Is tight blood sugar control right for older adults with diabetes?

Medha Munshi, MD

Contributor

One of the best parts of being a geriatrician (a specialist caring for older adults) is to meet individuals who are aging successfully, taking care of themselves, and taking their health seriously. Well-informed individuals usually like to know if their chronic health conditions are well controlled or not.

With improved public education, it is now common knowledge that uncontrolled diabetes leads to damage to the major organs of the body, such as the heart, kidneys, eyes, nerves, blood vessels, and brain. So, it is important to ask how tightly blood glucose (also called blood sugar) should be controlled to decrease the risk of harm to these organs.

Blood sugar: too high, too low, or just right?

To answer this question, first let’s discuss how diabetes is different than other chronic health conditions. For example, a doctor can tell you that your cholesterol levels need to be below a certain number to lower the risk of heart disease. Diabetes is different. Diabetes is a unique condition in which both high and low glucose levels are harmful to the body.

Diabetes control is measured as A1c, which reflects average blood sugar levels over the past two to three months. High glucose levels (A1c levels greater than 7% or 7.5%) over a long period can cause damage to the major organs of the body. However, medications and insulin that are used to lower glucose levels can overshoot and lead to glucose levels that are too low. Low glucose levels (known as hypoglycemia) can result in symptoms such as rapid heartbeat, excessive sweating, feeling dizzy, difficulty thinking, falling, or even passing out.

So, both high and low glucose levels are harmful. Thus, diabetes management requires balancing the risk of high and low glucose levels, and requires constant assessment to see which of these glucose levels is more likely to harm an individual patient.

Different blood sugar goals over a lifetime

The next consideration in answering the question about tight glucose control is to understand why younger and older adults need different goals. In younger individuals, longer life expectancy means a higher risk of developing complications over many decades of life. Younger adults typically recover from hypoglycemic episodes without severe consequences.

On the other hand, people in their 80s or 90s may not have several decades of life expectancy, and so the concern about developing long-term complications due to high glucose levels is decreased. However, hypoglycemia in these individuals may lead to immediate consequences such as falls, fractures, loss of independence, and subsequently a decline in quality of life. In addition, tighter control of diabetes frequently requires complicated treatment regimens, such as multiple insulin injections at different times of the day or a variety of glucose lowering pills. This further increases the risk of hypoglycemia, as well as stress, to both older patients and their caregivers at home.

Identifying the “why” of blood sugar control

Thus, when considering goals for blood glucose in older adults, it is important to ask why we are managing diabetes. As the reason to tightly control diabetes is to prevent complications in the future, tighter control of diabetes could be a goal in an older adults who are in good health and have few risk factors for hypoglycemia. Hypoglycemia risk factors include previous history of severe hypoglycemia that required hospital or emergency department visits, memory problems, physical frailty, vision problems, and severe medical conditions such as heart, lung, or kidney diseases.

In older individuals with multiple risk factors for hypoglycemia, the goal should not be tight control. Instead, the goal should be the best control that can be achieved without putting the individual at risk for hypoglycemia.

Lastly, it is important to remember that health status is not always stable as we get older, and the need or the ability to keep tight glucose control may change over time in older adults. Goals for all chronic disease, not just blood sugar control, need to be individualized to adapt to the changing circumstances associated with aging.

Related Information: Living Well with Diabetes

Comments:

  1. Ellen

    When I had an A1C of 5.0-5.5, I ended up having blackouts. I feel much better if my A1C is 7 or higher. My endocrinologist agrees with me on this. I have had diabetes since 2000, and I’m 4th generation diabetic, so I am very familiar with this disease. I have avoided all the complications except neuropathy in my feet. The statins prescribed for my high cholesterol just raise my blood sugars sky high. I exercise and try to eat healthy. You can get salads at fast food places too.

  2. Ch. R.

    Dear Dr. Medha,

    As Diabetic of 67 I thank you for your good explanations here where
    you really did try to be objective.
    I see the main problem at Health Professionals without commonsense
    or feelings or themselves not also diabetics to see the overall picture.
    If looking by Google at “Twitter WDHCO” there is to see the introduced
    Anti-Hypogenic Combination Therapy by Prolonged Metformin, Glucobay,
    Januvia with possibly also the flat-line Toujeo- or Tresiba- 24H Insulin.
    I’m using this Therapy and without Hypos can have A1C of 5.0 – 5.4%
    as every normal healthy person should have and All Diabetics.
    This easy to use Therapy has only one problem, many Basic US Health
    Insurances do not pay for these medications.
    Additionally since I daily supplement 1000mg Slow-Potassium, my Blood
    Pressure from Dia 80 and Sis 150-160, got down to my lifetime normal
    Dia 65-70 and Sis 110-120 by Pulse 65-70.

