Wednesday, April 13, 2011

Hemoglobin A1C target of 7 in the elderly. Really? REALLY???

I want to draw GeriPal readers attention to a terrific commentary in this week's JAMA by GeriPal's own Sei Lee.  Sei was also interviewed for the New York Times New Old Age blog here (see the comments for some great back and forth between readers and Paula Span).

The topic is very GeriPal - a thoughtful consideration of the benefits, burdens, and potential risks of tight glycemic control in frail elders with diabetes.  National guidelines generally recommend tight glycemic control - meaning a target hemoglobin A1C of less than 7.  Some of the questions Sei addresses in the commentary:

  • Does it make sense to target endpoints that may take years to achieve in frail elderly patients with a limited life expectancy? (I'll let you answer that)
  • If it takes ~8 years of tight glycemic control to prevent heart attacks and strokes, why aim for tight control in patient with a life expectancy of less than 5 years? (why indeed)
  • What are the burdens of tight glycemic control in the elderly? (e.g. hypoglycemia leading to falls)
  • What are the burdens of hyperglycemia in the elderly (e.g. urinary incontinence, neuropathy)
  • What are the goals of treatment of hyperglycemia in the elderly, and how should they change in light of the patient's prognosis and the goals of care?  (read his commentary!)

Sei argues for a nuanced approach to setting hemoglobin A1C targets that accounts for the benefits, burdens, and potential risks of tight glycemic control, in light of the patients prognosis, goals and values, and the clinical picture.

This is asking a lot of clinicians. But isn't that the kind of care you would expect of your doctor, or nurse practitioner?

by: Alex Smith

5 comments:

Kathleen said...

A persoanlized nuanced approach to (fill in the blank) is exactly the kind of care any of us would want and expect for ourselves when we get there and for our patients now---Thank you for the blog. I always fing the GeriPal postings thought provoking and spot on. I appreciate how articulate and wise you all are regarding the "big picture".
From a geriatric/family/palliative nurse practitioner in the trenches---providing priamry care to medicare patients.

Margo said...

I would like personalized care now!
Margo Smith/Mom

ken covinsky said...

I hope this commentary causes some providers to think beyond the numbers and instead think about what they are actually trying to accomplish with glucose control in frail elders with diabetes.

Nursing homes seem to be a setting where efforts at glycemic control can run amok. In this controlled setting, it is so easy to write orders for frequent finger sticks and complex insulin regimens.

But just because it is easy to do all this monitoring and titration does not mean it is the right thing for the patient.

What goes through the mind of a patient with advanced Alzheimers disease when their providers approach them multiple times a day for fingersticks and injections?Some must think they are being stabbed.

While we dont have much of an evidence base to guide us in terms of what degree of control is ideal, it sure seems that starting by asking what we hope to acheieve with our treatment regimen and how it relates to the goals of care will lead to better decisions.

As Lee and Eng note, it is probably the case that many in nursing homes will do better if the glycemic target is focused on reasonable control, than normoglycemia.

Mary Poole said...

Wish I could read the whole article or a summary to share with families who become obsessive about diet and glucose control

Landon said...

This is an important article. In Nova Scotia, we developed specific guidelines for glucose targets. Basically, they say that blood sugars below 7 are dangerous.

Diabetes Guidelines for Elderly Residents in Long-Term Care Pocket Reference, Diabetes Care Program of Nova Scotia