Publications

OBJECTIVES

To determine the hypo- and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM).

DESIGN

Guideline implementation.

SETTING

Program of All-Inclusive Care for the Elderly.

PARTICIPANTS

All participants in the before (October 2002-December 2004, n=338), early (January 2005-June 2006, n=289) and late (July 2006-December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement.

INTERVENTION

Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%.

MEASUREMENTS

Hypoglycemia (blood glucose<50 mg/dL), hyperglycemia (blood glucose>400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia).

RESULTS

Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P<.001) and insulin (23% before, 34% late, P<.001) and achieving the AGS glycemic target of HbA1c of less than 8% (74% before, 84% late, P<.001). Episodes of hyperglycemia (per 100 person-years) were dramatically lower in the late period (159 before, 46 late, P<.001), and episodes of hypoglycemia were similar (10.1 before, 9.3 late, P=.50). There were more episodes of severe hypoglycemia in the early period (1.1 before, 2.9 early, P=.03).

CONCLUSION

Implementing the AGS glycemic control guideline for frail older adults led to fewer hyperglycemic episodes but more severe hypoglycemic episodes requiring ED visits in the early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early guideline implementation period.

UNLABELLED

We have recently developed an animal model of fibromyalgia syndrome in the rat. In this model, rats exposed to unpredictable sound stress develop a delayed onset enhancement and prolongation of cytokine-induced mechanical hyperalgesia in muscle and skin. In this study, we tested the hypothesis that our model also manifests symptoms of common comorbid diagnoses: irritable bowel syndrome, temporomandibular disorder, and anxiety. Both visceral sensitivity and cytokine hyperalgesia in masseter muscle were present in the stressed rats. Furthermore, in an established model of irritable bowel syndrome-water avoidance-we observed significant muscle hyperalgesia. Finally, using the elevated plus maze to assess for anxiety level, we observed a significantly higher anxiety level in sound stress-exposed rats. Thus, unpredictable sound stress produces a condition in the rat with several features-delayed onset visceral and temporomandibular hyperalgesia and increased anxiety, as well as cutaneous and muscle hyperalgesia-commonly found in patients with fibromyalgia syndrome.

PERSPECTIVE

A stress model-unpredictable sound-in the rat exhibits several features (cutaneous, musculoskeletal, and visceral hyperalgesia, as well as anxiety) that are found in patients with fibromyalgia syndrome. Thus, this model may be used to test hypotheses about the underlying mechanisms and response to therapy in patients with fibromyalgia.