September 30, 2015

Managing Diabetes as You Age

Managing diabetes as we age creates many special problems. These include:
  • Cognitive ability.
  • Other illnesses (comorbid conditions).
  • Physical decline.
  • No one to assist you.
To this, we can also have doctors that like to bully us because we are elderly. These same doctors often do not properly assess us or have our best interests in mind when they decide to change our medications or change our goals.

Since there are very few studies on the elderly and diabetes, there is little that even we can rely on to counter the directions of some aggressive doctors. Most doctors look to the American Diabetes Association (ADA) for some guidance, but this is often not the case. Even some of the “experts” cannot agree among themselves.

The ADA call for hemoglobin A1C levels below 7%, blood pressure less than 140/90 mmHg and LDL cholesterol under 100 mg/dl. When the target levels were raised to a less stringent level – hemoglobin A1C under 8%, blood pressure under 150/90 mmHg and LDL cholesterol under 130 mg/dl – many seniors had better results, but many still did not meet the targets.

There is tremendous debate about appropriate clinical targets for diabetes in older adults, particularly for glucose control. Are some older adults being over-treated? Are some being under-treated? These are questions for which we don't have answers, because most studies exclude people over the age of 65. The other problem that surfaces is significant racial disparities, particularly in women, in how well diabetes is managed.

I know that the Centers for Medicare and Medicaid Services (CMS) will not pay for more patient education for diabetes. The CMS is fairly generous as it is, but our problem is finding qualified educators that are willing to work for the reimbursement CMS pays. Often there are not educators available because many people live in rural areas where CDEs are few and far between if they exist at all.

In a recent study of people aged 65 and older, in Maryland, Minnesota, Mississippi and North Carolina the participants almost had to be clustered around large cities.

Another problem is most educators do not want to work with groups of people or use telemedicine to work with groups. They prefer working one on one to be able to promote mantras and not have interruptions from people that might have some knowledge of self-monitoring of blood glucose (SMBG) or diabetes self-managing education (DSME). One diabetes support group I have spoken at refuses to have an educator talk to them, as the educator always talks to the lowest common level and presents no challenges for any level.

The other problematic aspect of working with educators and often supported by many doctors is that many of the complications associated with poor diabetes management take a long time to develop, possibly longer than the life expectancy of a patient with other illnesses. Failure to keep diabetes under control increases the risk of long-term health problems such as nerve damage, blindness and kidney disease.

The final problem is many doctors leave insulin as the medication of last resort and often the patient has received damage to their health that insulin cannot repair or manage.

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