Tight Blood Glucose Control in Older Folks with Diabetes

A writer at the New York Times recently blogged about diabetes: Older People Often Overtreated for Diabetes, Study Suggests. In her article, she discusses a recent VA study, Assessing potential glycemic overtreatment in persons at hypoglycemic risk. She also quotes an internal medicine physician who "called the results 'scary,' and said they 'challenge the current paradigm that emphasizes tight control of blood sugar for diabetes patients.'"

I disagree that the results challenge the need for tight control for older people, and I disagree whole-heartedly with the title of her blog: the study wasn't about older PWD, but about tight control in older PWD with dementia or kidney disease. And, amazingly, the study never documented that "overtreatment" (treating patients to A1C levels below recommended guidelines) was dangerous.

The study looked at 205,857 VA patients who were taking insulin or a sulfonylurea drug (two medications that are likely to provoke hypoglycemia), and who had an A1C below 7.0% (the values that most authorities want PWD to attain), and who were aged 75 years or older -- and who had an elevated serum creatinine value (a lab test for kidney malfunction) or who had a diagnosis of cognitive impairment or dementia. Altogether, it is certainly a subset of diabetes patients who would seem to be at high risk of hypoglycemia.

But the abstract of the study never mentions how many of the patients actually had hypos, let alone how many of the hypos were mild or moderate or severe, or life-threatening or fatal. The authors seem to have assumed that since lower A1C values are generally associated with hypos, that the low A1C values they had observed are a "risk for serious hypoglycemia."

The key finding, as I understand the study*, was simply documenting that indeed there are a substantial number of high-risk PWD who have A1C values lower than what some guidelines propose. And there's an omninous but unsubstantiated implication in the study: the authors of the study clearly implied that elderly patients who have kidney and cognitive issues should not be treated aggressively. They've done so before: in a similar 2011 publication, Risk of Hypoglycemia in Older Veterans with Dementia and Cognitive Impairment: Implications for Practice and Policy, they beat the same drum. This earlier article concluded that "Diabetes mellitus was managed more intensively in older veterans with dementia and cognitive impairment, and dementia and cognitive impairment were independently associated with greater risk of hypoglycemia." At least this earlier study actually measured hypoglycemia!

As I mulled over the implications of these two studies, some thoughts pop up: Are the authors truly worried about hypoglycemia, or are they trying to sell healthcare policymakers on the idea that diabetes should not be aggressively (and expensively) treated in elderly patients? I'd suggest that they sell the healthcare policymakers on a different idea: that all high-risk diabetes patients should be seen by diabetes teams with diabetologists and diabetes nurse educators, and should receive diabetes education. And that insulin pumps and CGM should be paid for in elderly patients (Medicare currently doesn't cover CGM!)

Of course, the algorithms for treatment of diabetes in high-risk patients with overwhelming illnesses should be different than for those used for healthy adults who happen to have diabetes. My classic hypothetical example is a stroked-out blind diabetic geezer in a nursing home with terminal metastatic cancer. In such a sad situation I would vote for glucose control to be limited to avoiding hypoglycemia at all costs, and avoiding life-threatening hyperglycemia with its risks of infection, diabetic ketoacidosis and hyperglycemic non-ketotic coma.

But unlike the writer of the NY Times blog, I simply can't advocate that all elderly folks should automatically avoid tight control of diabetes. As a healthy elderly educated and motivated patient, on an insulin by pump, and wearing a CGM, I shouldn't be thrown out with the bathwater.

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* This study was apparently done by a review of "administrative data" and as such, inevitably some factors were not evaluated. The abstract doesn't specify if the participants had T1D or T2D, or both. Nor is any mention of duration of diabetes. I'd also like to know: How many patients were treated by endocrinologists vs generalists? How many were seen by diabetes nurse educators, or had taken diabetes classes? How many were adherent to the prescribed treatment program vs how many were not? And most important, How many of the patients meeting the study criteria actually had hypos -- and were they the ones with the low A1Cs or not?