Older Adults & Blood Sugar: Why Less Monitoring?
Rethinking Diabetes Management: Balancing Blood Sugar in Older Adults
Table of Contents
- Rethinking Diabetes Management: Balancing Blood Sugar in Older Adults
- The Challenge of Hypoglycemia in Aging Diabetics
- Challenging Conventional Wisdom in Diabetes Care
- The evolving Guidelines for Older Adults with Diabetes
- New Medications and the Complexity of Treatment
- The Trade-Offs of Tight Glycemic Control
- The Risks of Hypoglycemia and the Importance of Open Interaction
- Exploring Choice treatment Options
- Prioritizing Patient Education and Safety
- Rethinking Diabetes Management in Older Adults: A Q&A Guide
- What is Hypoglycemia and Why is it a Concern for Older Adults with Diabetes?
- Why are A1c Targets Changing for Older Adults with Diabetes?
- What is “De-intensification” in Diabetes Treatment for Older Adults?
- What are the Risks and Benefits of Newer Diabetes Medications for Seniors?
- Which Diabetes Medications are Most Likely to Cause Hypoglycemia in Older Adults?
- Why is Open Dialogue with Doctors Crucial for Older Adults with Diabetes?
- What Should You Do if You Experience Hypoglycemia?
- Diabetes Management Strategies for Older adults: A Comparison
For Ora Larson, the signs are unmistakable. “it feels like you’re shaking inside,” she explains.”I’m speeded up.I’m anxious.” Even a simple question, like whether she wants a salad for lunch, can become overwhelming.
These episodes, which seem too be increasing in frequency, are a source of concern for both Ora and her daughter, Susan Larson. Susan, 61, describes the frightening experience of witnessing her mother’s condition: “She stares and gets a gray color and then she gets confused. It’s really scary.”
The Challenge of Hypoglycemia in Aging Diabetics
The culprit behind these episodes is hypoglycemia, a condition where blood sugar, or glucose, levels plummet too low – typically defined as below 70 milligrams per deciliter. While hypoglycemia can affect anyone using glucose-lowering medications, it’s particularly prevalent among older adults who have been managing diabetes for many years. As Dr. Sei Lee, a geriatrician at the University of California, San Francisco, notes, “If you’ve been a diabetic for years, it’s likely you’ve experienced an episode.”
For individuals like Ora Larson, 85, who has lived wiht Type 2 diabetes for decades, the risks associated with hypoglycemia are significant. Her endocrinologist and primary care doctor are concerned that these episodes could lead to falls, broken bones, heart arrhythmias, and even cognitive damage. This has led them to advise her to allow her hemoglobin A1c, a measure of average blood glucose over several months, to rise above 7 percent. The new approach is clear: “They say, ‘Don’t worry too much about the highs — we want to prevent the lows,’” according to Susan Larson.
Challenging Conventional Wisdom in Diabetes Care
This advice,however,clashes with Ora’s decades-long commitment to maintaining an A1c below 7 percent,a goal often celebrated in pharmaceutical advertising. She diligently injects her prescribed medication, Victoza, several times a week and carefully monitors her diet. She is also an active participant in an Aqua for Arthritis class.Therefore, the recommendation to aim for a higher A1c was met with resistance. “I think it’s a bunch of hooey,” she stated. “It didn’t make sense to me.”
Susan Larson explains that her mother had always received positive reinforcement from her doctors for her diligent diabetes management. “She got a lot of encouragement and recognition from her physicians for controlling her diabetes, staying on top of it,” she said. “They always praised her ‘tight control.’” This makes the shift in recommendations particularly challenging. “For someone who’s been so compliant all these years, it’s like they changed the rules.”
The evolving Guidelines for Older Adults with Diabetes
Indeed, the rules have changed. Over a decade ago, the American Geriatrics Society suggested a hemoglobin A1c of 7.5 to 8 percent for most older adults with diabetes, and even higher, 8 to 9 percent, for those with multiple chronic illnesses and limited life expectancy. Ora Larson, who also has multiple sclerosis and hypertension, falls into this category. othre medical societies, including the American Diabetes Association and the Endocrine Society, have also revised their guidelines to reflect this shift.
This adjustment in treatment goals frequently enough involves de-intensification, which can mean stopping a medication, lowering the dose, or switching to a different drug.
New Medications and the Complexity of Treatment
the introduction of newer diabetes drugs,such as GLP-1 receptor agonists (like Ozempic) and SGLT2 inhibitors (like Jardiance),has further intricate the landscape. While these medications can be safer alternatives to older drugs, not all older patients are suitable candidates, and insurance coverage can be a barrier due to their high cost. As a result, de-intensification is happening, but perhaps “too gradually.”
