title: Implementation of guidelines for type 2 diabetes mellitus in a post-acute geriatric setting.
abstract: OBJECTIVE
  Several health organizations have developed guidelines for type 2 diabetes mellitus, but it is known that population aging poses challenges to their application. We evaluated the reasons for not implementing guidelines for type 2 diabetes mellitus (DM) in patients admitted to a post-acute geriatric ward.
  
  
  METHODS
  209 patients (78.8+/-6.9 years old, female 72.7%) affected by DM, consecutively admitted in a Geriatric Evaluation and Rehabilitation Unit (GERU) between 2003 and 2005 for 32.2+/-11.5 days. The GERU geriatricians generated an algorithm for DM management following the guidelines proposed by the American Diabetes Association (2001) and the California Healthcare Foundation/American Geriatric Society (2003). The fit between medical choices and the guideline or the reasons for non-implementation were recorded on clinical charts.
  
  
  RESULTS
  Guidelines were implemented in 82.3% of cases. The main reason for non-application was the physician's judgment of the patient's clinical condition. Subjects in the non-implementation group had worse functional status, their somatic comorbidity was more severe, and their clinical condition more unstable. They were also affected by more serious psychological and behavioral symptoms associated with dementia. In a multivariate logistic regression analysis, adjusting for age, gender, cognitive, functional status, and number of drugs, the burden of comorbidity was the only independent determinant for not implementing the guidelines (OR 2.27, 95% CI 1.36-3.81, p=0.002).
  
  
  CONCLUSIONS
  although the guidelines for DM have previously been adapted to a geriatric setting, they are not applied in a significant percentage of old frail patients. Severe comorbidity is the main limitation for applying guidelines, but also polypharmacy, disability, cognitive impairment, and behavioral disturbances are factors taken into consideration before starting treatment of a very old patient affected by diabetes.
authors: Geriatric Research Group, Via Romanino 1, 25122 Brescia, Italy. cristina.cornali@yahoo.it
authors: Cristina
authors: C
authors: Cornali
authors: Simone
authors: S
authors: Franzoni
authors: Ignazio
authors: I
authors: Di Fazio
authors: Marco
authors: M
authors: Trabucchi
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D001168:Arthritis / Q000150:complications / Q000453:epidemiology; D019644:Arthroplasty, Replacement, Hip / Q000706:statistics & numerical data; D015897:Comorbidity; D003704:Dementia / Q000150:complications / Q000453:epidemiology; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000188:drug therapy / Q000628:therapy*; D005260:Female; D050723:Fractures, Bone / Q000150:complications / Q000453:epidemiology; D005853:Geriatrics / Q000458:organization & administration* / Q000706:statistics & numerical data; D006333:Heart Failure / Q000150:complications / Q000453:epidemiology; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007720:Knee Prosthesis / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic / Q000592:standards*; D020521:Stroke / Q000150:complications / Q000453:epidemiology; D016896:Treatment Outcome
chemical_list: D007004:Hypoglycemic Agents