Diabetes In Older People

By Kasia J. Lipska, MD

HOW IS DIABETES TREATED?

Treatment is different for different people. People differ in how they respond to and benefit from treatment and in the side effects and harms they experience. People also differ in their personal preferences about what treatments are right for them.

High blood sugar levels may cause

• Frequent urination
• Thirst
• Blurred vision

High blood sugar levels put people at risk for heart disease, stroke, kidney failure, vision and nerve problems, skin ulcers, and infections. To reduce the risk of these serious complications, people with diabetes should exercise and make changes in their diet. Many also take pills or insulin to lower their blood sugar levels. Lowering blood sugar levels to achieve a hemoglobin A_1c (HbA_1c) level of 7.5% (a marker of average blood sugar readings) reduces the chances of some of these complications.

However, in older people, the health benefits of lowering HbA_1c levels to below 7.5% are uncertain. This is especially true for people with several medical problems. Worse, low blood sugar levels can cause harm in some people. Aiming for HbA_1c levels below 7.5% increases the risk for hypoglycemia (low blood sugar). Severe low blood sugar can result in confusion, coma, falls, fractures, abnormal heart rhythms, and even death.

Older people are especially likely to develop severe hypoglycemia. With age, the kidneys become less efficient, which causes insulin (or other drugs) to accumulate in the body. This can lead to hypoglycemia. Older people also often take multiple medicines, some of which may interact with diabetes drugs. This, too, may cause hypoglycemia. Using multiple medicines or complex insulin regimens also increases the chances of errors. For example, a patient might take the wrong dose or the wrong type of insulin. Also, older people have fewer warning symptoms with mild dips in blood sugar. This leaves less time to treat the problem before it becomes severe.

Different treatments have different risks. The goal is to weigh the benefits and the risks to make a decision you are comfortable with.

WHAT CAN I DO?

It is important to talk to your health care clinician and discuss which treatment is right for you. For some patients, taking multiple insulin injections each day to reach an HbA_1c target of 7.5% makes sense. For other patients, this might be too risky.

In making decisions about treatment, you might consider

• The chances that the treatment will reduce risk of complications
• The chances that treatment will cause low blood sugar reactions or other side effects
• How the treatment will affect your day-to-day routines.

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