价值对于存在多种严重合并症及功能受限的老年人来说，强化血糖控制所带来的伤害很可能超过其所带来的益处。目的通过健康状况检测老年糖尿病患者的血糖控制水平，并评估糖尿病潜在过度治疗的发生率。设计、设定及参与者对国家健康与营养调查研究中2001—2010年进行了糖化血红蛋白（HbA1c ）测定的1288例老年（≥65岁）糖尿病患者的资料进行横断面分析。所有分析具备复杂的调查设计以生成国家代表性评估。表现健康状况分类：非常复杂/差，至少有两项日常活动做起来困难，或者依赖透析；复杂/一般，至少有两项日常工具的使用困难，或存在至少3种慢性疾病；相对健康，不具备以上几点。主要结果及措施严格的血糖控制（HbA1c ＜7.0％）以及糖尿病药物的使用很可能导致低血糖（胰岛素或磺酰脲类药物）。结果在1288例老年糖尿病患者中，50.7％〔95％ CI（46.6％，54.8％）〕的患者代表310万人〔95％ CI（270，350）万人〕为相对健康状况，28.1％〔95％ CI （24.8％，31.5％）〕的患者代表170万人〔95％ CI（140，200）万人〕为复杂/一般的健康状况，21.2％〔95％ CI （18.3％，24.4％）〕的患者代表130万人〔95％ CI（110，150）万人〕为非常复杂/差的健康状况。总体来说，61.5％〔95％ CI（57.5％，65.3％）〕的患者代表380万人〔95％ CI（340，420）万人〕其 HbA1c ＜7.0％；这个比例在3种健康状况中无差别｛62.8％〔95％ CI（56.9％，68.3％）〕为相对健康状况，63.0％〔95％ CI（57.0％，68.6％）〕为复杂/一般健康状况，56.4％〔95％ CI（49.7％，62.9％）〕为非常复杂/差的健康状况（P =0.26）｝。在HbA1c ＜7.0％的老年患者中，54.9％〔95％ CI（50.4％，59.3％）〕接受了胰岛素或磺酰脲类药物治疗；这个比例在各类健康状况糖尿病患者中近似。在研究涵盖的10年间，HbA1c ＜7.0％的老年患者比例（P =0.34）、HbA1c ＜7.0％且健康状况为复杂/一般或非常复杂/差的患者比例（P =0.27）、HbA1c ＜7.0％健康状况为复杂/一般或非常复杂/差但接受胰岛素或磺酰脲类药物治疗的患者比例（P =0.65）均无明显变化。结论及意义尽管对于健康状况为复杂/一般或非常复杂/差的老年糖尿病患者来说，强化治疗所带来的伤害很可能超过其带来的益处，但是大多数患者2001—2010年已经达到了严格的血糖目标。大部分患者接受了胰岛素或磺酰脲类药物治疗，这可能导致严重的低血糖。本研究发现，有相当大比例的老年糖尿病患者接受了潜在过度治疗。%Importance In older adults with multiple serious comorbidities and functional limitations,the harms of intensive glycemic control likely exceed the benefits. Objectives To examine glycemic control levels among older adults with diabetes mellitus by health status and to estimate the prevalence of potential overtreatment of diabetes. Dedign,Setting,and Participants Cross - sectional analysis of the data on 1 288 older adults(≥65 years)with diabetes from the National Health and Nutrition Examination Survey(NHANES)from 2001 through 2010 who had a hemoglobin A1c ( HbA1c )measurement. All analyses incorporated complex survey design to produce nationally representative estimates. Exposures Health status categories:very complex/ poor,based on difficulty with 2 or more activities of daily living or dialysis dependence;complex/ intermediate, based on difficulty with 2 or more instrumental activities of daily living or presence of 3 or more chronic conditions;and relatively healthy if none of these were present. Main Outcomes and Measures Tight glycemic control( HbA1c < 7. 0% )and use of diabetes medications likely to result in hypoglycemia(insulin or sulfonylureas). Results Of 1 288 older adults with diabetes, 50. 7% 〔95% CI(46. 6% ,54. 8% )〕,representing 3. 1 million〔95% CI(2. 7,3. 5) million〕,were relatively healthy, 28. 1% 〔95% CI(24. 8% ,31. 5% )〕,representing 1. 7 million〔95% CI(1. 4,2. 0)million〕,had complex/ intermediate health,and 21. 2% 〔95% CI(18. 3% ,24. 4% )〕,representing 1. 3 million〔95% CI(1. 1,1. 5) million〕,had very complex/ poor health. Overall,61. 5% 〔 95% CI( 57. 5% ,65. 3% )〕,representing 3. 8 million 〔 95% CI ( 3. 4,4. 2 ) million〕,had an HbA1c level of less than 7. 0% ;this proportion did not differ across health status categories{62. 8% 〔95% CI (56. 9% ,68. 3% )〕were relatively healthy,63. 0% 〔95% CI(57. 0% ,68. 6% )〕had complex/ intermediate health,and 56. 4% 〔95% CI(49. 7% ,62. 9% )〕had very complex/ poor health(P = 0. 26)}. Of the older adults with an HbA1c level of less than 7. 0% ,54. 9% 〔95% CI(50. 4% ,59. 3% )〕were treated with either insulin or sulfonylureas;this proportion was similar across health status categories. During the 10 study years,there were no significant changes in the proportion of older adults with an HbA1c level of less than 7. 0%( P = 0. 34),the proportion with an HbA1c level of less than 7. 0% who had complex/ intermediate or very complex/ poor health(P = 0. 27),or the proportion with an HbA1c level of less than 7. 0% who were treated with insulin or sulfonylureas despite having complex/ intermediate or very complex/ poor health( P = 0. 65 ). Conclusions and Relevance Although the harms of intensive treatment likely exceed the benefits for older patients with complex/ intermediate or very complex/ poor health status,most of these adults reached tight glycemic targets between 2001 and 2010. Most of them were treated with insulin or sulfonylureas,which may lead to severe hypoglycemia. Our findings suggest that a substantial proportion of older adults with diabetes were potentially overtreated.
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