Medical Care of Older Diabetes Patients

I am glad that someone else is writing about this. And she is right, older patients with diabetes are not receiving adequate medical care. Doctors are so busy spending more time looking at the computer, checking off “something” and not really listening to what the patients are saying. Older patients repeatedly expressed frustration at the lack of time they spend with their doctor and feel they are not being heard.

Now not all doctors are doing this, I know, as some of my doctors are using recording devices and either having someone enter the information later or are doing this themselves later.

Recent standards for treatment of older patients with diabetes include more flexibility in setting goals for this population, including current health status (comorbid conditions) and expected lifespan. Due to the many pathways to help monitor and control diabetes, along with the variable and ever changing goals, more individualized time is required to assess and set a disease management course during the patient’s visit to their health care provider. This one on one time, in reality, is shrinking.

I am fortunate to have doctors and nurse practitioners that are helping me along the way. I have left the Diabetes Clinic that served me well until I reached 70 years of age and then they kept telling me to let my A1c rise to 7.0% to 7.5%. Then in a fortunate move, the local Veterans Clinic added a Clinical Pharmacist specializing in diabetes that encourages me to manage my diabetes to the best of my abilities.

I can say that I do not agree with the author when she writes, “We as diabetes educators have such an important job. We can have a huge impact on the lives of the older person with diabetes and help to achieve the 2020 healthy goals for Americans which includes: “Reduce the disease and economic burden of diabetes mellitus (DM) and improve the quality of life for all persons who have, or are at risk for, DM””. This could true if most certified diabetes educators did not teach to a one-size-fits-all mantra. Plus most CDEs do not and will not work with type 2 diabetes people, especially the elderly.

Then with the lack of clinical evidence from trials that confirm treatment therapies for the elderly, those of us over the age of 65 have nothing to compare to for determining whether we are even being treated properly.

The last AACE conference heard of a trial promoting oral medications over insulin in a very small study of only 18 individuals under the age of 60 when oral medications were effective in lowering A1Cs effectively for people starting at 9.0% or higher. Many had stacked oral medications and lost weight as a result. The presenter emphasized that this was better than insulin which often caused weight gain. This only happens when endocrinologists do not advise patients to reduce the quantity of carbohydrates consumed and to find an exercise regimen they can follow.

Since the study did not include people over 65, we don't know if people with other conditions such as kidney problems and heart disease will be able to tolerate this therapy. Yet many doctors will force this therapy on the elderly because it worked for younger patients. This is just another case of elderly discrimination.

Elderly Discrimination Harms Elderly Patients

I am happy at least one doctor is on our side. I knew this would happen one day, but Stephanie E. Rogers, MD states that, “For the first time in human history, adults older than age 65 will outnumber children younger than age 5.” Then she continues, “In medical school, we receive training in treating young patients during the pediatrics lecture series and later in an extended clinical rotation, yet the training we receive for treating geriatric patients is significantly lacking.”

This is sad, but it helps explain why our doctors know so little about treating the people above 60 or 65 years of age. Despite recommendations of international regulatory agencies, exclusion of older individuals from ongoing trials regarding type 2 diabetes mellitus is frequent, higher than reported for other age-related diseases. This exclusion limits the value of the evidence that clinicians use when treating old, frail, and complex patients with diabetes mellitus.

“Pediatric units are common at most hospitals, where multidisciplinary teams including nurses and pharmacists are specialized in treating children and most children have access to an outpatient pediatrician. In contrast, few health systems have adopted the specialized models that exist to provide cost-effective care for older adults in hospitals, clinics, and at home. Furthermore, plenty of research literature exists regarding the care and treatment of children, while it is commonplace to exclude older adults from clinical trials due to age or multiple comorbidities, despite the fact that they are likely to benefit from the study interventions.”

The presence of ageism (age discrimination) is a glaring deficiency in our current health care system. Ageism is the “systematic stereotyping of and discrimination against people because they are old, in the way that racism and sexism discriminate against skin color and gender.” Dr. Rogers said. “In our study published online today in the Journal of General Internal Medicine, we report that this systematic discrimination by doctors and hospitals leads to earlier functional decline in patients. Using the Health and Retirement Study, a nationally-represented sample of 6,017 adults older than age 50, we found that 1 in 5 older adults reported experiencing discrimination in the healthcare setting. Those who reported the most frequent discrimination were more likely to have developed new or worsened disability over the next 4 years. The most common reason reported for this discrimination was age.”

Promoting health and well being for our diverse population cannot be achieved without paying attention to the precise needs of our aging nation. As a healthcare system, the U.S. has neglected our future selves long enough. Our older patients deserve devotion, in particular because of their age. Their long life experience and contribution to society should allow them the same attention and quality of care we offer to our children.

Clinical practice guidelines rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time.

Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines. The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “experts” could care less about treating the elderly.

By not including the elderly in diabetes trials, our doctors have clinical practice guidelines that rarely address the treatment of patients with three or more chronic diseases, and such patients make up half of the population greater than 65 years of age in the United States. When other aspects of chronic disease management (e.g., dietary or other lifestyle modifications, attending regular office visits, and laboratory monitoring) are added, the burden on elderly patients and their caregivers becomes onerous and, in many cases, unsustainable over time. Guidelines and quality assurance initiatives largely ignore the issue of marginal benefits of multiple medications as recommended by various sets of treatment guidelines.

