Saturday, September 5, 2009

Diabetes and geriatrics

Uh oh, I've been getting behind on my blogging. I still have to make this part of my routine. I see interesting things almost every day, and I've been thoroughly enjoying reading It's a great blog and I've realized that folks will discuss tons of tough tough issues online with peers over talking to their physician (which is fine of course). But I think I will make this mandatory reading for the medical students, residents and fellows that I teach. One example was a forum post that asked when other spouses started sleeping in separate rooms because their spouse's dementia progressed to the point where they weren't recognized in the middle of the night. Not a question that I've ever been asked in the office.

In any case, we had an interesting journal club yesterday. An article in JAMA is one of a growing body of literature that simply debunks the idea that all people with diabetes need to have tight control of their sugars (defined as a HbA1C <6.5 or fasting sugars less than 100 and after meal sugars less than 140). In this article it states that having one low sugar episode (< 70) which is common in people trying to maintain tight control, can increase the risk of Dementia by about 2-3% per year. This adds up quickly. While the stats are somewhat debatable, I think it adds to other articles that came out last year showing that low sugars increase the risk of death in hospitalized patients. The known risks of low sugars includes death, dementia, falls, confusion, hospitalizations etc.

So to review, what's the benefit of lowering sugars? Is it worth the risks in elderly patients? The answer is surprising: while high sugars increases the risk for heart attacks and strokes, lowering sugars does not reverse the increased risk. So what does it do? It decreases the risk for complications like kidney failure, blindness and nerve damage to the feet. Those aren't small complications but it may take over 8-10 years of tight control to see those benefits. Many of my patients are not going to live that long. And even if patients do have 10 years ahead of them, is the small decrease in blindness worth the increased risk of hospitalizations, death, dementia and falls? I doubt it.

At least among geriatricians, there is a large resistance to putting people on multiple oral medications and complicated insulin regiments to achieve tight control that has little or no benefit for the majority of our patients but carries significant risks of serious medication side effects.

I think the challenging aspect of geriatrics is every patient has different goals. It's important to remember not all geriatric patients are the same. I saw an 80+ year old female the other day who wakes up at 6:00 am to do aerobic exercise at a local gym. I have 70+ year old patients with end stage dementia in a nursing home. Tight control of sugars may be reasonable for some patients, but for many it is not. It needs to be considered thoughtfully.


drtaekim said...

Agreed - I'm a bit surprised that the "tight control" movement still has so much effort behind it, particularly with the article about ICU deaths and narrow ranges of control. Furthermore, given the long half-lives of the sulfonylureas an episode of hypoglycemia buys you if not admission, at least 23 hours of observation, and I see a ton of these patients.

Pem said...

But you leave out the possibility of tight control by diet alone, no diabetes medication or insulin at all. That should avoid the risks that come from low blood sugars. And for people whose diabetes isn't severe is it a change in lifestyle but not that hard to do. Thirty grams of carbohydrate per meal is a much less restricted diet than someone with gluten intolerance follows. It probably doesn't make sense for people who are frail, but for elderly who still do some exercise it should at least be an option.

joshuy said...

Pem, thank you for your comment. I missed it somehow. I totally agree. The basics are always important and very very low risk: eating right, sleeping well and exercise. People often ask me (almost every day) what they can do to prevent dementia and when I tell them physical exercise they are often surprised. Non pharmacological treatments (i.e. not using prescription medications) are the best way to go for most diseases.

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