Prognostic Value of Glycated Hemoglobin in Frail Older Diabetic Patients With Hip Fracture

Abstract

BackgroundPrevious studies have shown increased risk of fracture in older patients with poor or strict glycemic control (glycated hemoglobin, HbA1c, ≥ 8% or < 6-7% respectively); however, these reports did not investigate the oldest-old population. Comprehensive geriatric assessment (CGA) and a patient-centered approach have been proven to improve the quality of care in the management of Type 2 Diabetes Mellitus (T2DM) in the older patients, but data regarding T2DM in patients with fragility fractures are still lacking.AimTo investigate the prognostic role of HbA1c and frailty level in older diabetic patients admitted for hip fracture.MethodsProspective observational cohort study conducted on diabetic geriatric patients consecutively hospitalized for hip fracture in the orthogeriatric unit of a tertiary care hospital. Preoperative comprehensive geriatric assessment (CGA) was performed. Using the Clinical Frailty Scale (CFS), diabetic patients were categorized in robust (CFS < 5) and frail (CFS ≥ 5), and further stratified according to HbA1c values [Tertile 1 (T1) HbA1c < 48 mmol/mol, Tertile 2 (T2) 48-58 mmol/mol and Tertile 3 (T3) > 58 mmol/mol). Comparisons between continuous variables were performed with analysis of non-parametric test for independent samples, while relationships between categorical variables were assessed by chi-square test. Using logistic multivariate regression, we evaluated the determinants of 1-year all-cause mortality in diabetic older patients with hip fracture.ResultsAmong the 1319 older patients (mean age 82.8 ± 7.5 years, 75.9% females) hospitalized for hip fracture, 204 (15.5%) had a previous diagnosis of T2DM. T2DM patients showed an increased proportion of multiple concurrent fractures occurred during the accidental fall or syncope (12.7% vs 11.2%, p=0.02). One-year mortality after hip fracture surgery was significantly higher in T2DM as compared to not diabetic patients (21.2% vs 12.5%, p<0.001). No significant difference in mortality was found across HbA1c tertiles; however, frail diabetic patients in the second and third HbA1c tertiles showed higher mortality risk compared to the robust counterparts (26.9% vs 5%, p=0.001 for T2 and 43.5% vs 13.3%, p=<0.05 for T3), while no difference was observed among those in T1.ConclusionsFrail patients with HbA1c ≥ 48 mmol/L showed an increased mortality risk as compared to robust counterparts. CFS represents an important tool to select diabetic subjects with higher likelihood of adverse outcome.

What are the consequences of over and undertreatment of type 2 diabetes mellitus in a frail population? A systematic review

“…Two studies 23,24 investigated length of hospital stay as an outcome although this was a secondary outcome in both studies. Paterni et al 24 .…”

“…These two studies may reflect that those with increased service utilisation may well have the greatest health needs, but they can also suggest where further focus on care is required. Paterni et al 24 . found that frail participants without optimal glycaemic control determined by HbA1c showed a four‐ to five‐fold higher mortality compared to robust participants, whilst no difference in mortality rate was found between robust and frail participants with strict glycaemic control (HbA1c < 48 mmol/mol).…”

“…Two studies 23,24 investigated length of hospital stay as an outcome although this was a secondary outcome in both studies. Paterni et al 24 . showed that patients with diabetes faced significantly longer hospital stays than patients without diabetes but did not offer data for relationship to glycaemic control.…”

“…Four of the studies examined mortality as an outcome 19,20,26,28 . Frailty was shown to be associated with an increased risk of all‐cause mortality in participants with diabetes in four of the studies 21,24,26,27 . Reflecting the Cacciatore et al 37 .…”

Intertrochanteric Fracture Surgery Patients with Diabetes Mellitus are Prone to Suffer Perioperative Neurological and Endocrine/Metabolic Complications: A Propensity-Score Matched Analysis

“…We did not control all risk factors, such as smoking and other unknown confounders, which may potentially influence the findings. Although HbA1c is a reliable indicator of long-term glycemic control, providing a picture of patients’ average blood glucose levels during the previous two to three months, 31 conflicting results have been reported regarding mortality and postoperative complications after orthopedic procedures including hip fracture surgery. 32 , 33 Through this study, we aimed to compare the adverse outcomes following hip fracture surgery in DM and non-DM patients.…”