a validated algorithm,⁴ and were treated with 1 or more antihyperglycemic agent (eFigure in the Supplement). Index date was a resident’s first available HbA_1c test. We categorized residents as having intact/borderline, mild/moderate, and severe cognitive impairment using the validated Cognitive Performance Scale.⁵ We compared mean HbA_1c levels and the proportion of patients taking high-risk antihyperglycemic agents (insulin and/or sulfonylurea) treated to intensive glycemic targets (HbA_1c ≤7%) overall and across levels of cognitive impairment. In Ontario nursing homes, all insulin is administered by a nurse, with blood glucose monitoring completed prior to insulin administration, consistently for those residents treated with sliding scale insulin, and on an as-needed basis for those treated with stable doses insulin. Use of data was authorized under section 45 of Ontario’s Personal Health Information Protection Act, which does not require review by a Research Ethics Board.

Results

We included 15 034 adults with diabetes living in nursing homes in Ontario (Table). Overall, 9170 (61.0%) were women and 5864 (39.0%) were men, and the mean (SD) age was 82.37 (7.66) years. Mean (SD) HbA_1c level was 7.3% (1.3%) and 7592 (50.5%) residents had an HbA_1c level of 7% or lower (mean [SD] HbA_1c 6.5 [0.5%]). Adults with severe cognitive impairment had a lower mean (SD) HbA_1c than those with mild/moderate (7.1% [1.3%] vs 7.3% [1.3%], P < .001) and intact/borderline impairment (vs 7.3% [1.4%], P < .001). Among those treated with high-risk agents (n = 7479), severe cognitive impairment was associated with a significantly higher likelihood of HbA_1c levels of 7% or lower compared with those with mild/moderate (44.7% vs 39.3%, P = .01) and intact/borderline impairment (vs 38.4%, P = .004) (Figure).

Table. Characteristics of 15 034 Nursing Home Residents Treated With High-risk Antihyperglycemic Agents.

Characteristic	No. (%)
	Overall	Cognitive impairment
	Overall	Intact/borderline	Mild/moderate	Severe
No.	15 034	3958	9522	1554
Age, mean (SD), y	82.37 (7.66)	80.58 (7.91)	83.04 (7.50)	82.83 (7.31)
Female	9170 (61.0)	2396 (60.5)	5755 (60.4)	1019 (65.6)
Time in long-term care facility, y
≤1	7429 (49.4)	2268 (57.3)	4680 (49.1)	481 (31.0)
>1	7605 (50.6)	1687 (42.7)	4842 (50.9)	1073 (69.0)
BMI, mean (SD)^a	28.4 (6.2)	30.1 (6.8)	28.0 (5.9)	26.1 (5.0)
Diabetes duration, mean (SD), y	15.8 (7.3)	16.1 (7.2)	15.7 (7.3)	15.7 (7.4)
Performance of activities of daily living (ADL)
Independent/limited supervision	3059 (20.3)	1334 (33.7)	1698 (17.8)	27 (1.7)
Extensive supervision/dependent	11 975 (79.7)	2624 (66.3)	7824 (82.2)	1527 (98.3)
Falls in past 30 d	2884 (19.2)	634 (16.0)	1955 (20.5)	295 (19.0)
Specialist physician care (geriatrician/endocrinologist)	3608 (24.0)	1047 (26.4)	2260 (23.7)	301 (19.4)
HbA_1c at index, mean (SD), %	7.3 (1.3)	7.3 (1.4)	7.3 (1.3)	7.1 (1.3)
Serum creatinine at index, mean (SD), µmol/mL	99.5 (64.7)	108.4 (82.2)	98.2 (58.3)	84.6 (45.7)
Antihyperglycemic agent use at index
DPP4 inhibitor	4947 (32.9)	1324 (33.5)	3208 (33.7)	415 (26.7)
Metformin	9913 (65.9)	2456 (62.1)	6416 (67.4)	1041 (67.0)
Sulfonylurea (glyburide, gliclazide)	3504 (23.3)	943 (23.8)	2280 (23.9)	281 (18.1)
Insulin	6121 (40.7)	1798 (45.4)	3721 (39.1)	602 (38.7)
Other^b	123 (2.0)	116 (2.9)	173 (1.8)	16 (1.0)
No. of unique anti-hyperglycemic agents at index, mean (SD)	1.9 (1.0)	2.0 (1.0)	1.9 (0.9)	1.7 (0.9)
Diabetes complication^c
Amputations	365 (2.4)	200 (5.1)	154 (1.6)	11 (0.7)
CKD	4255 (28.3)	1440 (36.4)	2507 (26.3)	308 (19.8)
Dialysis	165 (1.1)	85 (2.1)	77 (0.8)	≤5 (0.2)
Skin/soft tissue infections	1232 (8.2)	510 (12.9)	663 (7.0)	59 (3.8)
Treatment for retinopathy	589 (3.9)	218 (5.5)	337 (3.5)	34 (2.2)
Emergency department visit/hospitalization for hypoglycemia (6 mo prior)	339 (2.3)	127 (3.2)	196 (2.1)	16 (1.0)
Clinical diagnosis^c
Cancer	2901 (19.3)	860 (21.7)	1800 (18.9)	241 (15.5)
Congestive heart failure	3091 (20.6)	1125 (28.4)	1816 (19.1)	150 (9.7)
Coronary artery disease	5395 (35.9)	1697 (42.9)	3337 (35.0)	361 (23.2)
Dementia	11 259 (74.9)	1859 (47.0)	7944 (83.4)	1456 (93.7)
TIA or stroke	1251 (8.3)	305 (7.7)	831 (8.7)	115 (7.4)

