What you don’t know won’t hurt you, as the saying goes. But that’s far from true when it comes to managing type 2 diabetes. Understanding the reasoning behind your individual treatment puts you on the right track to controlling your diabetes and helps better prepare you to make educated decisions about your self-care.
Yet, based on a recent study that involved a nationwide survey of 818 people ages 65 and older with type 2 diabetes, many patients don’t fully understand the reasons for certain aspects of their treatment, potentially setting them up to be over- or undertreated. For the study, published in September 2019 in JAMA Internal Medicine, researchers at Johns Hopkins asked patients to rate seven factors that would most affect their decision to increase or reduce diabetes medication.
Nearly half of the respondents’ answers were the opposite of what American Diabetes Association (ADA) guidelines recommend. Older adults tended to downplay significant factors that doctors consider when judging how aggressive treatment should be. Most respondents consistently opted for more aggressive treatment when the guidelines often called for less. While this might sound counterintuitive, the general trend in diabetes care is to recommend less aggressive treatment as people get older.
Blood Sugar Goals at a Glance
Guidelines from the American Diabetes Association (ADA) emphasize that diabetes treatment plans and blood sugar goals should be tailored to each patient. But the ADA considers these hemoglobin A1c test targets to be a reasonable guide.
A tailored approach
Successful diabetes control calls for an individualized treatment plan with a tailored blood sugar (glucose) goal, typically as measured by the hemoglobin A1c test. The hemoglobin A1c is a blood test that measures the amount of glucose attached to hemoglobin—the oxygen-carrying protein in red blood cells that gives blood its color. As blood sugar levels rise, so does the amount of glucose attached to hemoglobin.
Your diabetes care should be adjusted as you age, which includes modifying your medications. The study identified the following seven factors as key to deciding whether treatment should be more aggressive or less aggressive:
- Diabetes duration
- Established diabetes complications
- Other health conditions
- Life expectancy
- Risk of side effects from diabetes treatment
- Treatment costs
- The effort it takes to follow a diabetes treatment plan
Hypoglycemia: Know the Signs
The early symptoms of hypoglycemia—typically when blood sugar drops to 70 mg/dL or below—are a warning that you must immediately eat or drink something with sugar to raise your blood glucose level. Here's what to look for so you can act quickly.
How much do you know about your treatment?
Here’s what you need to know about the key factors that shape individualized diabetes care as you get older:
- Diabetes duration. If you’ve had diabetes for a long time, you may benefit from a less aggressive glycemic target. The risk of hypoglycemia—a very low glucose level (see inset above)—increases, especially as people age. Hypoglycemia can increase the risk of falls and injuries, and episodes of severe hypoglycemia have been linked to an elevated dementia risk. Dangerously low glucose levels, if not treated, can lead to seizures, a coma, or brain damage. The more aggressive your glycemic target, the greater the risk of hypoglycemia. Switching to a less aggressive target lowers the risk.
- Established diabetes complications. Type 2 diabetes can cause a wide range of problems, from nerve damage (neuropathy) and vision problems to cognitive decline and a heightened risk of cardiovascular disease. In some cases, these complications can make managing your diabetes more challenging. Vision impairment or loss of feeling in your fingers, for example, can make it more difficult to test your blood sugar levels on your own. Memory problems may make it difficult to remember to take your medication as directed. In situations such as these, doctors may decide that it’s best to simplify a diabetes regimen, either with fewer medications or lower dosages.
- Other health conditions. People 65 and older with diabetes who are in otherwise good health may opt for following the same treatment goals that younger people follow. For example, they may reasonably shoot for a target glucose level of less than 7.5 percent. But for people with other chronic conditions, such as heart disease or cognitive impairment, it may be wiser to set a less aggressive goal, such as less than 8.0 or 8.5. Also, older patients with other health problems often take a variety of medications, which raises the risk of dangerous drug interactions. A simpler and less intensive regimen for diabetes can help lower this risk.
- Life expectancy. If you’re older and dealing with several serious health problems in addition to diabetes, your life expectancy is likely to be lower than that of someone the same age who’s in excellent health. If you have a longer life expectancy, you may be better able to reap the benefits of more aggressive treatment for type 2 diabetes. If you have a limited life expectancy, your doctor may recommend less aggressive treatment.
- Risk of side effects from diabetes treatment. Some people do well following an aggressive blood sugar–lowering regimen. Others have adverse reactions to the diabetes medications they take. Side effects can range from stomach upset and weight gain to hypoglycemia. If you’re experiencing adverse effects that make it difficult to tolerate your diabetes drug regimen, your doctor may recommend less aggressive treatment to minimize them.
- Treatment cost. In the JAMA Internal Medicine study, most respondents viewed the cost of medication as one of the least important factors in making treatment decisions. However, if the cost poses a burden, doctors may be able to switch you to a less expensive regimen.
- The effort it takes to follow a diabetes treatment plan. The more aggressive your treatment goals, the more complicated managing your diabetes may be. For example, you may need to take multiple medications several times a day. Self-administering insulin can be particularly challenging, especially as you get older. If you’re beginning to struggle with managing your drug regimen, your doctor may recommend a simpler plan with a less aggressive glycemic target.
Beyond Medication: 3 Keys to a Healthy Life with Diabetes
Most people with type 2 diabetes require medication to control their blood sugar levels. Even so, following a healthy lifestyle is still important. Here’s what to focus on.
The take-home message
The optimum treatment regimen for type 2 diabetes may change as you get older. And the most aggressive treatment isn’t always the best—and in some cases may pose its own risks. It’s important to see your doctor regularly and discuss any difficulties you may have when following your diabetes treatment regimen.
This article first appeared in the January 2020 issue of UC Berkeley Health After 50.
Also see Diabetes Reversal?
Published January 21, 2020