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New Thinking on Diabetes Means Changes for Elderly
By
KELLY GREENE
If you're an older person with diabetes, controlling your blood pressure and cholesterol is at least as important as bringing down your blood sugar, a group of medical experts has concluded.
That's important news for a growing number of Americans. Between 13% and 15% of people age 65 or older currently have diabetes, and the numbers are rising as obesity spreads, says Carol Mangione, an associate professor at the David Geffen School of Medicine at the University of California at Los Angeles. She served as co-chairman of a group of doctors and researchers affiliated with the American Geriatrics Society and California HealthCare Foundation who recently wrote a guideline for doctors treating older patients with diabetes.
Such patients most commonly have type 2 diabetes, a condition in which the body fails to use insulin properly or to produce enough insulin. (Insulin is a hormone that converts sugar into energy.) Diet and drugs are the typical methods for managing the condition.
The new guideline stresses that most older people with diabetes actually die from heart attacks and strokes. "They have a metabolic problem that seems to put them at much higher risk," says Dr. Mangione. "The strong take-home message for patients is that blood pressure and cholesterol levels are just as important as blood sugar, and the way to help all three is to be more physically active and to lose some weight."
The guideline is also designed to help doctors with the hard choices involved in treating older patients with diabetes. "You may have blood pressure that's too high, even though the patient is on two medications," Dr. Mangione says. "And blood sugar may be too high, as well. So are you going to add a third blood-pressure medicine, or a second pill to lower blood sugar? We would say it's more important to get that blood pressure down."
Generally, the guideline says, a patient's A1C test, which reflects average blood-sugar levels, should be no higher than 7%. But doctors also need to keep in mind that "there's big variety in who we're talking about," Dr. Mangione says. Older patients with diabetes range from "the person who's 65, walks three miles a day and is still working, to the person who's 83, may already have had a stroke, and may have trouble walking across his apartment. There can't just be cookie-cutter points about how low the blood-sugar level should be."
So, in developing a treatment, your doctor should take into account your life expectancy and functional status, meaning what you can and can't do independently, such as walking, taking care of your basic needs, paying bills, and so forth. If you have a "limited life expectancy," a blood-sugar level of 8% may be "more appropriate," Dr. Mangione adds.
The guideline also calls for doctors to test older diabetes patients regularly for a number of chronic conditions to which they appear more susceptible, including depression, memory problems, frequent falling and chronic pain. "If you're in chronic pain, even if your blood pressure and blood sugar are controlled, your quality of life is going to be terrible," Dr. Mangione says. "Doctors need to incorporate short screenings for these other problems at least once a year."
And patients need to insist that those screenings get done, she adds. With frequent falls, for example, many diabetes patients have nerve damage in their feet, vision problems and take many medications, all of which are contributing factors. Sometimes, adjusting medications can stop the falls. "But a lot of patients don't recognize falls as a medical problem and wouldn't necessarily tell their doctors," Dr. Mangione notes. "We felt like it was important to say, 'Hey, look, these problems can be recognized and treated.'" Copyright
© 2002 Global Action on Aging
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