Diabetes Forecast

Should Seniors Loosen Glucose Control?

By Lindsey Wahowiak ,

Imagine you've been managing your diabetes for decades. Maybe you don't have to imagine—it's a reality for many seniors. After all that time tightly managing your blood glucose levels, striving for on-target A1Cs, should you be allowed to ease up a little bit after age 64?

That's a tricky topic, and one that researchers and health care professionals have touched on in the American Diabetes Association's most recent Standards of Medical Care in Diabetes. In essence, their answer is: It's complicated.

The Case for Looser Standards
As people age, they are at increased risk for health concerns: High blood pressure, heart disease, and cognition issues become factors in how diabetes must be treated. "It's not that we want someone to have a high blood glucose or a high A1C," says Andrew Goldberg, MD, director of the Geriatric Research, Education, and Clinical Center at the Baltimore VA Medical Center. "You really want to individualize their treatment to their lifestyle. In treating [the very elderly], you provide enough of a window for a 'soft landing,' a threshold point and protective layer to avoid hypoglycemia [low blood glucose]." Lows can be dangerous, even fatal.

Info for Seniors
To learn more about how type 2 diabetes affects older adults (much of the info applies to type 1 as well), visit diabetes.org/seniors, where you can download "Living Healthy With Diabetes: A Guide for Adults 55 and Up."

Also in play is the body's natural aging process, particularly in the kidneys, says Paulina Duker, MPH, RN, BC-ADM, CDE, the American Diabetes Association's vice president for diabetes and clinical programs. Our kidneys work as a filter, helping the body process medication and dispose of waste products and excess fluid. But as we age, our kidneys work less well. Think of a water filter. The longer it's been used, the less easily water filters through and impurities are eliminated. Similarly, the kidneys and liver are less able to break down insulin and diabetes pills such as sulfonylureas, giving them a longer half-life in the body. Essentially, the effects of the medication last longer—and if treatment isn't adjusted, this can cause a person with diabetes to have an episode of hypoglycemia, even if there's no diagnosed kidney disease. People who have had diabetes for many years may also be on older drugs that take longer to break down on their own, which can increase the risk.

Memory problems and the way they affect typical diabetes routines may become an issue for some older people. Regular blood glucose checks and logging results might become less frequent. So, persistently high blood glucose, which can lead to a coma, and dangerous low blood glucose may go unnoticed by both people with diabetes and health care providers. Having diabetes for a long time and frequent lows also can make people less able to recognize the symptoms of lows. Even if a person has an exemplary A1C (average blood glucose over two to three months), it may not reveal frequent lows or the whole diabetes management story.

When Control Matters
Yet not everyone needs a higher A1C goal. Older people with diabetes are still at risk for the same complications as their younger counterparts. That's why it's important—if they are able to continue with their treatment, regular blood glucose checks, eating well, and staying active—that their blood glucose and A1C targets should be the same as younger people's, says Jeffrey Halter, MD, director of the University of Michigan Geriatrics Center and the Institute of Gerontology. "The message is not 'older adults should have different targets from others,' " Halter says. "This is a highly heterogeneous population. One older adult and another older adult can be very different in what their needs are. Unless you assess those, there's no real basis [for a higher target]."

Many older adults are healthy, active, and functional, and their blood glucose control goals should be the same as younger people's. But no two people with diabetes are alike, and that's why each person should work with his or her health care professional to create an individualized diabetes management plan, Halter says.

But when anyone is juggling multiple health issues, it can be helpful to streamline. Working with a doctor, and being open to newer technology and treatments, can make life easier, says Duker, and help keep blood glucose levels in check. "You have to keep the treatment regimen simple," she says. "It's a balance with simplicity and good glucose control." That could mean using a slow-acting insulin with only one or two shots each day, or using a continuous glucose monitor to track patterns in highs and lows.

It's About Quality of Life
Ultimately, a slightly looser blood glucose target makes sense for some older people, Duker says, if it means they won't be at risk for potentially devastating lows. "It's quality of life. How much hypoglycemia are you willing to tolerate to get to goal?" she says. People need to feel confident they aren't going to pass out from a low and can remain independent for as long as possible.

Duker notes that bodies that might already be compromised by complications or other medical conditions can take longer to recover. People with diabetes, their families, and their health care team can weigh that risk and their life stage against the risk of lows.

It takes a combination of healthy eating, physical activity, and medication, along with careful observation of changes, to manage diabetes in old age. "Managing diabetes is not a number—it's a lifestyle," Goldberg says. "Management of an older diabetic patient is a team problem—nutrition, activity, good medical care, and awareness of the complications of diabetes."



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