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

I want to draw GeriPal readers attention to a terrific commentaryin 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 arguesfor 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