Intensive diabetes control increases the risk of hypoglycemia and has diminishing returns for older individuals. The message has not been understood by many, though.
Ora Larson has realized what's going on by this point. "You feel as if you're trembling on the inside," she remarked. I'm going really fast. Fear grips me. Nobody knows what to say when they ask whether she wants salad with her lunch.
These incidents appear to be happening more regularly; she has experienced multiple of them this year.
She becomes "gray and then she gets confused," according to her daughter Susan Larson, 61. It's terrifying, you know.
When glucose levels in the blood drop too low—typically below 70 milligrams per deciliter—a condition known as hypoglycemia sets in. Anyone managing their disease with drugs that lower glucose levels is at risk.
However, it's more common in older people. According to Dr. Sei Lee, a geriatrician at the University of California, San Francisco, who studies diabetes in older individuals, "If you've been a diabetic for years, it's likely you've experienced an episode."
Ms. Larson, who is 85 years old, has suffered from Type 2 diabetes for many years. Falling, breaking bones, cardiac arrhythmias, and cognitive loss are now concerns for her endocrinologist and primary care physician due to hypoglycemia.
Both doctors have told her to allow her hemoglobin A1c, which is a measurement of her average blood glucose over a few months, get above 7%. "They say, 'Don't worry too much about the highs — we want to prevent the lows,'" the younger Ms. Larson said.
The popular guideline, the aim that people sing and dance about in pharmaceutical advertising, is to keep an A1c below 7%, yet her mother has spent 35 years striving toward this goal.
About three times a week, she diligently injects herself with Victoza as prescribed, and she also carefully monitors her food intake. She's been going to the same pool in St. Paul, Minnesota, for her Aqua for Arthritis class since it first opened.
She was hence resistant to her doctors' recommendations for an elevated A1c. "In my opinion, it's completely false," she stated. "To me, it was completely confusing."
"She received numerous compliments and accolades from her doctors for effectively managing her diabetes," her daughter continued. "Her 'tight control' was always lauded."
"They seem to have altered the regulations, especially for someone who has been so cooperative throughout the years."
Actually, that's true. For elderly persons with diabetes, the American Geriatrics Society recommended a hemoglobin A1c range of 7.5% to 8% over 10 years ago. Those battling several chronic conditions and having a short life expectancy should aim for a range of 8% to 9%. (Alter Ms. Larson suffers from hypertension and multiple sclerosis.)
Not only that, but the Endocrine Society and the American Diabetes Association have also raised their recommendations for individuals aged 60 and up.
One method of easing harsh therapy is de-intensification, which entails discontinuing a drug, reducing its dosage, or changing to a different prescription.
Another factor that has changed things is the introduction of new diabetic medications, such as SGLT2 inhibitors (like Jardiance) and GLP-1 receptor agonists (like Ozempic). These newer, less dangerous drugs can replace the older, more dangerous ones for some individuals.
However, new medications can make decisions more difficult because not all elderly people can switch, and even for those who are, insurance companies may refuse to cover the expensive new prescriptions.
Consequently, de-intensification is happening, although at a snail's pace.
For example, diabetic Medicare recipients who experienced hypoglycemia-related hospitalizations or visits to the emergency room were the focus of a study conducted in 2021. Less than half of the patients had their medicine dosages reduced within a hundred days.
It is the inhabitants of nursing homes that end themselves in hot water, according to Dr. Joseph Ouslander, chief editor of The Journal of the American Geriatrics Society and a geriatrician at Florida Atlantic University.
More than half of the residents whose medications were prescribed for Type 2 diabetes had A1c readings lower than 7% in another study conducted in 2021 in nursing homes in Ontario. The most severely impaired patients were receiving the worst care.
From 2007 to 2011, overtreatment of diabetes in older persons caused around 40,000 annual visits to emergency rooms, according to Dr. Ouslander's calculations based on national research. In his opinion, the figures should now be substantially higher.
A quick overview: The serious consequences of diabetes, including heart attacks, strokes, loss of vision and hearing, chronic kidney disease, and amputations, make so-called stringent glycemic control a reasonable choice in middle age and young adulthood.
However, strict management, like any medical treatment, requires patience before the benefits are felt in terms of better health. It takes a long time with diabetes, likely eight to ten years.
Strict regulation may no longer be beneficial for the elderly because they already face multiple health problems. "When you were 50, it was really important," Dr. Lee added. "Right now, it's not as crucial."
This is not necessarily good news for older diabetics. According to Dr. Lee, "I thought they'd be happy," but they are actually resisting. "It's almost as if I'm attempting to deprive them of something," he continued.
Aging patients are more likely to have hypoglycemia due to tight management.
People may feel hot, anxious, and exhausted as a result. According to Dr. Scott Pilla, an internist and diabetes researcher at Johns Hopkins, "people can lose consciousness" in cases of extreme hypoglycemia. "These things can throw them off. An accident could happen if they're behind the wheel.
Even milder hypoglycemic events “can become a quality-of-life issue if they’re happening frequently,” causing anxiety in patients and possibly leading them to limit their activities, he added.
Experts point to two kinds of older drugs particularly implicated in hypoglycemia: insulin and sulfonylureas like glyburide, glipizide and glimepiride.
For people with Type 1 diabetes, whose bodies cannot produce insulin, injections of the hormone remain essential. But the medication is “widely recognized as a dangerous drug” because of its hypoglycemia risk and should be carefully monitored, Dr. Lee said.
The sulfonylureas, he added, “are becoming less and less used” because, while less risky than insulin, they also cause hypoglycemia.
The great majority of older adults with diabetes have Type 2, which gives them more options. They can supplement the commonly prescribed drug metformin with the newer GLP-1 and SGLT2 drugs, which also have cardiac and kidney benefits. If necessary, they can add insulin to their regimens.
Among the new drugs’ more popular consequences, however, is weight loss.
“For older people, if they’re frail and not very active, we don’t want them losing weight,” Dr. Pilla pointed out. And both metformin and the GLP-1 and SGLT-2 medications can have gastrointestinal or genitourinary side effects.
For 15 years, Dan Marsh, 69, an accountant in Media, Pa., has treated his Type 2 diabetes by injecting two forms of insulin daily. When he takes too much, he said, he wakes up at night with “the damn lows,” and needs to eat and take glucose tablets.
Yet his A1c remains high, and last year doctors amputated part of a toe. Because he takes many other medications for a variety of conditions, he and his doctor have decided not to try different diabetes drugs.
“I know there’s other stuff, but we haven’t gone that way,” Mr. Marsh said.
With all the new options, including continuous glucose monitors, “figuring out the optimal treatment is becoming more and more difficult,” Dr. Pilla said.
Bottom line, though, “older people overestimate the benefit of blood-sugar lowering and underestimate the risk of their medications,” he said. Often, their doctors haven’t explained how the trade-offs shift with older age and accumulating health problems.
Ora Larson, who carries chewable glucose tablets with her in case of hypoglycemia (fruit juice and candy bars are also popular antidotes), intends to talk over her diabetes treatment with her doctors.
It’s a good idea. “The biggest risk factor for severe hypoglycemia is having had hypoglycemia before,” Dr. Lee said.
“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?”
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