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“Tight Control” in Geriatrics: The Emperor Wears a Thong


Address correspondence to Thomas E. Finucane, School of Medicine, Johns Hopkins University, 5505 Hopkins Bayview Circle, Baltimore, MD 21224. E-mail:


The deep-seated faith in tight glycemic control for patients with type 2 diabetes mellitus shows signs of moderating, especially for elderly adults, but faith in the importance of a glycosylated hemoglobin goal of 7% retains a strong influence over many clinicians. This faith persists despite weak evidence from randomized controlled trials of any meaningful benefit from “tight control” in any patient group, consistent evidence of lack of benefit for many outcomes, and an almost complete lack of evidence about elderly adults or those with extensive vascular disease. Clinicians who care for these vulnerable individuals face a strong public belief in “tight control” and an orchestrated campaign to increase medication use. Although no benefit has been shown in elderly adults, some harms are clear, and others are likely.