Dialogue Volume 13 Issue 2 2017 - Page 7

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 7