Graydon S Meneilly1, Lori D Berard2, Alice Y Y Cheng3, Peter J Lin4, Lori MacCallum5, Ross T Tsuyuki6, Jean-François Yale7, Nahal Nasseri8, Jean-François Richard8, Lianne Goldin4, Anatoly Langer9, Mary K Tan4, Lawrence A Leiter10. 1. Department of Medicine, Vancouver Hospital and the University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: meneilly@mail.ubc.ca. 2. Winnipeg Regional Health Authority, Health Sciences Centre, Winnipeg Diabetes Research Group, Department of Medicine, Section of Endocrinology, University of Manitoba, Winnipeg, Manitoba, Canada. 3. Division of Endocrinology and Metabolism, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 4. Canadian Heart Research Centre, Toronto, Ontario, Canada. 5. Banting and Best Diabetes Centre, Faculty of Medicine and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada. 6. EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. 7. Division of Endocrinology and Metabolism, McGill University, Montréal, Québec, Canada. 8. Merck Canada Inc., Kirkland, Québec, Canada. 9. Canadian Heart Research Centre, Toronto, Ontario, Canada; Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada. 10. Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Ontario, Canada.
Abstract
OBJECTIVE: The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care. METHODS: Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics. RESULTS: More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents. CONCLUSIONS: Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly.
OBJECTIVE: The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care. METHODS: Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics. RESULTS: More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents. CONCLUSIONS: Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly.
Keywords:
diabète de type 2; fragilité; frailty; older individuals; personnes âgées; pharmacotherapy; pharmacothérapie; primary care; soins primaires; type 2 diabetes