Diabetes and Older Adults: Modifying Targets and Treatment?

I am 67 years old and have lived with Type 1 diabetes for over 42 years. In the last year I have read a lot about the possibility that I should consider modifying the intensity of my diabetes regimen and relaxing my targets. My endocrinologist suggested the same thing during my December visit saying that I have a lot of cushion in my numbers and could raise them without risking complications. Okay, she actually said I don’t have to worry about complications 20 years down the road…. Doesn’t she think I’ll be an active and vibrant 87-year old?

An article was recently published in The Journal of Clinical Endocrinology & Metabolism titled “Treatment of Diabetes in Older Adults: An Endocrine Society Clinical Practice Guideline.” The conclusions of the fairly long article were stated:

“Diabetes, particularly type 2, is becoming more prevalent in the general population, especially in individuals over the age of 65 years. The underlying pathophysiology of the disease in these patients is exacerbated by the direct effects of aging on metabolic regulation. Similarly, aging effects interact with diabetes to accelerate the progression of many common diabetes complications…. The goal is to give guidance to practicing health care providers that will benefit patients with diabetes (both type 1 and type 2), paying particular attention to avoiding unnecessary and/or harmful adverse effects.”

I was able to access the entire article online and was optimistic that I would find information relevant to my current age and diabetes status. The article addressed all seniors with diabetes which we know is mostly Pre-diabetes and Type 2. But Type 1 was specifically addressed in areas where our needs might differ from those with Type 2.

In general I found the article to be “unhelpful.” If you want to check it out, I suggest that you just read the first couple of pages which is the “List of Recommendations.” Most of the text after that was repetitive and didn’t provide specific guidance beyond the introductory list. 

Throughout the article the words and phrases that jumped out at me were heterogeneity, minimize hypoglycemia, simplify management, duration of diabetes, overall health, cognitive impairment, fall risk, and cardiovascular disease. Those are hugely important considerations for me and all people with diabetes. Unfortunately I have a hard time seeing myself in this article because the scope of the age and health status categories are too broad. Although the authors emphasized the heterogeneity of this population, I believe there was too little distinction between an active and relatively healthy 67 or 72 year old and someone in their late 80’s in a nursing home. But the authors specifically mentioned seniors who have lived with Type 1 for more than 40 years as a group that should be targeted for de-intensifying management. And that’s me.

Slightly off-topic:  As I was writing this blogpost, I read in the Minneapolis paper that Best Buy has purchased GreatCall to expand the “retailer’s connection to seniors.” As I was multi-tasking with my laptop, iPad, and iPhone, I shuddered at: “a diverse portfolio of devices tailored to older adults — including simple flip phones with large buttons and extra bright screens, wearable alert devices and a line of sensors for high-risk seniors that monitor daily activities at home.” Just as medical professionals need to consider seniors with diabetes who have come into the 21st century with pumps, CGM’s, low-carb diets, and the ability to maintain near-normal A1c’s, tech companies need to move beyond the stereotype of Grandma with a flip phone.

There may come a day when I need to simplify my diabetes regimen. But that is not today as I have recently ordered a Riley Link to experiment with looping using an Omnipod tubeless pump and my phone as the controller. I continue to be excited by new D-technology and don’t have cognitive impairment that limits my treatment options. Heck, the process of getting the medications and supplies that I need under Medicare require vigilance, organization, and super-cognition! I can still recite my 14-digit library card number and can easily remember 6-digit codes texted by Amazon and my bank.

My guess is that the “average” population of seniors who have lived with diabetes for 40, 50, and 60+ years is different than the seniors that I know online. Those of us involved in diabetes social media tend to be knowledgeable about our diabetes and highly motivated. Some of us have diabetes complications; some of us have other health issues; some of us struggle to get the care that we require. But as a group we are a bunch of opinionated, hard-headed seniors who battle for the medications and technology we want and need to keep us healthy. We are not ready to settle for high A1c’s and yesterday’s medications and tech.

