title: The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus.
abstract: OBJECTIVE
  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).
  
  
  METHODS
  Guideline implementation.
  
  
  METHODS
  Program of All-Inclusive Care for the Elderly.
  
  
  METHODS
  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.
  
  
  METHODS
  Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%.
  
  
  METHODS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Geriatrics, San Francisco Veterans Affairs Medical Center and University of California at San Francisco, San Francisco, California, USA. sei.lee@ucsf.edu
authors.forename: Sei J
authors.initials: SJ
authors.lastname: Lee
authors.forename: W John
authors.initials: WJ
authors.lastname: Boscardin
authors.forename: Irena
authors.initials: I
authors.lastname: Stijacic Cenzer
authors.forename: Elbert S
authors.initials: ES
authors.lastname: Huang
authors.forename: Kathy
authors.initials: K
authors.lastname: Rice-Trumble
authors.forename: Catherine
authors.initials: C
authors.lastname: Eng
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000378:metabolism; D003920:Diabetes Mellitus / Q000097:blood / Q000188:drug therapy; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use*; D007328:Insulin / Q000627:therapeutic use*; D008297:Male; D008687:Metformin / Q000627:therapeutic use*; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; D008687:Metformin