A 2021 study of Medicare beneficiaries with diabetes revealed that fewer than half of those who had been hospitalized for hypoglycemia had their medication regimens adjusted within 100 days. Dr.Joseph Ouslander, a geriatrician at Florida Atlantic University, emphasizes the vulnerability of nursing-home residents, stating that “Nursing-home residents are the ones that get into trouble.” Another study from Ontario nursing homes found that over half of residents taking drugs for Type 2 diabetes had A1c levels below 7 percent,with those with the greatest cognitive impairment being treated most aggressively.
Dr. Ouslander estimates that roughly 40,000 emergency room visits each year result from overtreatment of diabetes in older adults.He “thinks the numbers are likely to be much higher now.”
The Trade-Offs of Tight Glycemic Control
While strict glycemic control is beneficial in young adulthood and middle age to prevent long-term complications like heart attacks, stroke, and kidney disease, the benefits take time to materialize, typically eight to ten years. For older individuals with existing health problems, the benefits of tight control may not outweigh the risks. “It was really significant when you were 50,” Dr. Lee explains. “Now, it’s less importent.”
However, this message isn’t always well-received. Dr. Lee notes that some older diabetics push back against the idea of relaxing their control, feeling as though something is being taken away from them.
The Risks of Hypoglycemia and the Importance of Open Interaction
The risk of hypoglycemia increases with age, leading to symptoms like sweating, panic, and fatigue. In severe cases, it can cause loss of consciousness, confusion, and accidents. Even milder episodes can significantly impact quality of life,”causing anxiety” and limiting activities.
Experts identify insulin and sulfonylureas (like glyburide, glipizide, and glimepiride) as drugs particularly associated with hypoglycemia. While insulin remains essential for people with Type 1 diabetes, it is considered a “hazardous drug” due to its hypoglycemia risk and requires careful monitoring, according to dr.Lee. Sulfonylureas are also becoming less common due to their potential to cause hypoglycemia.
Exploring Choice treatment Options
Most older adults with diabetes have Type 2, which offers more treatment options. they can supplement metformin with newer GLP-1 and SGLT2 drugs, which also provide cardiac and kidney benefits. Insulin can also be added if necessary.
Though, the weight loss associated with some of these newer drugs can be a concern for frail or inactive older adults.Additionally, metformin and GLP-1 and SGLT-2 medications can have gastrointestinal or genitourinary side effects.
Dan Marsh, 69, has been treating his Type 2 diabetes with daily insulin injections for 15 years. He experiences nighttime hypoglycemia when he takes too much insulin but still has a high A1c. Despite the availability of other options, he and his doctor have decided not to change his regimen due to his other medications. “I know there’s other stuff, but we haven’t gone that way,” Mr. Marsh said.
Dr. Pilla acknowledges that “figuring out the optimal treatment is becoming more and more challenging” with the increasing number of options, including continuous glucose monitors.
Prioritizing Patient Education and Safety
Ultimately, “older people overestimate the benefit of blood-sugar lowering and underestimate the risk of their medications,” Dr. Pilla concludes. Often, “their doctors haven’t explained how the trade-offs shift with older age” and accumulating health problems.
Ora Larson, who carries glucose tablets to treat hypoglycemia, plans to discuss her diabetes treatment with her doctors. This is a crucial step, as “the biggest risk factor for severe hypoglycemia is having had hypoglycemia before,” according to Dr. Lee.
“If you have one episode, it shoudl be thought of as a warning signal. It’s incumbent on your doctor to figure out, Why did this happen? What can we do so your blood sugar doesn’t go dangerously low?”
Rethinking Diabetes Management in Older Adults: A Q&A Guide
managing diabetes in older adults presents unique challenges. This Q&A guide explores the evolving landscape of diabetes care,focusing on balancing blood sugar levels and minimizing risks for seniors.
What is Hypoglycemia and Why is it a Concern for Older Adults with Diabetes?
hypoglycemia is a condition characterized by abnormally low blood sugar levels, typically defined as below 70 milligrams per deciliter (mg/dL). While it can affect anyone using glucose-lowering medications, its particularly prevalent among older adults who have been managing diabetes for many years.
Why is it a concern? Hypoglycemia can lead to:
Falls and broken bones
Heart arrhythmias
Cognitive damage
Sweating, panic, and fatigue
Loss of consciousness and accidents
Anxiety and limited activities, impacting quality of life
Dr. Sei Lee, a geriatrician at the University of California, San Francisco, notes that experiencing hypoglycemia becomes more likely the longer you’ve had diabetes.
