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What's the Optimal HbA_1c Level in Elders?

In an observational study, glycosylated hemoglobin between 8% and 9% was best.

Experienced clinicians have long recognized that tight glycemic control can be perilous in frail older patients with type 2 diabetes. Now, an observational study addresses that concern. Researchers in San Francisco studied 367 community-dwelling, older patients (mean age, 80) with diabetes who participated in a comprehensive adult day-care program and were unable to live independently. Glycosylated hemoglobin (HbA_1c) levels were measured at baseline, and functional decline and death were tracked during 2 years of follow-up (during which, average HbA_1c levels didn't change much).

Analyses were adjusted for potentially confounding variables. Compared with patients in the reference category (HbA_1c levels, 7%–8%), patients whose HbA_1c levels were between 8% and 9% had a significantly lower incidence of functional decline or death (relative risk, 0.88), and those with HbA_1c levels <7% had a nearly significant higher incidence of functional decline or death. Overall, the relation between HbA_1c level and functional decline or death was somewhat U-shaped, with the best outcomes among patients in the 8% to 9% range. These basic patterns were noted both among patients who took only oral antidiabetic drugs and those who took insulin.

Comment: This observational study is subject to residual confounding, but it suggests that an HbA_1c target in the 8% to 9% range is reasonable for older patients with diabetes who are unable to live independently. The findings support a recent guideline in which less-tight glycemic control is acceptable in older adults with long-standing diabetes (JW Gen Med Jul 24 2012).

— Allan S. Brett, MD

Published in Journal Watch General Medicine August 9, 2012

Citation(s):

Yau CK et al. Glycosylated hemoglobin and functional decline in community-dwelling nursing home–eligible elderly adults with diabetes mellitus. J Am Geriatr Soc 2012 Jul; 60:1215. (http://dx.doi.org/10.1111/j.1532-5415.2012.04041.x)

• Medline abstract (Free)

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Review and add to remarks on this article

• HgbA1C in Elders
  Bernard A. Yablin, ret asst clin prof Peds---URMC, 10 Aug 2012 11:49 AM EST
  Specialty: Pediatrics
  But with levels of 8-9% is there still more of a worry of macro-and micro-complications?
• Target HBA1c for age>70
  Hayward Zwerling! MD, FACP, FACE, Lowell Disbetes & Endocrine Center, 21 Aug 2012 10:57 AM EST
  Specialty: Endocrinology Diabetes Metab
  In my practice, for patients > 70, I frequently aim for a HBA1c=age/10. Of course this "target" must be adjusted... [more]
• HGBA1C in elders over 80 years of age
  Tom S. Ch'ang, 21 Aug 2012 10:57 AM EST
  Specialty: Unspecified
  For those type 2 Diabetic patients surviving beyond age 80 - there are many heath worries with changing priorities. For... [more]
• Hgb A1c in elders
  Marc Sapir, former Medical Director, Center for Elders' Independence (PACE, Oakland), 21 Aug 2012 10:57 AM EST
  Specialty: Family Medicine
  Dr. Brett points out that there may be residual confounding. I think that is probably true. From the description of... [more]

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