Al sure did love his ice cream. Real ice cream. When the weather was good, he would sometimes drive his motorized chair to the ice cream stand at the end of his street. A few times he pulled up to the drive-through window to order a banana split. That is a true story! The manager asked his family to PLEASE call ahead and he’d have Al’s order ready, adding that he should go to the door, NOT the drive-through window.
Safety wasn’t the only worrisome issue when it came to Al’s penchant for ice cream. He also had type-2 diabetes. For a while his family tried to reason with him, but they began to wonder if it was worth the effort.
Consider Al’s situation. He was 82 years old and had a host of serious medical problems, including incurable lung cancer and unrelenting nerve pain because of shingles. He could no longer drive and early dementia had robbed him of his ability to work on his computer anymore. In other words, Al’s world had shrunk considerably and he was now often in pain and feeling discouraged. Ice cream was one of the few things that made him light up and forget the bad for a few moments.
Because she was worried about making a decision that might harm her father, his daughter asked the doctor if he could still eat his ice cream. He said yes — that sometimes quality of life trumps strict control, but that is was still important to monitor his glucose levels.
The advice that Al’s family got may not be appropriate for another elderly person. For instance, 80-year-old Mark, who is still fairly active, also has type-2 diabetes, but needs two insulin shots every day and has to stick to a strict diet. He’s always managed fine, but in the past few months has become a little forgetful and has experienced symptoms of low blood sugar on occasion.
Low blood sugar (hypoglycemia) symptoms
Can happen if you skip a meal.
- Clammy, cold skin
- Trembling or nervousness
- Blurred vision
- Lack of coordination
High blood sugar (hyperglycemia) symptoms
Can happen if you eat too much, aren’t as active as usual or miss a dose of insulin.
- Increased thirst and urination
- Sweet odor to the breath
- Agitation and confusion
- High levels of ketones in the urine
- Weight loss
Mark needs tighter control than Al did, so he and his wife are going to work with his doctor to figure out a better way to manage his diabetes. When his blood sugar gets low, he gets confused. Research has shown that low blood sugar can cause mental impairment and severe low blood sugar can damage neurons — it may increase the risk for developing dementia. Research has also shown that people with dementia are more likely to experience a “severe low blood sugar event.”
Diabetes in people over 65
According to the American Diabetes Association, more than 25 percent of adults age 65 or older have diabetes and roughly half have prediabetes. Older adults with diabetes also have the highest rates of:
- Diabetes-related lower limb amputations
- Heart attacks
- Vision problems
- Kidney failure
The rates climb even higher after the age of 75. A major problem, however, is that the 65 and over population has not been included in most diabetes treatment trials, so it has been difficult to set standard treatment recommendations. In February 2012, the Diabetes Association convened a special conference to hear what researchers and diabetes specialists know and don’t know about the disease in older adults (65+). Its report is known as the Consensus Report.
What is known about diabetes in the elderly
There is an epidemic of type-2 diabetes in all age groups in the United States, which has been linked to the increase in people who are overweight and obese. Older adults have an increased risk for developing type-2 diabetes.
That’s because with age:
- Cells in the pancreas that control the release of insulin don’t work as well as they should.
- The body becomes more insulin resistant.
One of the challenges in treating elderly people with diabetes is that, like Al, they often have several health problems at once for which they may take several medications. Al, for instance, took medication for his pain, high blood pressure, high cholesterol, diabetes and reflux disease. Managing multiple conditions along with multiple medications can make managing diabetes pretty complicated.
When treating an elderly person with diabetes it’s especially important to consider several factors that might affect not only how the person should be treated but also whether or not he/she can manage alone or needs help. Those factors include:
- Cognitive/mental abilities
- Physical abilities
- Vision or hearing impairment
- Nutrition issues
- Living arrangement
Choosing Wisely, an initiative of the American Board of Internal Medicine (ABIM) Foundation, encourages patients to ask questions and have conversations with their physicians about whether certain tests and procedures are necessary. The American Geriatrics Society, a partner in the initiative, developed a list of five things physicians and patients should question when caring for an elderly person. One item on the list is whether or not medication is necessary for “tight glycemic control” of type-2 diabetes in someone who is 65 or older. Tight glycemic control is defined as below 7.5 on the A1c test. While elderly people with diabetes certainly need to control their blood sugar, they may not need to control it as strictly as a younger patient.
The authors of the Diabetes Association Consensus Report recommended that diabetes treatment goals should be based on an individual’s health status and characteristics.
- Relatively healthy, few other chronic illnesses, functioning well cognitively and physically
- Many other chronic illness and difficulty caring for oneself
- Extremely poor health, end-stage chronic illnesses or moderate to severe cognitive impairment
Mark probably fits into the first category and would benefit from tighter control of his diabetes. Al was somewhere in between the middle and the last categories and, in fact, passed away from lung cancer less than a year after his forays to the ice cream store. In the last days of his life he was unable to eat much — except for spoonfuls of ice cream.
The takeaway message of this post is that diabetes is a complicated disease. As you age, it can get even more complicated. It’s important to consider all the things that might also be going on that could impact the disease and how it can be managed. What worked for Al won’t work for Mark and neither of their treatment plans may work for your loved one. It’s important to get a thorough evaluation and to understand all of the risks and the options.
How Advantage Home Care can help someone with diabetes
Our services include:
- Medication reminders
- Picking up prescriptions
- Meal planning
- Meal preparation
- Grocery shopping
- Monitoring diet and eating habits
- Escort to appointments
- Assistance with exercise
We would be happy to discuss services that you may need that are not on the list.
Also, if you would like to know more about Choosing Wisely, Maine Quality Counts is a participant and has information on its website — Choosing Wisely in Maine. It’s worth checking out.
Our Aging in Place blog is written by Diane Atwood, who also writes the blogs Catching Health with Diane Atwood and mylatestart.com.
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Originally posted November 15, 2013