Maintaining healthy blood glucose (sugar) levels is the cornerstone of diabetes management. However, data increasingly shows that for diabetes patients 65 and older, aiming for very low daily blood sugars or A1C (average blood glucose over several months) levels may not provide benefits, and may even cause harm.
As the authors of a JAMA Internal Medicine study put it, "Older persons, particularly those with complex medical problems, may derive less benefit from intensive strategies to lower glucose levels and are more susceptible to hypoglycemia [low blood sugar] and its consequences than younger, healthier persons."
Diabetes and Hypoglycemia
"Hypoglycemia can be severe, both for young and old patients," says Amber Taylor, MD, Director of Diabetes at The Center for Endocrinology at Mercy Medical Center in Baltimore. "In older patients or those with multiple co-existing conditions, hypoglycemia has been linked with increased falls, seizures, unconsciousness, 911 calls, and visits to the emergency room. The physiologic stress of hypoglycemia [the way the body responds to the condition] can also cause cardiac problems, especially risk of heart attack and death."
In the one study (the Diabetes Control and Complications Trial), people receiving intensive treatment to achieve tight blood sugar control had three times as many hypoglycemic reactions other study participants.
In addition, the American Diabetes Association (ADA)’s 2015 Standards of Care notes that there’s a lack of long-term studies demonstrating the benefits of tightly controlled blood sugar, blood pressure, and lipid (blood fats, like cholesterol) levels, especially in patients with complications and co-existing conditions. The Standards of Care also acknowledges the complicated nature of caring for older diabetes patients, whom the ADA says make up about 26 percent of seniors in the U.S.
A Different Approach
So for older adults, less intensive, more individualized blood sugar goals may make more sense than common treatment targets like A1C levels between 6.5 and 7 percent; those goals may be more appropriate for younger, healthier people. Furthermore, Taylor says, heart disease is a significant risk factor for diabetes patients, regardless of how well they control their A1C levels, so managing these risk factors is a good strategy.
"Tighter glycemic control has been shown to prevent some of the circulatory [heart, blood, and blood vessel] complications of diabetes, including damage to tiny blood vessels in the eyes and kidneys, and nerves in the hands and feet," says Taylor. "Unfortunately, no matter how tightly you control the A1C, patients with diabetes still have an increased risk of cardiovascular [heart and blood vessel] disease. This is best minimized with proven risk factor management, such as quitting smoking, controlling blood pressure, and, in most patients, using anti-cholesterol medication with statin therapy. Decreasing the risk of cardiac disease is more likely to have long-term benefit than tight glycemic control."
The bottom line is that higher blood sugars can be acceptable for older diabetes patients: "Patients who take medications that cause hypoglycemia, or who suffer from hypoglycemia, should talk to their primary physician or endocrinologist about their individual glycemic targets," Taylor says. "A safer medication might decrease their risk. Most patients with diabetes should also take medicine for blood pressure and cholesterol to help prevent cardiovascular disease. Healthy diet and exercise are also important as part of good lifestyle maintenance."
Amber Taylor, MD, reviewed this article.
Sources
Amber Taylor, MD Email message to author, February 23, 2015.
Lipska, Kasia J., MD, MHS, Ross, Joseph S. MD, Miao, Yinghui, MPH, Shah, Nilay D. PhD, Lee, Sei J. MD, MAS, Steinman, Michael A. MD. "Potential Overtreatment of Diabetes Mellitus in Older Adults With Tight Glycemic Control." JAMA Internal Medicine doi:10.1001/jamainternmed.2014.7345. Published online January 12, 2015.
American Diabetes Association. Diabetes Care 2003 26 supplement 1 s25-s27.
"Tight Diabetes Control." American Diabetes Association. Page last edited December 6, 2013. "Standards of Medical Care in Diabetes—2015." Diabetes Care 2015 38 (Suppl. 1): S1–S2 DOI: 10.2337/dc15-S001. "Statistics About Diabetes." American Diabetes Association. Page last reviewed February 19, 2015.