Why are A1c Targets Changing for Older Adults with Diabetes?
Conventional diabetes care often emphasizes maintaining a Hemoglobin A1c (HbA1c) level below 7%. However, guidelines are evolving for older adults. The American Geriatrics Society suggests A1c targets of:
7.5% to 8%: For most older adults with diabetes
8% to 9%: For those with multiple chronic illnesses and limited life expectancy
Why the change?
reduced Long-Term Benefits: The benefits of tight glycemic control in preventing long-term complications like heart attacks and kidney disease take years to materialize and may not outweigh the immediate risks for older individuals with existing health problems.
Increased Hypoglycemia Risk: Strict control increases the risk of hypoglycemia, which poses significant dangers for older adults.
Prioritizing Quality of Life: The focus shifts to preventing debilitating low blood sugar events and maintaining quality of life.
What is “De-intensification” in Diabetes Treatment for Older Adults?
De-intensification involves adjusting a patient’s medication regimen to reduce the risk of hypoglycemia. This can mean:
Stopping a medication
Lowering the dose of a medication
switching to a different medication
What are the Risks and Benefits of Newer Diabetes Medications for Seniors?
Newer diabetes drugs, such as GLP-1 receptor agonists (e.g., Ozempic) and SGLT2 inhibitors (e.g., Jardiance), offer potential benefits like improved safety compared to older drugs and additional cardiac and kidney benefits.
However, there are also risks:
Suitability: Not all older patients are suitable candidates.
Cost and Insurance Coverage: These medications can be expensive, and insurance coverage may be a barrier.
Weight Loss: The weight loss associated with some newer drugs can be a concern for frail or inactive older adults.
Side Effects: Metformin, GLP-1, and SGLT-2 medications can have gastrointestinal or genitourinary side effects.
Which Diabetes Medications are Most Likely to Cause Hypoglycemia in Older Adults?
Experts identify insulin and sulfonylureas (like glyburide, glipizide, and glimepiride) as drugs particularly associated with hypoglycemia. While insulin remains essential for people with Type 1 diabetes, it is considered a “hazardous drug” due to its hypoglycemia risk and requires careful monitoring. Sulfonylureas are also becoming less common due to their potential to cause hypoglycemia.
Why is Open Dialogue with Doctors Crucial for Older Adults with Diabetes?
Open and honest communication with doctors is essential. Older adults often overestimate the benefits of aggressive blood sugar lowering and underestimate the risks of their medications. Their doctors may not have adequately explained how the trade-offs shift with older age and accumulating health problems. A crucial step is to discuss the best treatment plan and voice any concerns. as Dr. Lee emphasizes, any hypoglycemic episode should be seen as a warning signal prompting a review of the treatment plan.
What Should You Do if You Experience Hypoglycemia?
If you experience symptoms of hypoglycemia, such as shaking, anxiety, or confusion, take immediate action to raise your blood sugar levels. Carry glucose tablets or another fast-acting source of sugar. Following resolution, discuss the episode with your doctor to determine the cause and adjust your treatment plan accordingly.
Diabetes Management Strategies for Older adults: A Comparison
| Strategy | Description | Benefits | Risks/Considerations |
| ——————– | ——————————————————————————————————————————————– | —————————————————————————————————————————- | ——————————————————————————————————————————————– |
| Tight Control (A1c < 7%) | Maintaining strict blood sugar levels. | May reduce long-term complications in younger individuals. | Higher risk of hypoglycemia, may not outweigh benefits in older adults with comorbidities. |
| Relaxed Control (A1c 7.5-9%) | Allowing for slightly higher blood sugar levels. | Reduced risk of hypoglycemia, improved quality of life for some older adults. | May increase risk of long-term complications if life expectancy is longer. |
| De-intensification | Reducing or stopping diabetes medications. | lowers risk of hypoglycemia, simplifies medication regimens. | Requires careful monitoring to ensure blood sugar levels don’t become dangerously high. |
| Newer Medications (GLP-1, SGLT2) | Using newer classes of diabetes drugs. | Can be safer then older drugs, may offer additional cardiac and kidney benefits. | Cost, potential side effects (weight loss, GI issues), suitability for all patients. |
| Patient Education | Understanding the risks and benefits of different treatment options.| Empowers patients to make informed decisions about their care, improves adherence to treatment plans. | Requires time and effort from both patients and healthcare providers. |
| Regular Monitoring | Regularly checking blood sugar levels.| Helps identify and prevent both hypoglycemia and hyperglycemia. | Can be burdensome for some patients, requires proper training and equipment. |