Joslin Diabetes Center, Harvard Medical School
Deprescribing of Diabetes Treatment Regimens in Long Term Care Residents with Alzheimer’s Disease and Related Dementias (ADRD)
Health Care Systems
Theoria Medical
Dr. Munshi is the director of the Joslin Geriatric Diabetes Program and an associate professor of medicine at Harvard Medical School. She is also a staff geriatrician at the Beth Israel Lahey Health in Boston. Dr. Munshi is board certified in geriatric medicine and endocrinology and metabolism. Since joining the Joslin Diabetes Center, Dr. Munshi has developed a unique Geriatric Diabetes Program. This model of care is an interdisciplinary program, beyond the traditional diabetes programs, that considers clinical, functional, and psychosocial barriers faced by older adults before formulating individualized treatment strategies. Dr. Munshi's clinical research is focused on identifying barriers to diabetes management and developing novel strategies to improve the care of older adults, including simplification of complex insulin regimens. Her current research also focuses on the use of technology in older adults with type 1 and type 2 diabetes, particularly for the prevention of hypoglycemia.
RATIONALE: De-prescribing of inappropriate glucose-lowering medications diabetes is recommended for long-term care facility (LTCF) residents to avoid hypoglycemia, but is not performed consistently. Diabetic residents with Alzheimer’s Disease and Related Dementias (ADRD) are at particularly high risk of experiencing hypoglycemia from these medications.
OBJECTIVE: To establish the feasibility of conducting an embedded pragmatic trial of a clinician-focused diabetic management educational intervention for LTCF diabetic residents with dementia in nursing home health care systems. The pilot study will test the intervention implementation into the clinical flow of the LTCFs and collection of clinical outcomes. The study also aims to validate the clinical outcomes obtained from the electronic health record against direct continuous glucose monitoring.
SETTING: Six long-term care facilities in Michigan and Ohio.
POPULATION: Long-term care residents with diabetes and ADRD.
INTERVENTION: STRIDE (Simplification of Treatment Regiment and Individualized Diabetes Education) is directed toward LTCF clinicians and consists of webinars, a tool-kit with deprescribing algorithms and educational materials, and monthly tele-mentoring sessions.
OUTCOMES: The primary clinical outcome is the proportion of LTCF residents with diabetes and ADRD using high-risk medications (e.g., oral sulfonylureas) at 6 months based on electronic health record pharmacy data. This outcome will be validated against continuous glucose monitoring in a subset of participants. Implementation outcomes include acceptability, appropriateness, and feasibility of the STRIDE intervention.
IMPACT: If successful, the pilot study will establish the foundation for the design and conduct of a large-scale ePCT. Ultimately, providing the evidence for widespread adoption of the STRIDE intervention has the potential to promote the reduction of common but preventable medication-related adverse events among high-risk LTCF residents with ADRD and diabetes.