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Seniors with diabetes may need a different approach to care.

There are nearly 26 million Americans living with diabetes, and more seniors have diabetes than any other age group--10.9 million (or 26.9 percent) of all people age 65 and older are affected, with the vast majority of these having Type II diabetes.

"Like Type I diabetes, Type II diabetes is linked with a considerably higher risk of various cardiovascular problems, including heart attack and stroke, as well as kidney disease, nerve damage in the extremities and limbs, hearing loss, and vision problems caused by damage to blood vessels in the eye," says Catherine Sarkisian, MD, a geriatrician and Associate Professor at UCLA's David Geffen School of Medicine. "These complications mean that optimizing diabetes treatment is vital." That said, a commentary published online September 10 in the Archives of Internal Medicine warns about the possibility of "over-treatment," particularly in individuals whose life expectancy is 15 years or less.

Should tight control be your goal? Research has shown that along with controlling blood pressure and cholesterol, one of the most important things people with diabetes can do to control their illness and lower their risk of developing complications is to maintain control of their blood glucose levels. "This can be done by maintaining an optimal weight and following a careful diet, and via insulin injections and/or oral medications," notes Dr. Sarkisian. The target glycemic measure (known as the A1C level) in most adults with diabetes should be 7 percent or less (by comparison, in a healthy non-diabetic adult the A1C level is typically 4.5 to 6 percent).

"In young diabetics, tight control has been shown to reduce the risk of blindness and kidney disease," Dr. Sarkisian observes. "It may also help ward off heart attacks and stroke among those newly diagnosed with diabetes, but the evidence from randomized trials is non-conclusive and suggests no cardiovascular benefit to tight control among those with long-standing Type II diabetes. While the goal of 7 percent or less may work well for otherwise healthy middle-aged people, it may not suit older adults." In fact, one major experimental study into the benefits and risk of tight control had to be stopped in 2008 because those in the group aggressively treated with tight blood glucose control were dying at higher rates. Two other studies showed no clear benefits and substantial risk of side effects for tight control in seniors.


With this in mind, the American Geriatrics Society recommends a target of less than 8 percent for frail older adults, while the Veterans Affairs and Department of Defense recommend 8 to 9 percent. The American Diabetes Association recommends "less stringent glycemic goals," but does not specify what those goals should be.

Risk-benefit equation different for frail elderly. Tight glycemic control means that medications may be stronger and monitoring more intense, for example requiring doing painful fingersticks several times a day. It requires dietary restrictions when a frail elder already may not be eating well. Moreover, it raises the risk of hypoglycemia (too little glucose in the blood), which is associated with a higher risk of heart attack and stroke in older adults. Seniors with coronary artery disease or vascular disease should not try tight control, nor should anyone with end-stage kidney disease or severe vision loss.

Keep in mind too that the goal of tight control is to prevent long-term complications, and it can take at least eight to 15 years of tight glycemic control to start seeing those benefits. "Complex treatment regimes that are designed to prevent long-term complications but that carry a high risk of short-term complications are not the best choice for people already near the end of their lives," says Dr. Sarkisian. Older adults with diabetes who are otherwise healthy and who have considerable life expectancy (10 years or more) should generally follow a treatment approach similar to that of younger adults. "But in frail elderly individuals who have multiple comorbidities, cognitive impairments, life expectancy less than 15 years, and/or a high risk of adverse events from tight control, glycemic treatment goals should be relaxed," Dr. Sarkisian explains.


To maintain your health with diabetes, follow these tips:

* Talk with your doctor about what kind of diet you should be on, how many calories you need, and what foods you should avoid.

* Talk with your doctor about optimizing your blood pressure and cholesterol.

* If you need medication, take it as directed and ask your doctor to clarify the dosage if you are uncertain.

* Wear your diabetes ID at all times, as it will alert emergency personnel to possible interactions with medications.

* Be aware of the symptoms of hypoglycemia, which include heart palpitations, shakiness, sweating, hunger, and double vision.

* Carry a snack at all times, as hypoglycemia can strike with little warning, and if it does it is vital to increase your blood sugar.
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Title Annotation:DIABETES
Publication:Healthy Years
Date:Dec 1, 2012
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