And yes, I need to remember that someday I may need a flip phone with large buttons and an extra bright screen. I may be in a nursing home where I cannot care for my diabetes. Like many seniors who have lived a long time with Type 1 diabetes, I have no faith that anyone else will be able to care for me. Type 1 is really, really hard even with my experience, motivation, and access to current D-tools. I can’t imagine anyone else doing it nearly as well as I do. My aim is to maintain my health so that I can care for myself as long as possible. And then when I can no longer care for myself, I hope my sister will “do me in.” Okay, that is a warped family joke but my sister who also has Type 1 and I have long joked about and been terrified of becoming incapacitated seniors with diabetes.

I am aware that it might not be a bad idea to raise my BG targets. I have too many moderate lows and know that I am overconfident in the safety net that my Dexcom provides. I haven’t needed help with a low in years. But that doesn’t mean I won’t tomorrow.

But I don’t know how to do diabetes differently.

If I can’t get it right with a target of 90, why should I miraculously be able to get it right at 100 or 120? My diabetes problems are not 10-20 unit variations. I struggle with false occlusion alarms on my Tandem pump and often get skyrocketing numbers when the cartridge gets down to 30 units or less. I don’t go from 80 to 100. I go from 63 to 197 or 241. I am at an age where I don’t have a lot of hormonal excursions. But lately I am seeing lots of up and double-up Dexcom arrows from lowish-carb meals or 2 glucose tabs. Is my Dexcom wonky or am I? My meter would say that it is me. I think it is my pump. For sure my diet has had more carbs than I know that I can handle. The frustration is that I rarely know precisely what is driving my blood glucose aberrations.

Oh cr*p, it’s just diabetes.

At the moment I don’t see changing my diabetes care because of my age. At the same time there are studies indicating that I might live longer if my A1c was higher. But not too high. And not too low. I look forward to looping and hope that it will ease the burden of my care, especially overnight. If not, I don’t expect to be worse off. I look forward to the Basal IQ update with my Tandem pump but it has been delayed for 6-9 months due to Dexcom not supplying the Dexcom G6 to seniors on a timely basis. I look forward to the Tandem Control IQ update but am concerned that Medicare recipients will not get access to the software update due to the likelihood that there will be a charge for the upgrade. 

I know in the short run that it would be a good idea to reduce the number of moderate lows I experience but I am not convinced that can be achieved by relaxing my care and targets. Actually I believe that more intensive regimens like Looping, Basal IQ, and Control IQ can address hypos more effectively. And probably the best way to level out my blood glucose numbers would be to get back on the wagon with more disciplined lowish-carb eating.

So on to another day with diabetes….

15 thoughts on “Diabetes and Older Adults: Modifying Targets and Treatment?

  1. Very well said

    I have been asked to relax my expectation for my A1c as for years I kept it at 5.5 to 6.7 and now I am at 7.0 and holding but that means that I have a wider swing in my readings and that gives me some pause to think is this really good for me. Well, I do not need the flip phone, am technology savvy, but have turned 80 and have some dreaded outcomes that age brings. But, I am choosing the omnipod for more careful simplicity….and a self determined control…the demise of animas has been a low blow. A studious reading all the pump manuals is a sure insight into their nuances of delivery. So i chose omnipod because it is the simplicity of delivery that appeals to me. As we are all different, so is our diabetes. It is always insightful to read about another persons journey and find that others use their native abilities to cope as well as they do. Thank you for sharing.

  2. As always, excellent work, Laddie. I, too, have had the double arrows up, longer lasting higher BG but I don’t think it is the Tandem pump. I suspect Dexcom sensors’ quality has declined. That being said, a lot of times my meter agrees with Dexcom? I almost never use to go over 240 but it happens now and then and no, I’m not happy with that. As we always have, we’ll keep on keeping on doing the best we can with what we have, trying new things and who knows, maybe 20-30 years from now we’ll be still going strong. Best of luck to you!

