Rethinking Diabetes Treatment in Older Adults: Balancing Control and Safety

For decades,tight glycemic control has been the gold standard in diabetes management. however, emerging evidence suggests that this approach may not always be the best strategy for older adults. The focus is shifting towards preventing hypoglycemia (low blood sugar) and optimizing quality of life, even if it means slightly higher A1c levels.

The Risks of Tight Glycemic Control in Aging Patients

The consequences of hypoglycemia can be particularly severe for older individuals. As Ora Larson, 85, who has had Type 2 diabetes for decades, describes, hypoglycemia “feels like you’re shaking inside…I’m speeded up. I’m anxious.” Her daughter, Susan Larson, 61, observes, “She stares and gets a gray color and then she gets confused…It’s really scary.”

According to the American Diabetes Association, a blood sugar reading below 70 milligrams per deciliter (mg/dL) is considered hypoglycemia. While it can affect anyone on glucose-lowering medications, it’s more common in older adults. the risks associated with hypoglycemia include:

• Falls and fractures [Source: national Institute on Aging]
• heart arrhythmias [Source: American Heart Association]
• Cognitive impairment [Source: Alzheimer’s association]
• Reduced quality of life

“Nursing-home residents are the ones that get into trouble,” notes Dr. Joseph Ouslander, a geriatrician at Florida Atlantic University and editor in chief of The Journal of the American Geriatrics Society, highlighting the vulnerability of this population.

Evolving Guidelines: A Shift in Focus

Recognizing these risks, medical societies and advocacy groups have revised their guidelines for older patients. More than a decade ago,the American Geriatrics Society recommended a hemoglobin A1c of 7.5 to 8 percent for most older adults with diabetes,and 8 to 9 percent for those with multiple chronic illnesses and limited life expectancy. This approach, known as “de-intensification,” aims to reduce the risk of hypoglycemia by relaxing aggressive treatment.

De-intensification can involve:

• Stopping a medication
• Lowering the dose of a medication
• Switching to a different medication

Newer Medications: A Double-Edged Sword

The advent of newer diabetes drugs, such as GLP-1 receptor agonists (e.g., Ozempic) and SGLT2 inhibitors (e.g., Jardiance), has further intricate the landscape.While these drugs offer benefits like cardiac and kidney protection, they also pose challenges.

As Dr. Scott Pilla, an internist and diabetes researcher at Johns Hopkins, points out, “older people overestimate the benefit of blood-sugar lowering and underestimate the risk of their medications.” He adds that often, “their doctors haven’t explained how the trade-offs shift with older age and accumulating health problems.”

Some considerations include:

• Weight loss: While beneficial for some, weight loss can be detrimental for frail, inactive older adults.
• Side effects: Metformin, GLP-1 agonists, and SGLT2 inhibitors can cause gastrointestinal or genitourinary side effects.
• Cost and access: Insurance companies may deny coverage for newer medications due to their high price tags.

Practical Advice for Older Adults with Diabetes

If you are an older adult with diabetes, here’s what you should do:

• Talk to your doctor: Discuss your A1c goals and medication regimen. Ask if de-intensification is appropriate for you.
• Monitor your blood sugar: Be aware of the symptoms of hypoglycemia (sweating, shakiness, confusion) and check your blood sugar regularly, especially if you take insulin or sulfonylureas.
• Carry a fast source of glucose: Keep glucose tablets, fruit juice, or candy bars on hand to treat hypoglycemia. As Ora Larson does, carrying chewable glucose tablets is a good idea.
• Advocate for yourself: Don’t hesitate to question your doctor’s recommendations if they don’t make sense to you. As Ora Larson stated, “I think it’s a bunch of hooey…It didn’t make sense to me” when her doctors first suggested raising her A1c target.

Dr. Sei Lee, a geriatrician at the University of California, San Francisco, emphasizes the importance of addressing hypoglycemic episodes promptly. “the biggest risk factor for severe hypoglycemia is having had hypoglycemia before…If you have one episode, it should 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?”

