The Risks and Benefits of Implementing Glycemic Control Guidelines in Frail Older Adults with 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.