Diabetes Treatment Approaches to Consider for Elderly People

By Alan L. Rubin

When deciding on treatment for an elderly patient with diabetes, you first have to consider the individual. Does this person have a low life expectancy? Or is this person physiologically young, with the possibility of living for 15 or 20 more years? If the patient is only 65 years old and in relatively good health, he or she has a life expectancy of at least 18 more years — plenty of time to develop complications of diabetes, especially macrovascular disease, eye disease, kidney disease, and nervous system disease. That person may require more intensive diabetes care than someone who is older and has worse overall health.

A study of a large representative population of elderly people with diabetes published in JAMA Internal Medicine in January 2015 showed that 51 percent were relatively healthy, 28 percent had intermediate health, and 21 percent had poor health, although the average hemoglobin A1c for the group was 7 percent. This level suggests that many elderly people with complex or poor health are being overtreated and suffering from hypoglycemia. Diabetes in patients older than age 75 have double the rate of emergency department visits for hypoglycemia than the general population.

The level of care provided to an elderly patient may be basic or intensive:

  • Basic care is meant to prevent the acute problems of diabetes like excessive urination and thirst. You can accomplish this goal by keeping the blood glucose under 200 mg/dl (11.1 mmol/L). Basic care is used for an elderly person with diabetes who is not expected to live very long, either because of the diabetes or other illnesses.

  • Intensive care is meant to prevent diabetic complications in an elderly person expected to live long enough to have them. The goal here is to keep the blood glucose under 140 mg/dl (7.7 mmol/L) and the hemoglobin A1c as close to normal as possible while avoiding frequent hypoglycemia. Elderly patients who have had diabetes for 20 or more years have a higher death rate when treated intensively.

The benefits in terms of preventing complications of diabetes are much greater when the hemoglobin A1c is lowered from 11 to 9 than when it is lowered from 9 to 7. The goal of treatment for many elderly people can be set higher in order to avoid hypoglycemia.

Treatment always starts with diet and exercise. Education about both can be of great value, especially if the patient’s spouse is also involved.

Exercise may be limited in the elderly person with diabetes. Recent studies have shown that exercise is helpful even in the very old because it reduces the blood glucose and the hemoglobin A1c. However, because elderly patients have more coronary artery disease, arthritis, eye disease, neuropathy, and peripheral vascular disease, exercise just may not be possible.

If an elderly patient can’t walk at all, he or she may still be able to do resistance exercises sitting in a chair. These exercises increase strength and lower the blood glucose.