Diabetes Managed More Tightly in Demented Patients

Ideally targeted glucose values for specific patient populations – such as those hospitalized with acute illness, or frail older adults – remains a series of moving targets.

Dr. Stephen J. Bekanich

Guidelines are offered for both populations and are not dissimilar. In 2011, the American College of Physicians put forth recommendations for glycemic control in hospitalized patients (Ann. Intern. Med. 2011;154:260-7). For non-ICU patients, intensive insulin therapy should not be given to control glucose strictly, nor should it be administered with the intent of normalizing glucose values. The American Geriatrics Society loosens the HbA_1c goal for the elderly to 8% (J. Am. Geriatr. Soc. 2003;51[5 suppl. guidelines]:S265-280). When these AGS guidelines are followed, the early part of the implementation process is accompanied by a rise in severe hypoglycemic episodes requiring emergency department visits (J. Am. Geriatr. Soc. 2011;59:666-72).

The association between hypoglycemia and cognition prompts hospitalists to be more wary of the ACP guidelines, and to implement thoughtful discharge plans around glycemic control for their elderly patients. It appears that an attempt at tighter control of glucose values may lead to less-desirable outcomes in the form of diminished cognition and greater resource utilization. This association may also cause us to reevaluate an even more liberal view on elderly HbA_1c goals.

Dr. Stephen J. Bekanich is the medical director of palliative care services at the University of Miami.