    Happy Time To You

  3. Ch. R.

    Please help by reposting spread this in the WEB to Help Diabetics worldwide !! This also to escape from Google-Greed $1.5 per AdWords-Click making any humanistic charity acts impossible. )
    World Diabetes Health Care Org. ……http://worlddiabeteshealthcareorg.business.site

  4. Dinah

    My internist thought 6.5 A1c was “too high”…and he has a point. Info on the internet talks about pre-diabetes numbers having symptoms such as a small decline in vision (me too), and tiny flicks of sensation in my feet. I self prescribed a dietary change of no artificial sweeteners, incl. stevia 🙁
    Low use of whole wheat, found an artisanal bakery w/ mixed grain “healthy loaf”, artichoke pasta (you get the picture) still eat mandarin oranges, apples, a meal with animal or veg protein, (those veggie burgers aren’t bad w/ mayo or mustard…cheat with some pickle relish!) smaller portions to keep my body mass index at 21. Cheated with Happy Meals with tiny open face burger…could not go without French fries 🙁 I was able to ignore obvious sweet treats and alcohol but the med that helped did a number on my kidneys and swollen ankles and had to stop. Amlodipine. Tested a1c at 5.7. This was “the best I could do” and lasted 3 mo. Now I’m hoping to learn if I can have 5oz red wine or not. The best part of this was the artisanal bakery that offered tiny samples of their cinnamon bun. Can I say Grateful! Oh, that one bite without having to buy and try to have one bite. Exercise was the positive trigger, but It’s hard unless it’s fun for me. Getting used to “less” took 2 years. It didn’t happen at once, it was slow and it’s really hard for me to not have sweet beverages. I use coffee creamers (duh), and a teensy bit of honey. With all of this, I just learned about Suze Cohen and John McDougal…so the next phase begins.

  5. Deb

    In my experience, it is rare that any doctor can tell a patient or send a patient to someone who can explain to them what and how *to* eat. If you want patients, type I or II to need less medication and have less risk from hypoglycemia, then they need to be taught to eat properly, to count carbohydrates for the number appropriate for thier size and function level of their pancrease. If type I, they need to understand how insulin helps them gain weight and how to eat to avoid needing high levels of it, especially since the more insulin you take, the higher the risk of going too low in blood sugar. And for type II’s to avoid the digestive complications of things like metformin, how to eat properly to avoid them. Doctors seem to know very little about how to best live a good life with diabetes and blame patients for eating badly when they only say things like don’t drink sugary soda. People need to be re-educated. It does not have to be a disease of avoiding foods, it is a disease requiring counting portions and
    it can be a disease forcing patients to eat a good diet that many, many people would benefit from if our society all moved a little in that direction.

  6. Pat MM

    I would like to thank Susie for her reply about the strong genetic influence, in her family, of diabetes. I have the same genetic history on one side of the family (including two deaths attributable to diabetes, vision issues, etc.) The popular press — and many doctors — endlessly play up the “life style” angle. But I don’t eat a high carb diet or fast foods (at all) or drink soda and, yes, I measure my food carefully, etc. etc. etc. When I was 60 years old — yes, 60 — an endocrinologist finally told me that I was insulin resistant — and probably always had been.

    So, I work at it, take oral medication, watch my diet, and exercise religiously. My A1c hangs around 5.8.

    But, I am tired, really, really tired of being stigmatized by the medical community, the media, and the uninformed.

  7. viji selvaraj

    so what is the ideal HbA1C , for type 2 diabetes over 60 years of age? over 7.0 is high .what is the lower limit for safe HgA1C?

  8. Jay Yudof

    [posted by a health educator dealing with T2DM and serious sequelae for decades]

    Lifestyle as the cause – almost definitely true.

    Lifestyle best course of prevention – of course

    Treatable thru lifestyle alone – varies by the pt;prevention of
    sequelae and maximizing QoL is the goal

    Do people respond later in life who may hvae not adapted lifestyle earlier – emphatic yes, I am one of many I know

    Best ways for a practitioner to help a person make lifestyle improvements
    -avoid condemnation or argument, praise sucesses and efforts
    -use transtheoretical (stages of change) model, motivational interviewing, coaching approaches, pt education/decision aids
    -always connect goals to personally desired outcomes, e.g., functional fitness, longevity for family roles
    -use a full team approach – like many I see PCP, endocrine, cards, podiatry, nephrology – even the dentist is part of the team
    Team is not just “doctors” – we use dietitians/nutritionists, life and wellness coaches, trainer at the gym – family, friends, and clergy can be implicit parts of the team