Conclusion: A Personalized Approach to Diabetes care

Managing diabetes in older adults requires a nuanced approach that prioritizes safety and quality of life. By understanding the risks of tight glycemic control and working closely with your healthcare provider, you can develop a personalized treatment plan that meets your individual needs. are you or a loved one managing diabetes? Take the first step towards a safer, healthier future by discussing your concerns and treatment options with your doctor today.

What are the potential risks and benefits of newer diabetes medications, such as GLP-1 receptor agonists and SGLT2 inhibitors, for older adults?

Rethinking Diabetes Treatment in Older adults: An Interview wiht Dr. Emily Carter

For decades, maintaining tight glycemic control has been the standard approach in diabetes management. However,recent evidence suggests this might not be optimal for older adults. Today, we’re talking with Dr. Emily Carter, a leading endocrinologist specializing in geriatric diabetes care, to explore the evolving landscape of diabetes treatment in older adults. Welcome, Dr. Carter!

The Shift Towards Personalized Diabetes Care in Older Adults

Archyde: Dr. carter, thank you for joining us. Can you elaborate on why tight glycemic control may not be the best approach for older patients with diabetes?

Dr. Carter: certainly. While aiming for low A1c levels is generally beneficial, older adults are more susceptible to the risks associated with hypoglycemia, or low blood sugar. Thes risks include falls, cognitive impairment, heart problems, and a reduced overall quality of life. It’s about balancing the potential long-term benefits with immediate safety concerns.

Hypoglycemia: A Serious concern for Seniors with Diabetes

Archyde: Hypoglycemia seems to be a central concern. What makes older adults more vulnerable to it?

Dr.Carter: several factors contribute. Older adults often have reduced kidney function, which can affect how medications are processed.They may also be taking multiple medications for other health conditions, increasing the risk of drug interactions that can lead to hypoglycemia. Moreover, cognitive decline can make it harder to recognize and manage low blood sugar episodes.

De-intensification: redefining Diabetes Management in the Elderly

Archyde: We’ve heard about “de-intensification.” Could you explain this approach?

Dr. Carter: De-intensification, in the context of diabetes management, refers to relaxing the treatment targets to reduce the risk of hypoglycemia. This might involve stopping a medication, lowering the dose, or switching to a diffrent medication. The goal is to find a balance where blood sugar is reasonably controlled without causing dangerous lows. For many older adults, an A1c between 7.5% and 8.5% may be a safer and more appropriate target than striving for a lower number.

Newer Medications and their Role in diabetes Treatment

Archyde: Newer diabetes drugs, like GLP-1 receptor agonists and SGLT2 inhibitors, offer additional benefits. How do these fit into the picture for older patients?

dr.Carter: These medications can offer cardiac and kidney protection, but they also present unique challenges. Some can cause weight loss, which might potentially be detrimental for frail elders. Others have side effects that may not be well-tolerated. Cost and insurance coverage are also important considerations. Prescribing these medications requires a careful assessment of individual needs and potential risks.

Practical Advice for Diabetes Management in Older Age

Archyde: What practical advice would you give to older adults managing their diabetes?

Dr. Carter: First, talk openly with your doctor about your A1c goals, medications, and any concerns you have. Be aware of the symptoms of hypoglycemia and check your blood sugar regularly, especially if your on insulin or sulfonylureas. Always carry a fast-acting source of glucose to treat low blood sugar. And most importantly, advocate for yourself. Question your doctor’s recommendations if they don’t make sense to you.

A Personalised Approach to Diabetes Care

Archyde: What do you consider the most critically important takeaway for our readers?

Dr. Carter: I think the key is that diabetes management in older adults should be highly personalized. There’s no one-size-fits-all approach. It’s about working closely with your healthcare provider to develop a plan that prioritizes your safety, well-being, and quality of life.This requires careful consideration of your individual health status, medications, and personal preferences.

Archyde: Thank you, Dr. Carter, for sharing your insights with us. It’s clear that a revised approach to diabetes care for older adults is essential.

Dr. Carter: My pleasure.