    • BJ, that’s interesting that you’re having the same double-up experience. In the days of G4, double-up arrows meant that you were soaring over 200-250 and it was always wise to react. With G5, I sometimes get double-ups at 100 and level off at 119. So I need to watch before dosing. But patience is not always one of my virtues….

  3. Well said … I think i’m also dealing with the same older T1D thinking from my docs. We are being lumped together with folks that might not understand or care, and they want me to lighten up on my settings. Also, thanks for mentioning your problem with your Tandem pump and insulin reservoir having less than 30 units, I might had the same problem … will keep an eye on it.

    • I get most of my occlusion alarms when my reservoir is trending low and I get unexplained highs occasionally that don’t resolve until I change the cartridge. I don’t know whether it is air or pressure, but kind of a PITA. I have read of others who always change out their cartridges at 20 units because of poor insulin delivery. Others use their cartridges to the last drop and seemingly have no problems. I’ve given up trying to get answers and just cope. Plus I went back to my Animas pump for a months this winter and am considering doing it again. Thanks for reading.

  4. I’ve read many references to clinicians relaxing blood glucose performance expectations for seniors. I understand their motivation but I don’t identify strongly with my age cohort on this. I’ve been using a pump since 1987 and a CGM since 2009. I currently use the automated insulin dosing system, Loop. I’m not as tech savvy as I’d like to be but I surely don’t long for a flip phone with large number display! 😉 I will turn 66 this year. I believe that the clinicians in general are overly fearful of insulin. Good long-term decisions are rarely made based on fear. Fear clouds judgement and in diabetes management will often lead to extended periods of hyperglycemia. Doctors may feel comfortable with running their senior patients high but they don’t have to live with the consequences. I think they are motivated more by legal vulnerability and fear than by rational thought. Even moderately high blood sugars degrade how I feel. This discussion has not yet been raised by my doctors but I’m certain it’s in my future. If or when I lose my cognitive ability, I think my overall health will quickly degrade. My only mitigating hope is that technology can keep me metabolically afloat when/if my cognition fails. Great topic, Laddie!

    • Thanks, Terry. I always appreciate your wisdom. I am excited to try Looping but won’t receive my Riley Link until late June or July. I kind of think that this more complex regimen might simplify my management. To be determined of course…

  5. Hi Laddie,

    It is gratifying to mead to read your comments. I think I told you that I am seeing an endo here is Las Vegas. I was forced to see an endo for the first time in many years because I could not find an internist willing to write prescriptions for my pump supplies. Doctors today are highly specialized and uptight about the legal ramifications of going beyond the scope of those specialities.

    The endo I consulted recently raised all the issues to me that you wrote about. It was an interesting doctor interview for me. I came away at least in part thinking I didn’t like being given special treatment because of my age. I still feel it is important for me to keep my bg readings as close to normal as I possibly can. The endo reports that I should ease up. Further, he didn’t like all my little boluses to keep my readings hovering at 100 or below. He stated, “That’s not the way the pump is supposed to be used.” “Wow,” I thought. Who set those rules for using the pump? When the automatic system is implanted, will they program it to wait until your glucose level has risen to 150 or so before it starts to address the problem? I think not. Small amounts of insulin will be dispensed to keep the numbers in the proper range.

    Then the endo asked me who will take care of me when I am sick, the selfsame issue you raised. I didn’t (and still don’t) have an answer. You are lucky to have your sister. I decided not to waste my time worrying about the answer. For sure somebody will have that job but if I’m really sick, then I’ll be about to die and good control won’t matter anyway. Perhaps I’ll just sleep away like my Mom and everything will be resolved but for sure I’m not wasting my waking hours in this life worrying about my future. I prefer to think about my quilting or my square dancing skills.