  9. Randy Philipp

    Why isn’t anyone talking about Insulin? This is the heart of the problem with Diabetes. Controlling glucose levels is all well and good, but this is not the cause of the problem, it is Insulin. Type 1 Diabetics need Insulin to control their blood sugar, and more importantly to store glucose has fat. They need it to live. Type 2 on the other hand are Insulin resistant, the only reason to give them Insulin is to lower their glucose levels, and in the process of giving them Insulin, you make them more Insulin resistant. If you do not address the root cause of the problem, you are not doing any good. You don’t tell a patient with a fever to take a cold shower, and you shouldn’t be giving a Type 2 Diabetic Insulin.

  10. Paulo Augusto Franke

    Living well with diabetes…

    This is a typical Harvard-style atrocity.

    Diabetes T2 is fully, 100%, entirely, completely, radically, totally reversible with a diet free of toxic sugars and cereals.

    Stop the dietary intoxication with sugars and cereals and T2DM disappears.

  11. Marcia

    Give it to them straight. Do they want to live long or die young?
    If they won’t listen to you, send them to another practitioner, they are wasting your valuable time. “You can take a horse to water but you cannot make it drink”

  12. Francis Flores

    Hello, good afternoon, I am a medical student at UVM University,How can I help my patient to leave foods with lots of carbohydrates or sugary drinks?,I have patients who refuse to make that change, they arrive with glucose above the parameters

  13. Hessah Alhussaini

    I want to comment on Ton’s commonts:
    -Tony had cut meat products and scientifically meat has no Carbs on it
    -Also, he had cut milk and the milk content of carbs is 12 grams almost the same for starch and fruits which is 15 grams of carbs / serving whether the serving is rice or bread or milk or meat or fruit. So, cutting protien will effect body muscles.

  14. Rachel

    Commenters need to recognize that TYPE 2 is a totally different animal than TYPE 1. You don’t have any other avenue but insulin for TYPE 1 and articles and people tend to focus on TYPE 2 because it can be helped with diet. Some of people need to be on insulin and this information is useful to them. Your complaints about TYPE 2 not getting enough air time in this article is behaving as if people with TYPE 1 can’t get advice tailored to the fact this is never going away for them. Go on your diet. Some of us have to live with an incurable disease called “my pancreas died”.

  15. Susie

    John and Carla:
    Do either one of you have diabetes or know anyone personally or are related to or live with someone who has diabetes? Somehow I doubt it because your comments are very ignorant and uneducated. You’re entitled to your opinions of course, but as somebody who has been diabetic for the last 17 years and comes from a long line of diabetics who became diabetic through no other reason than heredity, it is not that simple. Generalized sweeping statements like “you don’t need carbs to live” and “type 2 diabetes is often a lifestyle issue and can be resolved through diet and exercise” are overly simplistic and an insult to those of us who are doing the best we can to live with a disease that is not easily managed and controlled when you have a lot of other factors to consider. I am one of nine children whose father was diabetic and died of complications from diabetes, specifically a major stroke due to hypertension. Our oldest sister died at the age of 28 from colon cancer. Of the surviving eight of us only two have not yet been diagnosed as diabetic. We are all now in our 50’s and 60’s with the oldest almost 69. And yet we have each outlived our father who died at the age of 51 and it is because we have access to the kind of medical technology and care that he did not have. All of us are convinced that had he had the kind of medical care that we have now, he would have lived a lot longer.
    Of the six of us who are diabetic, one was just diagnosed last month and is on insulin and the rest are on oral medications and/or injectable medications that help our bodies use the insulin we make more efficiently. We each have our own medication regimens and no two are alike. That is because we are individuals, and as such we require individual plans to manage this horrible disease as best we can with the ultimate goal of living a quality life. Quality of life becomes the most important thing when you are battling this disease and any other chronic illness that affects every part of your life. Four of us are also battling autoimmune disorders as well as hypertension and other diseases that are complications of diabetes.
    So unless you have been in our shoes, I would suggest that you think before you make such uneducated and ignorant statements as the ones I quoted above. It doesn’t help anyone to make flippant remarks about a disease about which you obviously have no personal knowledge or experience. I am very grateful for all of the medical care and help my siblings and I have been and are receiving. Without it our lives would be quite different and we might not even be living today.
    Lastly, and by the way, I started out on an oral medication and after a few years the oral meds stopped working and I had to start using insulin. I was using two types of insulin everyday plus another injectable med to help my body use insulin better. In 2014 I was diagnosed with a very rare autoimmune disorder that caused my body to not adequately absorb nutrients and I lost a lot of weight because of it, but it also caused a lot of other problems which I won’t go into now for purposes of this discussion. With the changes that were going on in my body, I found that I required less and less insulin and eventually had to stop taking insulin because I was becoming hypoglycemic. To this date I only take one injectable med and the dosage has been decreasing steadily over the past 2 years. Now my major concern is the autoimmune disease that has changed my body and caused me to become permanently disabled.
    So you see, things aren’t that simple as you think they might be. There’s always something that can go wrong with a body that no one can foresee. We can only do the best that we can with the knowledge and technology available to us. And hopefully along the way, we will learn a thing or two and be able to share that wisdom with others. I hope that you take these words to heart from somebody who has been through it and continues to go through it every day, but is very thankful to have another day each day when I wake up.

