Letters to the Editor
Dear Editor
Re: Risk Factors for Fall in Seniors
(Dialogue, Volume 13, Issue 1, 2017)
The Issue 1, 2017 edition of Dialogue contains an article
on patient safety which focuses on risk factors for falls
in seniors.
On page 40, in a section on oral hypoglycemic ther-
apy, it is stated that the target A1C for the frail elderly
should be 0.08 – 0.12. An A1C of 12% is indicative of
a mean blood glucose of 16.5 mmol/l (95% CI 13.3-
19.3) for the past 2-3 months.
Sustained hyperglycemia of this magnitude is likely
to have significant adverse effects including polyuria,
incontinence, hyperosmolar states, hypovolemia and
hypotension, thereby increasing the risk of falls.
Twenty-five percent of people over the age of 65 have
diabetes.
They can be divided into three subgroups:
(1) Those who are fit,
(2) Th
ose with multiple co-existing illnesses or mild to
moderate cognitive impairment and intermediate
remaining life-expectancy, and
(3) Th
ose with end-stage illnesses or moderate to severe
cognitive impairment and limited life expectation.
There is a consensus among the Canadian Diabetes
Association, the American Diabetes Association and
the American Geriatrics Society that all targets for the
comprehensive management of the older person with
diabetes should be individualized and both hypoglyce-
mia and sustained hyperglycemia should be avoided in
this vulnerable population.
In the 2013 Canadian Diabetes Association Guideline,
it is suggested that an A1C up to 8.5% may be appro-
priate in this age group.
In the same year, the American Geriatrics Society
suggested an A1C of 8-9% for those in Group 3. The
American Diabetes Association revised their guidelines
1
in 2017 stratifying those in Group 2 for whom a “rea-
sonable A1C target” is 8%, while for those in Group 3,
it can be 8.5%.
The only apparent reference for a proposed A1C of
12% comes from an article published in 2013 by a
group of health-care providers in Nova Scotia. En-
titled, “Evidence-informed guidelines for treating frail
older adults with type 2 diabetes” it was published in
the Journal of the American Medical Directors Associa-
tion (JAmMedDirAssoc.2013 Nov; 14(11): 801-8).
As stated by the authors, it is “provocative” includ-
ing a statement that an A1C of 8-12 is “acceptable if
asymptomatic”, moreover an A1C of “more than 12” is
acceptable “if there are no reversible symptoms such as
polyuria.” Furthermore, they opine that routine blood
glucose testing is not required for those on oral hypo-
glycemic medication or stable doses of basal insulin.
There has been no published follow-up of the out-
comes of these unique recommendations and no evi-
dence that this approach has been adopted elsewhere.
Yours sincerely,
Anne B. Kenshole MB, BS, FRCP(C), FACP
The Geriatric and Long-Term Care Death
Review Committee responds:
We thank Dr. Kenshole for her thoughtful comments
regarding our recommendations.
We agree with Dr. Kenshole that symptomatic hyper-
glycemia should be treated. Indeed, when the authors
of the 2013 paper 1 recommended a target HbA1C of
up to 12% in frail elders, they emphasized the words “if
asymptomatic”. Certainly, we agree that symptomatic
hyperglycemia should be treated judiciously to elimi-
nate symptoms.
The fact remains, however, that there is much higher
morbidity and mortality from tight glucose control in
the frail elderly (“Group 3” in Dr. Kenshole’s letter)
allery LH, Ransom T, Steeves B, Cook B, Dunbar P, Moorhouse P. Evidence-Informed Guidelines for Treating Frail Older Adults With Type 2 Diabetes:
M
From the Diabetes Care Program of Nova Scotia (DCPNS) and the Palliative and Therapeutic Harmonization (PATH) Program. J Am Med Dir Assoc. 2013
Nov;14(11):801–8.
Issue 2, 2017 Dialogue
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