The guidelines are all set up for people under 60 years of age with only one chronic condition. The elderly are discriminated because no research has been done to determine how to treat people with multiple chronic conditions. Yet, the so-called “diabetes experts” and researchers could care less about treating the elderly.

Are Older Adults Really Being Overtreated for Diabetes?

The people publishing studies in the Journal of the American Medical Association (JAMA) Internal Medicine seem determined to destroy healthcare for the elderly. The topic in the Endocrinology Advisor is titled “Older Adults May Be Overtreated for Diabetes.” To this, I am saying, in whose determination.

They do use the American Diabetes Association guidelines of course and state, “Despite the prevalence of diabetes in older people, optimal glucose levels are still poorly defined. Currently, the American Diabetes Association (ADA) and American Geriatrics Society (AGS) agree that glycemic targets should be higher for older patients with compromised health. I say that these “experts” have not done their homework and have very few studies available to justify their pronouncement.

They are claiming that most patients with diabetes aged 65 and older still maintain HbA1c levels of less than 7%. In older patients, there are limited benefits to such tight glycemic control, and they have a high risk for complications, such as hypoglycemia, with the use of some glucose-lowering medications.

“Researchers wanted to determine if older adults with diabetes were potentially being overtreated for the condition.

The study included data from 1,288 patients aged 65 years and older with diabetes from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2010. The patients were divided into three groups based on health status. 

The first group was considered as having very complex/poor health, where patients had difficulty with ≥2 integral daily tasks or dialysis dependence. The second group was categorized as complex/intermediate, where patients had difficulty with ≥2 integral daily tasks or had ≥3 chronic conditions. The third group was composed of relatively healthy participants if they did not fit the criteria for the other groups.

Tight glycemic control was considered an HbA1c level <7 i="">

Using these parameters, 21.2% had very complex/poor health, 28.1% had complex/intermediate health, and 50.7% were relatively healthy. Out of all the participants, 61.5% achieved tight glycemic control; this proportion did not significantly differ based on health status.

Of the patients with tight glycemic control, 54.9% were treated with either insulin or sulfonylureas; again, this proportion did not significantly differ based on health status.”

Now this study is more reasonable in the method used in placing people in the three groups, but one thing still bothers me. Why are not people being given an opportunity to express their opinion about their care? Everything seems to be determined for them and though not mentioned in the abstract, the three groups were determined by a one-size-fits-all determination.

Again, hypoglycemia and the fear of hypoglycemia by the researchers play a big role in the group they were placed in for the study. The other weakness of the study is about 55 percent of all groups were on insulin or sulfonylureas. Unknown is the medications that the other 45 percent were taking.

To my way of thinking, the study was done to provide information to discriminate against the elderly and not to find out if the elderly are capable of managing diabetes in what they determined was tight control of less than 7.0% for A1c.

The only time I could agree with the researchers would be if there was cognitive issues and they did not have a capable caregiver available.

For another interesting read, this on Medscape is good and has some very interesting comments that express a few of my conclusions.  Then Gretchen Becker has a different source and writes about this topic from a different perspective.

There are other blogs about this topic, but I still believe that this is discrimination against the elderly, especially the way the study was performed and even more the way it was presented. 

Why Are Elderly with Diabetes Discriminated Against?

When one of our support group members told me about his being cut loose by his doctor because of his age and A1c, I was going to vent and write a non-complementary blog about doctors. Now that I have had a few days to cool down and read a couple of other blogs, I know what needs to be said.

Allen had an A1c result of 5.0% and being on insulin, his doctor went ballistic and said he was no longer a patient. That A1c converts to an average blood glucose reading of 97 mg/dl. Allen showed me that he only had two readings below 70 mg/dl, one of 68 and one of 66 mg/dl. He had many readings for the last three months between 80 and 115 mg/dl, but only one reading at 129 mg/dl. Allen is on a low carb – high fat meal plan and has medium protein as part of the meal plan. He does eat a lot of self-caught fish and he does eat other purchased fish.

His doctor did not believe his meter readings and asked where his second meter was to be able to download that. Allen has a very good attitude and replied, “What you have is what you get, there ain't no more. If Dr. Bernstein can do this as a type 1, why can't I as a type 2?” For someone that was interested at one time on going back to oral medications, I don't think we could convince him to stop insulin now. He has even stated this to us, and said when he has problems or memory lapses, he will consider it then.

He is about five pounds under weight and says this is where he feels best and exercise is what he does to keep it there. We are all hoping he can find another doctor, but he does not seem concerned at this time. He says if he needs to rely on his VA doctor, so be it. He has mentioned Dr. Tom, but seems in no hurry.

This is an overt discrimination of the elderly to my way of thinking. Even I am considering a change now as my doctor has been asking me to raise my A1c to above 7.0%. We know what the doctors are afraid of and that is hypoglycemia. Never mind that we are managing our diabetes. I have a long way to improve mine to be at the level Allen is maintaining. In addition, I have more medications and other health problems of high blood pressure and cholesterol which are managed by medications.

Many of our group are concerned now and wondering why doctors have a difficult time assessing us properly and treating us accordingly. I won't use the person's name, but one of our members said that it may be because we are elderly and no longer contributing to society that they don't like us to be concerned about our health. He continued, they wish we would quietly die.