Intensive diabetes control provides less benefits as patients age and increase the probabilities of hypoglycemia. However, many people still do not accept it.
At this point, Ora Larson recognizes what is happening. “I feel as if it tremble inside,” he said. “I’m accelerated. I’m anxious.” If someone asks if you want a salad to eat, you don’t know what to answer.
This year he has had several episodes of this type, and seem more and more frequent.
“He stares at his gray color and gets confused,” said his daughter, Susan Larson, 61. “It’s very scary.”
Hypoglycemia occurs when blood sugar levels, or glucose, fall too much. A reading of less than 70 milligrams per deciliter is an accepted definition. It can affect any person who takes hypoglycemic drugs to control the disease.
But it is more frequent at advanced ages. “If you have been diabetic for years, you are likely to have suffered an episode,” said Sei Lee, Geriatrician of the University of California in San Francisco, who investigates diabetes in older adults.
Larson, 85, has suffered from type 2 diabetes for decades. Now, both its endocrinologist and your primary care doctor fear that hypoglycemia can cause falls, bone fractures, cardiac arrhythmias and cognitive deterioration.
Both have advised not to let your hemoglobin A1C, a measure that reflects medium blood glucose over several months, goes too much. “They say: Don’t worry too much about the highs, we want to prevent the bass,” said his daughter.
However, His mother has been trying for 35 years to maintain one A1C below 7 %, a habitual recommendation, objective on which he is even sung and danced in pharmaceutical ads.
The prescribed medication, Victoza, about three times a week is faithfully injected, and takes care of its diet. He is the most veteran member of the aquaterapy class for arthritis in a local pool of Saint Paul, Minnesota.
Therefore, when his doctors recommended to maintain a higher A1C, he was reluctant. “I think they are nonsense,” said Larson Mother. “It didn’t make sense to me.”
“He received many praise from his doctors for his control of diabetes and for keeping up,” said his daughter. “They always praised their ‘strict control.”
“For those who have been so complying all these years, it is as if the rules had changed.”
In fact, they have changed them.
More than a decade ago, The American geriatrics society proposed an A1C hemoglobin between 7.5 and 8 % for most diabetic older adults, and between 8 and 9 % for those who face multiple chronic diseases and a limited life expectancy. (Larson suffers from multiple sclerosis and hypertension).
Other medical societies and groups such as the American Diabetes Association and Endocrine Society have also reviewed their guidelines for older patients.
Relaxing an aggressive treatment may involve suspending a drug, reducing a dose or changing medication, in a process called disintensification.
The appearance of new effective drugs-GLP-1 receptor agonists, such as Ozempic, and SGLT2 inhibitors, such as Jardiance-has further modified the panorama. Some patients may replace these safer medications with older and more risky more.
But the new drugs can also complicate decisions, since not all older patients can access them, and insurers often be reluctant for their high prices.
Thus, disininsification progresses, but slowly.
A 2021 study on Medicare beneficiaries with diabetes analyzed patients who came to emergency or were hospitalized for hypoglycemia. Less than half, the medication was disintempted in the next 100 days.
“Residents in nursing homes are the ones who suffer the most,” said Joseph Ouslander, geriatrician from the Atlantic University of Florida and chief editor of The Journal of the American Geriatrics Society.
Another study, also from 2021, on residences in Ontario, found that more than half of the residents who took drugs for type 2 diabetes had A1C less than 7 %. Those with the greatest cognitive impairment received even more aggressive treatments.
Ouslander calculated in a national study that between 2007 and 2011 about 40,000 annual emergency visits were due to excessive diabetes treatment in older adults. He believes that today the figures are greater.
A brief introduction: diabetes can cause serious complications – myocardial infarctions, stroke, loss of vision and hearing, chronic kidney disease, amputations -, so strict glycemic control makes sense in young and middle -aged adults.
But such control requires years to reflect in health improvement. With diabetes, that period can be 8 to 10 years.
Older people who already face multiple health problems may not live enough to benefit from that strict control. “It was very important when you were 50,” Lee said. “Now, it’s less important.”
Major diabetics do not always welcome this news. “I thought they would be glad,” Lee said. But they resist. “It’s as if they were taken away,” he added.
The risk that strict control causes hypoglycemia also increases with age. Can cause sweating, panic and fatigue. In severe cases, “people can lose knowledge,” said Scott Pilla, internist and diabetes researcher at Johns Hopkins. “They can be confused. If they drive, they can have an accident.”
Even mild episodes “can affect the quality of life if they are frequent”, by generating anxiety and leading patients to limit their activities, he added.
Experts point out two types of old drugs specially involved: insulin and sulfonylureas, such as gliburide, glipizide and glymepirid.
For people with type 1 diabetes, whose bodies do not produce insulin, injections remain essential. But this medication “is widely recognized as dangerous,” said Lee, and must be handled carefully.
Sulfonylureas, he added, “are used less and less”, although they have less risk than insulin.
The majority of older adults with diabetes have type 2, which offers more options. They can combine metformin with LPG-1 and SGLT2, which also offer heart and kidney benefits. If necessary, insulin can be added.
However, a popular consequence of these new drugs is weight loss.
The risk that strict control causes hypoglycemia also increases with age. It can cause sweating, panic and fatigue. (Free Press Photo: Pixabay)
“In fragile and little active older people, we don’t want them to lose weight,” Pilla warned. In addition, both metformin and GLP-1 and SGLT2 can have gastrointestinal or genitourinary side effects.
For 15 years, Dan Marsh, 69, accountant in Media, Pennsylvania, has treated his type 2 diabetes with two daily insulin injections. When he is injected too much, he wakes up at night with “the damn bass” and needs to eat or drink glucose.
Even so, its A1C is still high and, last year, part of a foot of the foot amputated. As other medications for various conditions take, he and his doctor decided not to try other drugs.
“I know there are other options, but we haven’t followed that path,” he said.
With so many alternatives, including continuous glucose monitors, “finding out what is the optimal treatment is increasingly difficult,” Pilla said.
In summary, “older people overestimate the benefit of reducing blood sugar and undervalue the risk of medicines,” he said. Often, their doctors do not explain how priorities with age and accumulated problems change.
Pray Larson, who carries with it chewable glucose tablets in case it presents hypoglycemia – juices and sweets are also common antidotes – plans to speak with their doctors about their treatment.
It is a good idea. “The biggest risk factor of severe hypoglycemia is having suffered it before,” said Lee. “If an episode occurs, it should be considered an alarm signal. It is up to the doctor to ask: why did this happen? What can we do to prevent your glycemia from descending dangerously?”