Open in a new tab

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CKD, chronic kidney disease; DPP4 inhibitor, dipeptidyl peptidase-4 inhibitor; HbA_1c, hemoglobin A1C; TIA, transient ischemic accident.

^{^a}

BMI measure is only for those with a valid measurement, and we had missing data on 345 (2.3%) of the cohort for this variable.

^{^b}

Other antihyperglycemic agents category includes: sodium glucose cotransporter-2 (SGLT2) inhibitors, acarbose, glinides.

^{^c}

Look back 5 years prior to index.

Figure. — Mean HbA_1c levels among nursing home residents treated with high-risk antihyperglycemic agents were compared among levels of cognitive impairment. Mean HbA_1c was categorized as: HbA_1c of 7.0% or lower, 7.1% to 8.5%, higher than 8.5%. Cognitive status was determined using the validated MDS Cognitive Performance Scale and residents were classified as follows: intact/borderline impairment, 0-1; mild/moderate impairment, 2 to 3; severe impairment 4 or higher. Among residents treated with high-risk antihyperglycemic agents (n = 7479), those with severe cognitive impairment were significantly more likely to be treated to intensive glycemic targets (HbA_1c <7%) compared with residents with mild/moderate cognitive impairment (44.7% vs 39.3%, P = .01) and intact/borderline cognitive impairment (44.7% vs 38.4%, P = .004).

Discussion

We found that over half of nursing home residents with diabetes were treated to intensive glycemic targets, and that residents with severe cognitive impairment recieving high-risk antihyperglycemic agents were significantly more likely to be treated to intensive targets than those with milder cognitive impairment. Importantly, nearly a quarter of residents received sulfonylurea, a medication that is relatively contraindicated in older, frail adults. These findings are in direct contrast to national diabetes guidelines and campaigns advising against intensive glycemic targeting agents in older adults.^2,3

Our findings suggest that a substantial proportion of vulnerable nursing home residents are receiving unnecessary and potentially unsafe treatment for diabetes. These findings may be related to resource limitations in nursing homes, competing priorities among health care workers, lack of evidence-based deintensification strategies, treatment expectations from residents and family members, and failure to adjust antihyperglycemic agents following resident weight loss and changes in eating patterns.⁶

Limitations include lack of information on resident and/or family preferences and clinician perspectives. Overall, these findings underscore the need to improve the safety of diabetic control in nursing home residents, and to better understand the reasons for intensive diabetes treatment and barriers to deintensification strategies in this vulnerable population.