    So while my first endo visit in many many years was a shocking experience, I suppose I have done what Daniel once accused me of: burying my head in the sand, ignoring the issues and going on my merry way.

    I’m not planning to cut down on my life, my goals, my activities and all the joy I have from remaining alert and alive in my elderly years. I just keep a-chugging along. Thanks for your input.

    As ever, Evie

    On Tue, May 21, 2019 at 5:55 AM Test Guess and Go wrote:

    > Laddie posted: “I am 67 years old and have lived with Type 1 diabetes for > over 42 years. In the last year I have read a lot about the possibility > that I should consider modifying the intensity of my diabetes regimen and > relaxing my targets. My endocrinologist suggested t” >

    • Evie-Sorry you are having some differences in goals, techniques, and targets with your new endo. I will embrace you as one of my “opinionated, hard-headed senior” friends and since you’ve been doing this for 60 or 70 years, I think you know what you are doing. Keep up the good fight. 💙

  6. I first heard of this idea several years ago while my grandmother was in a nursing home. grandma was a type 2 person with diabetes who was placed on insulin. The doctor prescribed a regiment but the facility docotr objected and using a bit of give and take her standard was set. She received insulin twice per day, her blood sugar usually ranged form 160 to 240 and she routinely got ice cream etc.

    I was concerned and asked about it. Once they discussed the issue with me I understood. Grandma was not capable of managing or taking her blood sugar. When she first started on insulin she had several low blood sugars and frankly she was most unhappy because to her diabetes meant death, she had seen my mom pass and worried about me, then she was using insulin.

    The deciding factor for me was her quality of life. Once the restrictions were lifted, she stopped crying each day, she found a boy friend (they got fake married) and her mood benighted significantly.

    I had to come to the conclusion that the facility doctor knew best. Yes grandma passed when she was 87, she thought she was married and she loved strawberry ice cream. Grandma passed of heart disease, an issue she had long before diabetes. She had no additional complications and as she said last time I saw her. “Hey I am married.” If tight control is designed to increase life expectancy, reduce complications, and increase quality of life, well grandma achieved that.

    So for me I hope others allow me someday to have a peanut butter buster parfait. I hope I am still married, not fake married (though grandma loved being “married” even if the fellow never spoke) and I hope someone lets me do mostly what I want, without worrying to much about the consequences. I am not there yet, but yes someday, I hope.

    • Thanks for the nice story about your Grandma, Rick. There will be a time when that level of care is appropriate for me and like you, I hope to get some ice cream.

  7. Gosh, what a wonderful blog post and discussion here in the comments! Thanks, Laddie. The topic – how scary it is for in-control diabetics to think of losing their ability to manage their own BGs – is on my mind so often. But I keep my thoughts to myself, because I know no other person, neither doctor nor family nor friend capable of fully “getting” what close management requires from me. My husband believes he could do it with practice (which he doesn’t have time to do at this point), but I know the constant attention and frequent failures no matter how hard one tries would frustrate the hell out of him. I’m terrified of hospitals, due to previous experiences I’ve had with their T1 diabetes incompetence. I’ve even figured a way I can “do myself in” – as you and your sister joke. I’d want it so no one ever knows it was my choice.

    Because we are dealing with my 91 year old father-in-law’s slow demise in assisted living, it’s just way too close a look at the awful way so many non-diabetic people dwindle away in wheelchairs, urine soaked diapers, behind locked doors to keep them from wandering off… Add in bad diabetes care, and I’d truly rather be shot!

    Like you, I’ll be 67 in Sept., have had diabetes many years (51), along with other autoimmune problems, and am tech savvy. I really appreciate that you brought this topic up for discussion. Thank you!

  8. I think that endos tend to get stuck in whatever practices were current at the time they were trained. My endo isn’t particularly interested in an AGP report that shows time in range 94% and SD 29, he wants to know about my BG 2 hours after meals. I humor him and continue LOOPing.

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