Diabetes in the elderly remains little studied

A quarter of nursing home residents have diabetes, but doctors are only now recognizing that they may need different medical treatment than younger people with the disease.

Elbert Huang, a University of Chicago primary care doctor who conducts diabetes research, bemoans the fact that clinical trials rarely include elderly diabetics even though nearly half of people with diabetes are over 65.

Three recent, large trials of measures to keep tight control of blood sugar did include older people but yielded either detrimental results or no benefit.

"If you're taking care of an older person with diabetes, you're really working in a confusing time," Huang said.

He persuaded the American Diabetes Association to hold its first-ever session on diabetes in the elderly at its annual meeting last year. At this year's meeting, being held though Tuesday in Philadelphia, he drilled down further, leading a symposium Friday on taking care of diabetics in long-term care settings. That includes everything from home care to nursing homes.

Huang, who is on the association's scientific planning committee, is also part of a consensus panel on treating the elderly that will soon report to the group.

"I don't think anyone really knows what the right way to approach diabetes care in nursing homes is," he said.

Diabetics are at greater risk of dementia, so Huang asked one presenter to talk about patients with both conditions. Another talked about palliative care. Elderly diabetics, who often are overweight, frequently have arthritis or other sources of pain. "A large percentage of them have chronic pain, and it seems to get worse as they come closer to death," Huang said.

The biggest issue is how to balance quality of life with health in patients who may not have many years left.

Drug companies tend to test new medicines in relatively healthy people. It's easier to measure the impact of one variable - a new drug - when patients aren't being treated for lots of chronic problems. But that leaves doctors without key information when they treat real patients, who are likely to be old and have lots of things wrong with them.

Nationally, almost 19 million people have been diagnosed with diabetes, which causes people to have too much sugar, or glucose, in their blood. Obesity is an important risk factor. Diabetes causes heart disease, stroke, kidney failure, and blindness.

The percentage of nursing home patients with diabetes declines with age, said Helaine Resnick, an epidemiologist who is president of the consulting firm Resnick, Chodorow & Associates. Though half of nursing home residents are over 85, just 13.1 percent of people in that group have diabetes. The reason: Diabetics don't live that long.

Diabetes, she said, is an age accelerator that damages every part of the body. "They get to be a train wreck," she said.

Barbara Resnick, a University of Maryland geriatric nurse practitioner and a past president of the American Geriatric Society, said doctors and nurses had recently begun to take a more relaxed approach to diabetes management in nursing homes.

Typically, diabetics are told to keep tight control of their glucose levels because it helps prevent major health problems that develop over many years. That's less important when people don't have many years to look forward to.

"How important is hyperglycemia [too much sugar in the blood] when your mother is 99?" she asked. "Do you really want to say to her, 'You can't go to the birthday party and eat cake with everybody else.'?"

She gives older people more leeway when it comes to diet and then uses medication to keep blood sugar under control. "We let you eat whatever the heck you want to eat and we regulate your diabetes around that," she said.

Barbara Resnick, who is not related to Helaine Resnick, said either too much or too little blood sugar can cause thinking problems, a particular concern in a population that already is at high risk for cognitive difficulty. Too much sugar can also lead to frequent urination, more infections, and healing problems.

But too little sugar, or hypoglycemia, is actually a bigger problem in the elderly, especially people who may not be able to communicate that they don't feel well. It can lead to falls and even death, she said.

Mark Mullen, medical director of Holy Redeemer Lafayette, said the more relaxed medical approach was difficult for some doctors to accept. It dovetails nicely, however, with the trend toward more homelike long-term care and individualized treatment.

If patients weren't very disciplined eaters at home, Mullen says, nursing homes are now less likely to impose strict rules on them. As a comfort measure, the homes also may test for blood sugar less frequently.

"More important than tight sugar control is the happiness of the resident," Mullen said.

Follow the news from the American Diabetes Association's 72d scientific meeting on our live blog, and look up the prevalence of diabetes in our region on an interactive map: philly.com/ada2012EndText