Supplement.

eFigure 1. Flow diagram showing creation of study cohort

Click here for additional data file.^{(208.5KB, pdf)}

References

1.Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356-362. doi: 10.1001/jamainternmed.2014.7345 [DOI] [PMC free article] [PubMed] [Google Scholar]
2.American Diabetes Association . 12. Older Adults: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(suppl 1):S139-S147. doi: 10.2337/dc19-S012 [DOI] [PubMed] [Google Scholar]
3.Society AG. Ten Things Clinicians and Patients Should Question. Published 2019. Accessed October 26, 2020. https://www.choosingwisely.org/societies/american-geriatrics-society/
4.Hux JE, Ivis F, Flintoft V, Bica A. Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care. 2002;25(3):512-516. doi: 10.2337/diacare.25.3.512 [DOI] [PubMed] [Google Scholar]
5.Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol. 1994;49(4):M174-M182. doi: 10.1093/geronj/49.4.M174 [DOI] [PubMed] [Google Scholar]
6.Raghavan S, Matlock D. Diabetes Mellitus Treatment Deintensification: When Well-Controlled Diabetes Mellitus Becomes Overcontrolled. Circ Cardiovasc Qual Outcomes. 2017;10(4):e003706. doi: 10.1161/CIRCOUTCOMES.117.003706 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure 1. Flow diagram showing creation of study cohort

Click here for additional data file.^{(208.5KB, pdf)}

[ild210001r1] 1.Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356-362. doi: 10.1001/jamainternmed.2014.7345 [DOI] [PMC free article] [PubMed] [Google Scholar]

[ild210001r2] 2.American Diabetes Association . 12. Older Adults: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42(suppl 1):S139-S147. doi: 10.2337/dc19-S012 [DOI] [PubMed] [Google Scholar]

[ild210001r3] 3.Society AG. Ten Things Clinicians and Patients Should Question. Published 2019. Accessed October 26, 2020. https://www.choosingwisely.org/societies/american-geriatrics-society/

[ild210001r4] 4.Hux JE, Ivis F, Flintoft V, Bica A. Diabetes in Ontario: determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care. 2002;25(3):512-516. doi: 10.2337/diacare.25.3.512 [DOI] [PubMed] [Google Scholar]

[ild210001r5] 5.Morris JN, Fries BE, Mehr DR, et al. MDS Cognitive Performance Scale. J Gerontol. 1994;49(4):M174-M182. doi: 10.1093/geronj/49.4.M174 [DOI] [PubMed] [Google Scholar]

[ild210001r6] 6.Raghavan S, Matlock D. Diabetes Mellitus Treatment Deintensification: When Well-Controlled Diabetes Mellitus Becomes Overcontrolled. Circ Cardiovasc Qual Outcomes. 2017;10(4):e003706. doi: 10.1161/CIRCOUTCOMES.117.003706 [DOI] [PMC free article] [PubMed] [Google Scholar]

PERMALINK

Glycemic Control and Use of High-risk Antihyperglycemic Agents Among Nursing Home Residents With Diabetes in Ontario, Canada

Iliana C Lega, MD

Michael A Campitelli, MSc

Jeremy Matlow, MD

Yingbo Na, MSc

Nathan M Stall, MD

Paula A Rochon, MD

Lorraine L Lipscombe, MD

Abstract

Methods

Results

Table. Characteristics of 15 034 Nursing Home Residents Treated With High-risk Antihyperglycemic Agents.

Figure. Mean Glycated Hemoglobin (HbA_1c) Levels Among Residents Treated With High-risk Antihyperglycemic Agents by Degree of Cognitive Impairment (CI).

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

Glycemic Control and Use of High-risk Antihyperglycemic Agents Among Nursing Home Residents With Diabetes in Ontario, Canada

Iliana C Lega, MD

Michael A Campitelli, MSc

Jeremy Matlow, MD

Yingbo Na, MSc

Nathan M Stall, MD

Paula A Rochon, MD

Lorraine L Lipscombe, MD

Abstract

Methods

Results

Table. Characteristics of 15 034 Nursing Home Residents Treated With High-risk Antihyperglycemic Agents.

Figure. Mean Glycated Hemoglobin (HbA1c) Levels Among Residents Treated With High-risk Antihyperglycemic Agents by Degree of Cognitive Impairment (CI).

Discussion

References

Associated Data

Supplementary Materials

ACTIONS

PERMALINK

RESOURCES

Similar articles

Cited by other articles

Links to NCBI Databases

Figure. Mean Glycated Hemoglobin (HbA_1c) Levels Among Residents Treated With High-risk Antihyperglycemic Agents by Degree of Cognitive Impairment (CI).