  16. Tony

    The article didn’t provide me with any extra information more than what I already know. I saw my family physician for 16 years and was taking my medication (Glyburude-metphorman). I was on the ball with A1C between 7-8.1 but most o.j f the years was 7.1-7.3. All these years mu doctor never ever mentioned my diet or my diabetes could be reversible. One day I went to my rheumatologist for gout treatment and he sent to a nueroligist . The nueroligist told me it ‘s nueropathy and not gout. I hit the roof and was so pissed off at my family physician. The nueroligist told me you need to see a good endocronologist. I was down for a couple of days and decided that I will not go gentle into that good night. I began searching on diabetes cure. Listen to over 100 lectures on yo un tube and read few books. I watched Dr Jason Fung, John McDougall, Joel Furhman, Neal Barnard and Caldwell Esseleystene. It has been a bout 9 months. No more diabetes medication, lost 50 lbs, changed my doctor, and my A1C now is 6.5 and expected it to drop to 6 by Christmas. What I did is drastic . I cut all meat including fish. All oils including olive oil. All dairy. My main food is 70 % starch complex like potatoes, corn , beans and pasta and some wheat bread. Lots of greens and fruits. I used the McDougall program (the starch solution). It is what the doctor ordered for me. All blood marker are better and also dropped the chelestrol medicine.

  17. Carla

    What John said…100 percent. This article didn’t bother addressing the root cause of the issue. Type two diabetes is often a lifestyle issue and can be resolved through diet and exercise.

    To drug or not to drug? The question is irrelevant if you eat a WFPB diet (or a Keto diet) and exercise. Carbs and processed foods are NOT mandatory in the human body…they are optional. My opinion.

  18. Alicia salazar

    I had a fall back in August 2017 n hurt my knee n now I am so scared to walk I am using a wheelchair to move around da housei have not gone to da doctor I am diabetic 3 years ago I took invokana for one month I had to stop taking it cause I would get alot of upset stomach

  19. Frank Miller

    I appreciate your article on high and low sugars you guys do a good job my wife’s a nurse and she was filled out these I don’t know what you’d want to call them things for you for over the years she’s unable to do that now because she has Huntington’s and she’s in the nursing home doing pretty good with it but anyway thank you much keep up the good work

  20. Swaraj Chakrabarti

    I am about 69 years old. I read from American College of Physicians recommended article that senior people with A1C number between 7 to 8, may not need diabetes medicine. However, though I brought this information to my endocrinologist, she had no idea but still insisted me to take medicine to keep A1C at 6.5. No diabetes medicine suits me. Her past recommendation of Invokana medicine almost landed me into emergency. Currently my A1C varies between 7 to 7.75 and I don’t take any diabetes medication.. I am otherwise healthy. Why endocrinologists have different opinion from ACP? Is it because there is vested interest in this diabetes medicines industry?Almost everyday a new medicine is coming in the market and doctors prescribe it immediately. This creates more grief for people like us. Can you advise once and for all if seniors in general are better off without medicine while keeping A1C between and 7 and 8?

    .

  21. Porfie Duran

    sugars are very high

  22. Sharon

    It is clear that people need better care but they do not need and do not deserve the efforts of many doctors to follow only lab results, then Force drugs upon them as the only means to correct an issue. Although occasionally and A1C can go high if you are experiencing zero symptoms of hyperglycemia but more often during a bump hypoglycemia giving them these Force drugs just makes the symptoms worse. Take all these worse symptoms created by drugs and life falls apart so why worry about living with any disease. I’ve had three doctors say I have pheochromocytoma but my primary care with blood pressures in the 390s over 270 s. So when the A1C goes up its quick oh my God she’s a diabetic give her drugs and all this does create worse outcomes and the desire not to pursue medicine.

  23. John

    Do you tell your patients they do not need carbohydrates to live? Do you help them stop eating the stuff that is killing them? If the answer is ” No” you should find a new specialty.

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