A study in the April edition of the Journal of the American Geriatrics Society highlights some of the challenges in dealing with diabetes in the frail elderly population.
What is Type 2 diabetes and what are the complications?
The vast majority of diabetics have Type 2 diabetes, meaning they have trouble processing dietary carbohydrates such as glucose, leading to a higher than normal amount of glucose in the bloodstream.
If left untreated, high blood glucose can cause serious complications, including heart attacks and kidney disease.
The good news is that we know how to prevent or delay the onset of these complications using lifestyle modifications such as regular exercise and healthy eating habits.
When these changes aren't enough, medication might be necessary in the form of pills or insulin injections.
To estimate how well blood sugar has been controlled over the previous four months, doctors can measure the amount of glucose attached to the body's oxygen carrying cells, also known as Hemoglobin A1c.
In people without diabetes, Hemoglobin A1c is less than six per cent.
What is hypoglycemia and what are the dangers?
Since many diabetics take medications to lower their blood sugar, sometimes the blood sugar can drop too low. This is known is hypoglycemia.
Mild hypoglycemia causes symptoms such as irritability, tremor and difficulty thinking clearly, while severe hypoglycemia can cause seizures, coma and even death.
In the frail elderly, hypoglycemia is more likely to result in confusion -meaning that the frail elderly diabetic with low blood sugar may not take the steps necessary to correct their blood sugars or call for help.
If they are living alone, this can result in falls and potentially catastrophic consequences.
What is the conventional wisdom around glycemic control?
Traditionally, the philosophy has been that maintaining lower blood sugars is better.
And for most diabetics this is true -the American and Canadian Diabetes Associations agree that keeping Hemoglobin A1c to less than seven per cent translates to fewer heart attacks and strokes, as well as better eyesight and kidney function.
The American Geriatrics Society suggests a target of less than eight per cent for the frail elderly.
It is important to keep in mind that many of our seniors do not have enough years ahead of them to reap the potential benefits of strict glucose control.
What was this study about?
While it's important to know what the guidelines tell us about tight control of sugar levels in diabetes, the way things work in the real world is also critical.
This study reports the results of how the introduction of a diabetic control program for the elderly affected episodes of high and low sugar.
What is Type 2 diabetes and what are the complications?
The vast majority of diabetics have Type 2 diabetes, meaning they have trouble processing dietary carbohydrates such as glucose, leading to a higher than normal amount of glucose in the bloodstream.
If left untreated, high blood glucose can cause serious complications, including heart attacks and kidney disease.
The good news is that we know how to prevent or delay the onset of these complications using lifestyle modifications such as regular exercise and healthy eating habits.
When these changes aren't enough, medication might be necessary in the form of pills or insulin injections.
To estimate how well blood sugar has been controlled over the previous four months, doctors can measure the amount of glucose attached to the body's oxygen carrying cells, also known as Hemoglobin A1c.
In people without diabetes, Hemoglobin A1c is less than six per cent.
What is hypoglycemia and what are the dangers?
Since many diabetics take medications to lower their blood sugar, sometimes the blood sugar can drop too low. This is known is hypoglycemia.
Mild hypoglycemia causes symptoms such as irritability, tremor and difficulty thinking clearly, while severe hypoglycemia can cause seizures, coma and even death.
In the frail elderly, hypoglycemia is more likely to result in confusion -meaning that the frail elderly diabetic with low blood sugar may not take the steps necessary to correct their blood sugars or call for help.
If they are living alone, this can result in falls and potentially catastrophic consequences.
What is the conventional wisdom around glycemic control?
Traditionally, the philosophy has been that maintaining lower blood sugars is better.
And for most diabetics this is true -the American and Canadian Diabetes Associations agree that keeping Hemoglobin A1c to less than seven per cent translates to fewer heart attacks and strokes, as well as better eyesight and kidney function.
The American Geriatrics Society suggests a target of less than eight per cent for the frail elderly.
It is important to keep in mind that many of our seniors do not have enough years ahead of them to reap the potential benefits of strict glucose control.
What was this study about?
While it's important to know what the guidelines tell us about tight control of sugar levels in diabetes, the way things work in the real world is also critical.
This study reports the results of how the introduction of a diabetic control program for the elderly affected episodes of high and low sugar.
In 2004, a group of geriatricians caring for seniors in the On Lok seniors health program in San Francisco realized that more than 30 per cent of the diabetic patients they were following had Hemoglobin A1c levels of greater than eight per cent.
As a result, they decided to adopt the American Geriatrics Society guidelines on diabetes, which recommended specific strategies that would enable the elderly to get to a level of under eight per cent.
The doctors in this program worked hard to achieve these goals in their 300 or so elderly patients, whose average age was 80.
The research looked at three phases around the implementation of these guidelines: before the recommendations were developed; early after their introduction; and then again once the new system had been in place for well over a year.
What did the study show?
The program was very effective in attaining its targets. The number of high sugar episodes in their patients dropped dramatically from 159 in the before phase to only 46 after the program had been in place for some time.
Not surprisingly, the use of medications and insulin was up sharply and the percentage of patients with a Hemoglobin A1c of under the eight per cent level went from 74 to 84 per cent.
Unfortunately, there was a downside. The number of hypoglycemic episodes requiring emergency department care nearly tripled in the early period of guideline introduction.
On the up side, this problem did level off with time and approached more expected levels.
The researchers determined that using insulin, either in combination with pills or as opposed to pills, had the strongest association with these low sugar attacks.
What does all this mean for elderly diabetics?
The bottom line is that lower is not necessarily better -while most elderly diabetics should keep their Hemoglobin A1c less than eight per cent, the best care is individualized to the patient.
Drs. Lang and Oliver are emergency physicians based in Calgary and Winnipeg with an interest in medical journalism and in explaining research to the public.
As a result, they decided to adopt the American Geriatrics Society guidelines on diabetes, which recommended specific strategies that would enable the elderly to get to a level of under eight per cent.
The doctors in this program worked hard to achieve these goals in their 300 or so elderly patients, whose average age was 80.
The research looked at three phases around the implementation of these guidelines: before the recommendations were developed; early after their introduction; and then again once the new system had been in place for well over a year.
What did the study show?
The program was very effective in attaining its targets. The number of high sugar episodes in their patients dropped dramatically from 159 in the before phase to only 46 after the program had been in place for some time.
Not surprisingly, the use of medications and insulin was up sharply and the percentage of patients with a Hemoglobin A1c of under the eight per cent level went from 74 to 84 per cent.
Unfortunately, there was a downside. The number of hypoglycemic episodes requiring emergency department care nearly tripled in the early period of guideline introduction.
On the up side, this problem did level off with time and approached more expected levels.
The researchers determined that using insulin, either in combination with pills or as opposed to pills, had the strongest association with these low sugar attacks.
What does all this mean for elderly diabetics?
The bottom line is that lower is not necessarily better -while most elderly diabetics should keep their Hemoglobin A1c less than eight per cent, the best care is individualized to the patient.
Drs. Lang and Oliver are emergency physicians based in Calgary and Winnipeg with an interest in medical journalism and in explaining research to the public.
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