Now Ora Larson is aware of what's going on. “It feels like you're rocking inside,” she said. “I'm being speeded up. I'm worried.” When someone asks if she wants a salad for lunch, she doesn't know how to respond.
She has some such episodes this year, but it appears they come more often.
“She stares and turns gray, then she gets confused,” said her daughter, Susan Larson, 61. “It's really scary.”
Hypoglycemia occurs when blood glucose levels, or glucose, are too low. Readings below 70 milligrams per deciliator are accepted definitions. It can cause pain to those who use glucose-lowering medications to control their condition.
However, it occurs more frequently in older people. “If you've been a diabetic for years, you're likely going through the episode,” said Dr. Say Lee, a geriatrician at the University of California, San Francisco.
Elder Larson, 85, had type 2 diabetes for decades. Now, her endocrinologist and primary care physician are concerned that hypoglycemia can cause falls, fractures, arrhythmia in the heart and cognitive damage.
Both advised to increase hemoglobin A1c, a measure of average blood glucose over several months, by 7%. “They say, 'Don't worry too much about highs – we want to prevent lows,'” said the young Larson.
However, her mother has been working for 35 years to keep her A1c below 7%. This is a general recommendation, where people sing and dancing in perma commercials.
She faithfully injects her prescribed drug, Victorza, about three times a week, and watches her diet. She is the oldest member of Aqua for Arthris Class at a local pool in St. Paul, Minh.
So when the doctor recommended a higher A1c, she resisted. “I think it's a lot of Huey,” she said. “That didn't make sense to me.”
“She gained a lot of encouragement and recognition from the doctors by controlling her diabetes and staying on top of it,” her daughter explained. “They always praised her for their 'strict control.' ”
“For those who have been very compliant over the last few years, it seems like they've changed the rules.”
In fact, they have.
More than a decade ago, the American Geriatric Association asked for hemoglobin A1c between 7.5 and 8 for most elderly people with diabetes, and 8-9% hemoglobin A1c for multiple chronic diseases and limited life expectancy. (Elder Larson has multiple sclerosis and hypertension.)
Other health and advocacy groups, including the American Diabetes Association and the Endocrinology Society, have also revised their guidelines for older patients upwards.
Mitigating aggressive treatment involves approaches called cessation of drugs, lowering doses, or switching to another drug, or decentralisation.
Emerging of new effective diabetic drugs – GLP-1 receptor agonists (e.g. Ozempic) and SGLT2 inhibitors (e.g. Jardiance) further altered the landscape. Some patients can replace these safer medications with dangerous older medications.
However, new drugs can complicate decisions because not all older patients can switch. And for those who can, the insurance company may acknowledge at the higher prices of the new drug and reject coverage.
Therefore, the non-enhancement is progressing, but progressing gradually.
For example, a 2021 study of Medicare beneficiaries with diabetes looked at patients who went to emergency rooms and hospitalized for hypoglycemia. Less than half of the medication regimen were removed within 100 days.
“Nurs' residents are residents who are in trouble,” said Dr. Joseph Oslander, a geriatrician at Florida Atlantic University and editor-in-chief of the American Gerontology Association.
Another 2021 study from the Ontario Nursing Home found that over half of residents taking drugs due to type 2 diabetes had A1C levels below 7%. Those with the greatest cognitive impairment were the most actively treated.
Based on a national survey, Dr. Ouslander calculated that around 40,000 emergency room visits resulting from overtreatment of diabetes in older adults between 2007 and 2011 result in around 40,000 emergency room visits each year.
Simple Primers: Diabetes can cause such serious complications, such as heart attacks, strokes, vision and hearing loss, chronic kidney disease, and amputation.
But like all treatments, strict controls include periods before improvements in health are rewarded. With diabetes, it probably takes 8-10 years to get long.
Elderly people who already suffer from a variety of health problems may no longer live long enough to benefit from strict control. “When I was 50, it was really important,” Dr. Lee said. “Now that's not that important.”
Older diabetics don't always welcome this news. “They thought they were happy,” Dr. Lee said, but they pushed back. “It's like I'm trying to take something away from them,” he added.
The risk of tight control causing hypoglycemia increases as patients age.
It can make people sweat, panic and exhaust. “We've seen a lot of trouble with our patients,” said Dr. Scott Pira, a physician and diabetes researcher at Johns Hopkins. “They can be confused. If they're driving, they can have an accident.”
Even mild hypoglycemic events, he added, “if it's happening frequently, it can be a substantial problem,” causing patients' anxiety, and perhaps leading them to limit their activity.
Experts point to two older drugs, such as glyburide, glypizide and glymepiride, that are particularly linked to insulin and sulfonyluria hypoglycemia.
For people with type 1 diabetes, the body cannot produce insulin, hormone injections are essential. However, Dr. Lee said the drug needs to be monitored carefully because it is “widely recognized as a dangerous drug” due to its risk of hypoglycemia.
Sulfonylureas “has a lower risk than insulin, but are “used less and less,” he added, as they cause hypoglycemia.
The majority of diabetic elderly people have type 2, giving them more options. They can replenish the commonly prescribed drug metformin with new GLP-1 and SGLT2 drugs, which also have cardiac and kidney benefits. If necessary, they can add insulin to their regimen.
However, among the more common outcomes of new drugs, weight loss is.
“For older people, if they are frail and less active, we don't want them to lose weight,” Dr. Pira pointed out. Additionally, both metformin and GLP-1 and SGLT-2 drugs can cause gastrointestinal or urogenital side effects.
For 15 years, Dan Marsh (69), an accountant for Pennsylvania Media, treated type 2 diabetes by injecting two forms of insulin daily. If he takes too much he wakes up at night with “damn low” and says he needs to eat and take glucose pills.
However, his A1C remains high, and last year the doctor cut off a part of his toe. He and his doctors have decided not to try different diabetic medications because he is taking many other medications in various conditions.
“We know there are other things, but we don't do that,” Marsh said.
With all new options including continuous glucose monitoring, “understanding the best treatment is becoming more and more difficult,” Dr. Pira said.
In conclusion, he said, “older people are lowering blood sugar levels and underestimating the risks of drugs.” Often, their doctors do not explain how trade-offs change with older age and accumulate health problems.
Olalason, who carries glucose tablets that can chew in the case of hypoglycemia (a popular antidote for fruit juice and candy bars), is planning to talk to his doctor about diabetes treatment.
That's a good idea. “The biggest risk factor for severe hypoglycemia is having previously suffered from hypoglycemia,” Dr. Lee said.
“If there's one episode, you should think of it as a warning signal. It's an obligation for your doctor to understand, why did this happen? What can we do to prevent your blood sugar levels from getting dangerously low?”
