Are Elderly People Overtreated?

A research study currently making the rounds on the Internet suggests that older people with diabetes may be "overtreated." They define "older" as older than 65, and "overtreatment" as treatment with drugs that can cause hypoglycemia, such as insulin and sulfonylureas. They define "tight control" as an A1c below 7.

The New York Times recently ran a story about this. This is not the first time this idea has been publicized. The Times has run several articles on previous studies (to which their articles are linked) that said approximately the same thing: in June 2014 and April 2011, for example.

I would agree with the authors that for someone with a life expectancy of a couple of years and an inability to correctly calculate insulin doses or remember whether or not they’d taken a sulfonylurea the risks of taking such drugs would probably be greater than the benefits.

Although there’s clear evidence that higher blood glucose levels are associated with higher levels of microvascular complications in the nerves, eyes, and kidneys, as well as cardiovascular problems, some of these complications take up to 10 years of poor control to express themselves, and if someone’s life expectancy is much lower than that, it’s probably not worth the risk.

My mother had diabetes in her last years, but when she was 97 and had heart disease and some dementia and was taking a handful of drugs, her doctor and I agreed that it wouldn’t be beneficial to add diabetes drugs. I also felt it was more important for her to enjoy what she could of her remaining life than to aim for strict control, so if she wanted ice cream, I gave her ice cream.

However, one problem with all the publicity surrounding this latest study is that people, including some doctors, may think it means everyone older than 75 who has diabetes should aim for an A1c of 7. I know several patients with good control for years who have been told to increase their A1cs to 7.

But in fact, this study didn’t say that at all. What it recommended was that everyone older then 75 should be evaluated to see if that person was benefiting with "tight control."

They said those who are "relatively healthy with a long life expectancy" (long was not defined) could benefit from lower A1cs. And they suggested that even those in poor health can aim at lower A1cs if they are consistent with the patient’s goals and especially if the patient is using low-risk medications like metformin, or lifestyle modifications. It’s the drugs that can cause hypoglycemia that they’re worried about.

What this means for you is that if your doctor tells you to get your A1c higher, you should ask why. If you’re reading diabetes blogs, you’re unlikely to have dementia, so you should be able to deal with calculating insulin doses. If you’ve been told you have only three years to live, then you have to decide for yourself whether a stellar A1c or enjoying your remaining years is more important. We never know for sure how long we’ll live. Despite a grim prognosis, you may outlive your doctor.

And if you’re 76 or 96 and still playing tennis, keep doing what you’ve been doing, and don’t let anyone bully you into higher A1cs.