people with diabetes are often told about the importance of
keeping their blood sugar levels under control to prevent
long-term complications, like cardiovascular disease or kidney
damage. But studies are showing that some are actually
controlling their disease too tightly, which is raising
additional health risks.
in keeping blood sugar levels steady is measured by the HgA1c
blood test, known as A1C. The normal range is about 4 to 6
show that tight control is not for everyone," said
Patricia Bononi, medical director of the Joslin Diabetes
Center affiliates at Allegheny Health Network, in
Pennsylvania. "Treatment should be individualized."
study reviewing data from older adults with diabetes, divided
into three groups depending on how many other health
conditions they had, found that some people striving for the
lower range of A1C numbers, under 7 percent, might have had
higher rates of experiencing low blood sugar. Symptoms range
from sweating and dizziness to confusion and slurred speech,
and can lead to coma and death.
medications such as insulin and sulfonylurea medicines
(including glyburide), the tight blood-sugar control might
reflect an overtreatment of their diabetes, according to the
study in the Jan. 12 online edition of JAMA Internal Medicine.
study reported high rates of death among high-risk patients
with Type 2 diabetes who were in a program that kept their
average blood sugar levels at what is considered ultra-tight:
below 6 percent. After at least three years, the rate of death
among people with tight control was 19 percent higher than the
group of patients getting the standard therapy, with A1C
targets of 7 percent to 7.9 percent.
recently, in the Jan. 15 online edition of Diabetes Care, a
review of care for 15,880 veterans 65 years old and up with
diabetes and dementia found that many were at a high risk of
hypoglycemia. Of the tightly controlled patients, 75 percent
used sulfonylureas or insulin or both. Lead author was Carolyn
T. Thorpe, assistant professor in the University of Pittsburgh
School of Pharmacy.
people get older, Dr. Bononi said, they should periodically
reassess their treatment and talk to their doctor to determine
their target blood sugar and A1C levels. For example, the
longer people have diabetes, the harder it becomes to
recognize the signs of low blood sugar.
you do have problems recognizing low blood sugar, the A1C
should not be super tight," she said. "They might
not be eating as much, or feeling ill and not taking their
Bononi said itís not surprising that the people in the
recent study who had the most health problems also had high
rates of low blood sugar.
sickest people were on dialysis and had a lot of things going
on Ö (blood sugar is) harder to manage. There may be other
things going on that caused them to have hypoglycemia.
Dialysis patients donít always have counter-mechanisms (to
regulate blood sugar)."
the middle group, she said, multiple conditions with different
medicines make it hard to determine if there was overtreatment.
challenge of managing diabetes is really too much for an
elderly patient and the family doctor alone, said Linda
Siminerio, executive director of the Diabetes Institute at the
University of Pittsburgh.
said individual assessments are often not being done.
seniors, their eating habits change, their activity level
changes Ö their lives change. Sometimes your social
situation changes, your spouse dies," she said, adding
that a spouse can notice behavior that indicates low blood
sugar. Older people with diabetes are at a higher risk for
cognitive problems, too, which also might make it harder to
manage their glucose monitoring.
why we need resources," Siminerio said, "working
with a dietitian when there are nutrition changes. Or maybe itís
someone who really canít manage Ö a pharmacist or diabetes
educator need to be involved. Itís a lot of work."
geriatrician, David Nace said for about 10 years his field has
recognized the need for individualized goals for glucose
control, that people 65 and over are not all the same.
the director of long-term care programs in the division of
geriatric medicine at the University of Pittsburgh and chief
of medical affairs for UPMC Senior Communities.
his elderly patients who have diabetes eventually need insulin
and sulfonylureas, which he called a "notorious group of
have a particularly long half-life, that take longer to clear
the kidney system," he explained, resulting in higher
levels of the drug remaining in the body. And, because of
age-related changes, the body uses the drugs differently, he
hypoglycemia may be harder to detect, he said. "Older
adults tend to be on a lot of medicine, certain ones might
mask the symptoms."
Bononiís primary advice to avoid hypoglycemia remains the
same: "1. check your glucose regularly, and 2. have some
fast-acting glucose with you so if you have a low glucose
level, you can treat it quickly."
season, with many patients hospitalized with the flu, Dr.
Bononi said itís particularly important for sick elderly
people with diabetes to check their glucose level.
"Sometimes every couple of hours, if they are getting
high levels or low levels. If they canít take their pills,
that may be time to seek medical advice. Or if they canít
eat and blood sugars are so low that it might be they need
intravenous glucose. Ö Itís not an easy disease."