For Elderly Diabetics, Questions About Aggressive Care

By PAULA SPAN

The more I talk to researchers about caring for older people, the more a couple of themes emerge. Namely:
a) Sometimes less really is more. Overtreatment can create big problems, as a recent post on prescribing antibiotics for common urinary tract infectionsreported, and it happens frequently.
b) Older bodies respond differently from younger ones, a reality health care providers don't always take into consideration. A routine that includes a few late-day cocktails, to take one of many examples, can be a pleasure for a 40-year-old but a danger for an 80-year-old.
The latest conversation I've had along those lines, with Dr. Sei J. Lee, a geriatrician at San Francisco's V.A. Medical Center, concerned diabetes, a huge health issue for seniors. More than a quarter of adults over 65 have diabetes, according to the American Diabetes Association.
Should the elderly respond to Type 2 diabetes in the same way as younger patients? Maybe not, Dr. Lee suggested in a recent commentary in The Journal of the American Medical Association.
People with Type 2 diabetes hear a lot about "glycemic control," keeping their blood sugar levels down through diet and exercise and, when necessary, medications. The target number, for most adults under most guidelines, is 7 percent on the commonly used A1C hemoglobin test.
"For younger patients, if we can get them down to near-normal levels, then over the long term — 10 or 20 years — the risk of severe complications, like the need for kidney dialysis, are lower," Dr. Lee explained. Lower blood sugar substantially reduces the odds of diabetics' developing blindness and kidney disease, research shows; it also appears to help ward off heart attacks, strokes and amputations, though that's less well documented.
Maintaining that number — what's called "tight glycemic control" — can be an arduous undertaking, Dr. Lee acknowledged, but "for someone who's 30, we expect many years of life, so it's absolutely worth doing."
However, it takes years of tight glycemic control — at least eight, probably closer to 10 — to produce those benefits. For frail old people, Dr. Lee believes the risk-benefit equation works out differently.
"They have so many other health conditions that the chances they will survive long enough to benefit from these reductions are very low," Dr. Lee said. "The average life span of people in nursing homes is less than three years, which reflects how sick they are."
Moreover, stringent adherence to glycemic guidelines may prove quite difficult for frail elders. If their blood sugar levels slip too low, for example, they can sink into hypoglycemia, more dangerous for them than for younger diabetics. Seizures, coma and brain damage are among the scarier consequences.
But even if that doesn't happen, "tight control imposes a major burden on how people live their lives," Dr. Lee said. "We have to resort to stronger medicines and more monitoring" — finger sticks several times a day, perhaps insulin injections at least daily, dietary restrictions for people who may already not be eating well.
"In nursing homes, patients tell me, 'I used to enjoy so many things that I can't do anymore. Food is one of the few pleasures I still have, and now you're going to take that away from me?'" Dr. Lee said. "Some patients don't care, but some care a lot."
A tough regimen for lots of older patients, tight control can be particularly problematic for those with dementia, who have a terminal disease and who may not be able to understand the reason behind all the needles and constraints.
"Let's be a bit more balanced," Dr. Lee suggested. "In the frail elderly, trying to get to near-normal blood sugar levels doesn't make sense."
Frail elders can still benefit from treatment, he hastened to add. Uncontrolled diabetes can exacerbate incontinence, for instance, and it can increase falls.
Moreover, age itself is not the criterion. "If your parent is 70 and playing tennis three times a week, he or she should be treated like a younger patient," Dr. Lee said. Someone that healthy and active might well survive long enough to reap the benefits of a stringent approach to lowering blood sugar.
But for someone who is 85 and frail, has other chronic diseases and already takes lots of medications, who lives in a nursing home or needs that level of care, aggressive treatment for diabetes is unlikely to pay off in better health, Dr. Lee said. Looser glycemic goals might serve better.
"The focus should be less on long-term outcomes, more on what's important for each person," Dr. Lee said. That would involve deeper discussions between physicians and patients, he acknowledged, rather than doctors' reflexively urging patients to maintain a number more logical for 40-year-olds.
But he suspects that many doctors already see that the push for lower blood sugar levels can prove troublesome for their older patients. "I wrote the commentary," he said, "to give them a rational reason to do what they already felt, in their guts, is right."

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