Glycemic control, complications, and death in older diabetic patients: the diabetes and aging study

Elbert S Huang, Jennifer Y Liu, Howard H Moffet, Priya M John, Andrew J Karter, Elbert S Huang, Jennifer Y Liu, Howard H Moffet, Priya M John, Andrew J Karter

Abstract

Objective: To identify the range of glycemic levels associated with the lowest rates of complications and mortality in older diabetic patients.

Research design and methods: We conducted a retrospective cohort study (2004-2008) of 71,092 patients with type 2 diabetes, aged ≥60 years, enrolled in Kaiser Permanente Northern California. We specified Cox proportional hazards models to evaluate the relationships between baseline glycated hemoglobin (A1C) and subsequent outcomes (nonfatal complications [acute metabolic, microvascular, and cardiovascular events] and mortality).

Results: The cohort (aged 71.0 ± 7.4 years [means ± SD]) had a mean A1C of 7.0 ± 1.2%. The risk of any nonfatal complication rose monotonically for levels of A1C >6.0% (e.g., adjusted hazard ratio 1.09 [95% CI 1.02-1.16] for A1C 6.0-6.9% and 1.86 [1.63-2.13] for A1C ≥11.0%). Mortality had a U-shaped relationship with A1C. Compared with the risk with A1C <6.0%, mortality risk was lower for A1C levels between 6.0 and 9.0% (e.g., 0.83 [0.76-0.90] for A1C 7.0-7.9%) and higher at A1C ≥11.0% (1.31 [1.09-1.57]). Risk of any end point (complication or death) became significantly higher at A1C ≥8.0%. Patterns generally were consistent across age-groups (60-69, 70-79, and ≥80 years).

Conclusions: Observed relationships between A1C and combined end points support setting a target of A1C <8.0% for older patients, with the caution that A1Cs <6.0% were associated with increased mortality risk. Additional research is needed to evaluate the low A1C-mortality relationship, as well as protocols for individualizing diabetes care.

References

    1. UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837–853
    1. Huang ES, Zhang Q, Gandra N, Chin MH, Meltzer DO. The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes: a decision analysis. Ann Intern Med 2008;149:11–19
    1. Greenfield S, Billimek J, Pellegrini F, et al. Comorbidity affects the relationship between glycemic control and cardiovascular outcomes in diabetes: a cohort study. Ann Intern Med 2009;151:854–860
    1. Gerstein HC, Miller ME, Byington RP, et al. ; Action to Control Cardiovascular Risk in Diabetes Study Group Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545–2559
    1. Patel A, MacMahon S, Chalmers J, et al. ; ADVANCE Collaborative Group Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560–2572
    1. Duckworth W, Abraira C, Moritz T, et al. ; VADT Investigators Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129–139
    1. Stratton IM, Adler AI, Neil HAW, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405–412
    1. Currie CJ, Peters JR, Tynan A, et al. Survival as a function of HbA(1c) in people with type 2 diabetes: a retrospective cohort study. Lancet 2010;375:481–489
    1. Rodbard HW, Blonde L, Braithwaite SS, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus. Endocr Pract 2007;(Suppl. 1):1–68
    1. Brown AF, Mangione CM, Saliba D, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes Guidelines for improving the care of the older person with diabetes mellitus. J Am Geriatr Soc 2003;51(Suppl. 5 Guidelines):S265–S280
    1. Karter AJ, Parker MM, Moffet HH, et al. Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients. Med Care 2004;42:110–115
    1. Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV. Ethnic disparities in diabetic complications in an insured population. JAMA 2002;287:2519–2527
    1. Iribarren C, Karter AJ, Go AS, et al. Glycemic control and heart failure among adult patients with diabetes. Circulation 2001;103:2668–2673
    1. Karter AJ, Ackerson LM, Darbinian JA, et al. Self-monitoring of blood glucose levels and glycemic control: the Northern California Kaiser Permanente Diabetes registry. Am J Med 2001;111:1–9
    1. Schafer JL. Multiple imputation: a primer. Stat Methods Med Res 1999;8:3–15
    1. Katakura M, Naka M, Kondo T, et al. Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano Study. Diabetes Care 2003;26:638–644
    1. Blaum CS, Volpato S, Cappola AR, et al. Diabetes, hyperglycaemia and mortality in disabled older women: the Women’s Health and Ageing Study I. Diabet Med 2005;22:543–550
    1. Nelson KM, Boyko EJ, Koepsell T. All-cause mortality risk among a national sample of individuals with diabetes. Diabetes Care 2010;33:2360–2364
    1. Riddle MC, Ambrosius WT, Brillon DJ, et al. ; Action to Control Cardiovascular Risk in Diabetes Investigators Epidemiologic relationships between A1C and all-cause mortality during a median 3.4-year follow-up of glycemic treatment in the ACCORD trial. Diabetes Care 2010;33:983–990
    1. Kim TN, Park MS, Yang SJ, et al. Prevalence and determinant factors of sarcopenia in patients with type 2 diabetes: the Korean Sarcopenic Obesity Study (KSOS). Diabetes Care 2010;33:1497–1499
    1. Selvin E, Steffes MW, Zhu H, et al. Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults. N Engl J Med 2010;362:800–811
    1. Nathan DM, Singer DE, Godine JE, Perlmuter LC. Non-insulin-dependent diabetes in older patients. Complications and risk factors. Am J Med 1986;81:837–842
    1. Bertoni AG, Kirk JK, Goff DC, Jr, Wagenknecht LE. Excess mortality related to diabetes mellitus in elderly Medicare beneficiaries. Ann Epidemiol 2004;14:362–367
    1. Dekker FW, de Mutsert R, van Dijk PC, Zoccali C, Jager KJ. Survival analysis: time-dependent effects and time-varying risk factors. Kidney Int 2008;74:994–997
    1. Huang ES, Brown SE, Ewigman BG, Foley EC, Meltzer DO. Patient perceptions of quality of life with diabetes-related complications and treatments. Diabetes Care 2007;30:2478–2483

Source: PubMed

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