Rationale

  • Older adults living in long care facilities are generally frail. The Nova Scotia Department of Health and Wellness data indicates that in 2010/2011, 27% of admissions had diabetes with a length of stay of 2.5 years.
  • It takes at least five years to achieve benefits from tight control – an irrelevant timeframe with frailty.2-5
  • When there is long standing diabetes (as occurs with frailty), studies show limited benefit3, no benefit4, or harm5 with tight control.6
  • The demonstrated microvascular benefits in randomized controlled trials are surrogate, not clinical, outcomes that have limited relevance in frailty2,6,7 including:
    • Decreased photocoagulation, but no difference in vision.
    • Less albuminuria, but no difference in creatinine.
    • Less neuropathy, not based on clinical symptoms, but based on outcomes measured that may not be related to neuropathy, including changes in reflexes, biothesiometer readings, R-R intervals on EKG, lying and standing blood pressure measures, and self-reported erectile dysfunction.
  • In the Veterans Affairs Diabetes Trial4, there was no difference in positive outcomes or serious hyperglycemic adverse events when HbA1c was 6.9% compared to 8.4%. Therefore, a HbA1c target above 8% is reasonable. The targeted range of HbA1c (>8 to <12%) was chosen to allow individualized treatment decisions based on drug tolerance and symptoms, as some frail patients may be able to tolerate higher blood glucose and HbA1c measures.
  • The most consistent finding of randomized controlled trials of intensive blood glucose control has been an increased risk of hypoglycemia, which is particularly problematic for the elderly.
  • There is increased hospitalization with intensive treatment.
  • The cost and human resources needed to measure and maintain tight control in long-term care is significant.