Individualizing the Care of the Older Patient With Diabetes Mellitus
I was recently asked by a colleague if there was an upper “age limit” beyond which customary follow-up and preventive care for persons with diabetes mellitus was no longer considered beneficial. Upon further discussion, I learned that the new electronic medical record that was being introduced into this physician’s general medicine practice had templates for customary preventive care, and persons age 75 years and older were excluded from the usual measurements of hemoglobin A1c (HbA1c) and ophthalmological follow-up, among other things, even if they had diabetes mellitus.
I told my colleague that, in my opinion, based on my own experience and readings, age in itself is NOT a criteria to no longer follow the same practices one would follow for younger-aged persons with diabetes mellitus, but that one’s expected lifespan would influence the potential benefits and therefore needed to be considered when planning the patient’s individualized healthcare. This encounter provided me with the opportunity to re-read the “Guidelines for Improving the Care of the Older Person with Diabetes Mellitus” that was developed under the auspices of the California Healthcare Foundation and the American Geriatrics Society (AGS) Panel on Improving Care for Elders with Diabetes. This document was approved by the AGS Board of Directors in February 2003 and was published in the Journal of the American Geriatrics Society.1
In brief, in the “Importance of Individualized Goal-Setting in Diabetes Mellitus Care” section, it states, that “The goals of DM care in older adults, as in younger persons, include control of hyperglycemia and its symptoms; prevention, evaluation, and treatment of macrovascular and microvascular complications of DM; DM self-management through education; and maintenance or improvement of general health status.”1 It goes on to further state, “For older persons, whose life expectancy may be shorter than the time needed to benefit from an intervention, a key clinical issue is the expected time horizon for benefit from specific interventions.”1 It is noted that studies have reported that “approximately 8 years are needed before the benefits of glycemic control are reflected in a reduction in microvascular complications” but that “only 2 to 3 years are required to see benefits from better control of blood pressure and lipids.”1 While no data are provided regarding the potential benefit of good blood sugar control on wound healing, symptoms of hyperglycemia such as polyuria and fatigue may in themselves be associated with quality-of-life issues, increased risk of falling, increased rate of infections, and changes in cognition, so clinicians will need to make individual decisions regarding the benefits and risks of intervening in patients with these goals in mind.
Regardless of one’s age, the guidelines call for keeping the HbA1c level at 7% or lower, with perhaps an 8% goal set for “frail older adults, persons with life expectancy of less than 5 years, and others in whom the risks of intensive glycemic control appear to outweigh the benefits.”1 They also comment that the benefit of any specific treatment must be weighed against the risk, including its impact on quality of life for the patient’s remaining years. While “intensive glucose control” was more in favor when these guidelines were published, more recent information suggests a greater risk from hypoglycemia than originally thought and greater consequences when the HbA1C level is pushed too low; caution is advised against too tight control of blood sugar, especially in older persons who may not have the ability to respond to the low blood sugar and exhibit few of the usual warning signs of a serious problem.
So, when does one stop the usual preventive measures and monitoring when caring for the older person with diabetes mellitus? This is an individual consideration, and my reading provides little data from which to choose a universally accepted age. While some claim 5 years of expected remaining life as a good time to begin winding down customary preventive care, we have no crystal ball or ability to determine with certainty when a specific patient will die. In fact, women age 70 years live, on average, close to 18 additional years, and recent life expectancy data report that men even at age 90 years have an average remaining life expectancy of 4.3 additional years and women at age 90 years have an average remaining life expectancy of 5.1 years. It is important to individualize the care of patients of any age; don’t write-off older persons as potentially unable to benefit from some intervention without carefully examining their entire health record, current health status, individual wishes and concerns, and expected longevity.
1. Brown AF, Mangione CM, Saliba, Sarkisian CA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. J Am Geriatr Soc. 2003;51(5 suppl):S265-S280.
Dr. Gambert is Professor of Medicine and Associate Chair for Clinical Program Development, Co-Director, Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Maryland School of Medicine, Director, Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center, and Professor Medicine, Division of Gerontology and Geriatric Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Send comments to Dr. Gambert at: email@example.com