This work was presented at the 2010 National Annual Meeting of the Society for General Internal Medicine, Minneapolis, Minnesota, and the 2010 National Annual Meeting of the American Geriatrics Society, Orlando, Florida.
The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Older Adults with Diabetes Mellitus
Article first published online: 11 APR 2011
© 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society
Journal of the American Geriatrics Society
Volume 59, Issue 4, pages 666–672, April 2011
How to Cite
Lee, S. J., Boscardin, W. J., Stijacic Cenzer, I., Huang, E. S., Rice-Trumble, K. and Eng, C. (2011), The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Older Adults with Diabetes Mellitus. Journal of the American Geriatrics Society, 59: 666–672. doi: 10.1111/j.1532-5415.2011.03362.x
- Issue published online: 14 APR 2011
- Article first published online: 11 APR 2011
- glycemic control;
- diabetes mellitus
OBJECTIVES: To determine the hypo- and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM).
DESIGN: Guideline implementation.
SETTING: Program of All-Inclusive Care for the Elderly.
PARTICIPANTS: All participants in the before (October 2002–December 2004, n=338), early (January 2005–June 2006, n=289) and late (July 2006–December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement.
INTERVENTION: Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%.
MEASUREMENTS: Hypoglycemia (blood glucose<50 mg/dL), hyperglycemia (blood glucose>400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia).
RESULTS: Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P<.001) and insulin (23% before, 34% late, P<.001) and achieving the AGS glycemic target of HbA1c of less than 8% (74% before, 84% late, P<.001). Episodes of hyperglycemia (per 100 person-years) were dramatically lower in the late period (159 before, 46 late, P<.001), and episodes of hypoglycemia were similar (10.1 before, 9.3 late, P=.50). There were more episodes of severe hypoglycemia in the early period (1.1 before, 2.9 early, P=.03).
CONCLUSION: Implementing the AGS glycemic control guideline for frail older adults led to fewer hyperglycemic episodes but more severe hypoglycemic episodes requiring ED visits in the early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early guideline implementation period.