By Eileen B. Wyner, NP
Bulfinch Medical Group
The Americans Diabetes Association has addressed the care of the older person living with diabetes in their 2014 Clinical Practice Recommendations Standards of Medical Care. These recommendations do not define “older” by any specific numerical reference but instead are based on a person’s medical conditions. Quite honestly, this makes it easier for me to interpret these recommendations when I am caring for patients because I do not know what is considered “older” anymore. I think age is just a number that I personally hope keeps getting higher and higher, especially those decade celebrations because those silly cards are my all-time favorites.
The average lifespan of Americans is approximately 76 years for men and 81 years for women. This expectation has been slightly increasing over the years and everyone has an opinion as to why this is. I believe people are living longer due to a combination of better medical care, use of technology, and (quite frankly) attitude. I have been practicing for 30 years and I see people both living longer and living younger. I’d like to discuss this recommendation and offer some suggestions to help you and your family better understand and manage diabetes across your lifespan. I also want to remind you that these practice recommendations are just that: recommendations. Each person’s care should be individualized with their health care provider.
The Standards of Medical Care from the American Diabetes Association was developed because older adults with diabetes have a greater chance of premature death, cognitive impairment, and coexisting illness such as hypertension and heart disease. However, there are not many long-term studies available about the benefits of intensive control of blood sugar and blood pressure in the older population. The ADA has determined that people with few coexisting illnesses and intact cognitive and functional abilities should have similar goals for treatment as the general population. Those with multiple coexisting illnesses and some impairment (cognitively and /or functionally), end stage chronic illnesses, and/or severe cognitive impairment should have less stringent goals for treatment per the same recommendations. Health care providers need to consider that the goals for blood sugar management need to be directed to be sure that the acute complications of hyperglycemia, such as poor wound healing, dehydration, and coma, are avoided. It’s also important for health care providers to remember to screen for complications across the lifespan and individualize this screening to be most aware of complications such as visual and lower extremity injury that can develop quickly and seriously impact functional status.
Now, how can we break this down so people living with diabetes can use this information to stay well? As we age, we may be faced with challenges such as multiple medical conditions, decreased memory ability, decreased agility and mobility, and financial challenges. People with many medical conditions have to manage multiple medications and medical appointments. It’s helpful to bring a friend or family member to appointments to be sure all important information is provided to the health care provider, and make sure that the provider’s suggestions are understood. A visiting nurse home evaluation may be in order to help with medication safety.
People who are struggling with memory issues may forget when their appointments are. They may also forget if they took their medications which could have life threatening implications, including hypo or hyper –glycemia. Family members may be able to set up simple reminders like Post- it® notes on the bathroom mirror or the kitchen counter. A simple large calendar may help with the appointment reminders.
People with mobility issues may not be able to exercise as they once did, so glucose control may be hindered. They may also be at greater risk of injury from falling. A safety assessment of the living space may be needed to avoid falls. Osteoarthritis can make checking blood sugars, administering insulin, and food preparation difficult or even unsafe. They may actually not be able to do frequent glucometer checks, meaning medication dose(s) may need to be adjusted to ensure safety.
Financial needs are very important to identify and address as costs of medications, testing supplies, and food can definitely impede people’s health. Health care providers need to inquire about these issues as people may be too embarrassed to bring it up themselves. Referral to social services for assistance is an important piece to try to work on a solution to this problem.
These are complicating factors on their own, but people with diabetes may also have severe visual impairment as the chance of developing retinopathy increases across the life span. This factor alone can be a huge negative impact on a person’s health status. Diabetes is difficult to manage at times. It takes time and dedication for the person living with diabetes, their family, and their providers. Aging is another unavoidable bump in the road of management. Adjustments in your diabetes care plan are sometimes needed because of this unavoidable fact, but the goal of these changes is to continue your good health. I think that the best approach is not to get caught up in the A1C values, but rather continuing to do all you can to stay healthy and keep collecting those silly birthday cards!