Managing diabetes in older adults requires a nuanced approach. For many, strict control may do more harm than good.
A rise in hemoglobin A1c may actually signal improved safety for the elderly.
Relaxed A1c Targets for Older Adults
Older people may not need to watch blood sugar so closely, especially as they age. Research suggests that aggressive management of diabetes can lead to serious complications, such as hypoglycemia. Medical professionals, including those from the American Geriatrics Society, are now recommending higher A1c targets for older adults—for many, 7.5% to 8% is considered acceptable. This shift focuses on mitigating risks associated with low blood sugar levels, which become more frequent as patients age.
Understanding Hypoglycemia Risks
The risk of hypoglycemia increases significantly for those of advanced age. If blood sugar levels drop below 70 mg/dL, patients can experience symptoms like confusion, anxiety, or even loss of consciousness. This can create serious challenges, particularly if an elderly individual is engaged in potentially dangerous activities like driving or exercising. Data shows that approximately 40,000 emergency room visits annually can be linked to overtreatment of diabetes in older adults.
New Medications for Safer Management
Innovations in diabetes management, including medications like GLP-1 receptor agonists (e.g., Ozempic) and SGLT2 inhibitors (e.g., Jardiance), have provided new avenues for treatment. These medications not only help regulate blood sugar but also have additional benefits for heart and kidney health. However, access can be a challenge; the high cost of these medications often leads to coverage denials from insurance companies, limiting options for some elderly patients.
Communication Gaps in Diabetes Management
Older adults often underestimate the risks associated with diabetes medications. Many have been conditioned to aim for strict blood glucose control, so proposed shifts in management, such as relaxing A1c targets, may be met with resistance. Doctors must enhance communication around the evolving understanding of diabetes management and the complex interplay of risks versus benefits in older age. There’s a pressing need for physicians to explain that decreasing the intensity of treatment isn’t a matter of neglect, but rather a strategy aimed at improving overall quality of life.
Navigating Treatment Decisions
De-intensification involves stopping a drug, lowering doses, or switching to safer alternatives. Although these strategies are increasingly recognized, they have not been implemented uniformly. A recent study revealed that only a small fraction of diabetic patients over 65 saw their medication regimens de-intensified after experiencing severe hypoglycemic events. The inertia in treatment adjustments can lead to gaps in care that jeopardize patient safety.
Side Effects and Quality of Life
The introduction of newer medications is not without concern. While metformin, Ozempic, and Jardiance offer various health benefits, they can also produce undesired side effects, such as gastrointestinal issues or weight loss. Weight loss can be particularly problematic for frail older adults who may already struggle with nutrition.
The Importance of Personalizing Care
In balancing blood sugar levels and preventing complications, personalization is crucial. Aging adults often handle multiple chronic conditions and medications, complicating their diabetes care. Dan Marsh, a 69-year-old Type 2 diabetic, illustrates this challenge. He has experienced amputations and continues to manage his diabetes with daily insulin injections while navigating other medications for various health issues. His story is a reminder that medical professionals should work with patients to develop tailored plans that address their unique health needs.
Encouraging Better Patient-Doctor Conversations
The risks linked to strict glycemic control may come as a shock to many patients who have been well-versed in tight diabetes management for years. It is essential that healthcare providers address the psychological impacts of changing treatment goals, ensuring patients feel supported rather than neglected. Educational materials, shared decisions around treatment options, and ongoing dialogue can help foster an environment where patients like Ora Larson, who frequently experience hypoglycemia episodes, can make informed choices about their care.
With the right approach, it is possible to prioritize safety and well-being in diabetes management for older adults. In doing so, healthcare professionals can ensure that their patients live not only longer but with a better quality of life, managing complications while effectively navigating their health care choices.