A daily dose of insulin may be enough for elderly patients to limit hypoglycemia

For years Sanford Sloane went from doctor to doctor trying to get his blood sugar level under control. Efforts like diet and oral drugs worked for his type 2 diabetes — but only for a while. Eventually placed on insulin, that, too, seemed to serve him well.

But managing his blood sugar — the test pricks and the shots — was more like a game of chance. “They increased the insulin to four times a day and that didn’t work either,” remembers Carlos Quinteros, Sloane’s caretaker and life partner of 47 years. “His glucose level was either very high or very low.” At least twice he fainted as a result of low-blood sugar.

Sanford Sloane, 81, who has type 2 diabetes, was put on a once-a-day shot of 15 units of Lantus, a long-acting form of insulin, instead of getting multiple shots per day.
Sanford Sloane, 81, who has type 2 diabetes, was put on a once-a-day shot of 15 units of Lantus, a long-acting form of insulin, instead of getting multiple shots per day.

In 2019, a desperate Quinteros took Sloane, 81, to Dr. Rajesh K. Garg, an endocrinologist with the University of Miami Health System. The doctor put the retired librarian on a once-a-day shot of 15 units of Lantus, a long-acting form of insulin. Now, gone are the sky-high glucose levels. Gone are the dizziness spells. Gone, too, is a diabetic ulcer on the big toe of his right foot that had refused to heal for months.

“No more pricking his finger four times a day,” Quinteros adds. “He can eat almost anything and still stay at his level.”

Treatment for elderly patients

This kind of de-intensified diabetes treatment has increasingly become a go-to treatment for other elderly patients who are often at higher risk of hypoglycemia, or low blood sugar levels.

“Research in the past 20 years has shown that aggressive control in older patients is not as helpful as in younger patients,” says Garg, who published an original article in Endocrinology Practice about reducing certain diabetes treatment in elderly patients. “Actually it can be harmful.”

Dr. Rajesh Garg
Dr. Rajesh Garg

Controlling blood sugar in type 2 diabetes is a delicate dance. Unlike type 1, when the pancreas makes no insulin ( or very little), the pancreas of type 2 diabetics either doesn’t work properly or doesn’t make enough insulin, the hormone that turns food sugar into energy. Typically type 2 diabetes can be controlled with diet and exercise and oral medications, with about 20 percent of patients needing insulin, Garg says.

Among elderly diabetics, however, the percentage on insulin is much higher. That’s because elderly patients often suffer from other health issues, which makes oral drugs more dangerous or less effective. Age-related deterioration of organs, including the liver and kidneys, makes processing these drugs difficult. What’s more, elderly patients “may have had diabetes longer and the drugs have lost their effect. At that point only insulin is effective,” says Garg, who is also director of the Comprehensive Diabetes Center at The Lennar Foundation Medical Center.

But how much insulin is good enough?

Dr. Pascual De Santis, endocrinologist with Baptist Health South Florida, points to the American Diabetes Association’s standards that no longer aim for a strict blood glycemic level but a more “reasonable and flexible goal.”

In healthy older adults, an A1C of 7 percent or less is acceptable. For those in poor health or with limited life expectancy, an A1C reading of less than 8.5 percent is considered adequate. (A1C measures the amount of hemoglobin in the blood that has glucose attached to it. For people without diabetes, a normal reading is between 4 to 6 percent.)

Dr. Pascual DeSantis, a Baptist Health South Florida endrocrinologist
Dr. Pascual DeSantis, a Baptist Health South Florida endrocrinologist

But, as De Santis is quick to point out, “What works for one patient may not work for another. You have to adjust and adapt.” Also, not every patient is as compliant in following treatment or honest with the doctor about eating habits.

“It’s not a cookie recipe,” agrees Dr. Lorena Lewy-Alterbaum, an endocrinologist with Memorial Healthcare System. “Every patient’s treatment has to be individualized.”

‘Step-by-step’ treatment

Most endocrinologists introduce treatment “in a step-by-step fashion” in hopes that the least invasive measures work. Lewy-Alterbaum says patients diagnosed with high blood sugar tend to receive initial care from their primary care doctors, who prescribe lifestyle changes, including a restricted diet and more exercise. Some may need oral drugs, too. “By the time they get to me, that’s not working so well,” she adds.

Dr. Lorena Lewy-Alterbaum, an endocrinologist with Memorial Healthcare System
Dr. Lorena Lewy-Alterbaum, an endocrinologist with Memorial Healthcare System

That’s to be expected, De Santis says. “Diabetes is a progressive disease. It worsens over time and it’s not uncommon for patients to need more and more drugs and eventually to not respond to non-insulin drugs.” Which is when they land in an endocrinologist’s office.

Treating with the least amount of insulin

Typically patients are usually started on long-acting basal insulin. (Some may continue on oral medications as well.) If the target blood sugar level is not achieved, a short-acting insulin shot is introduced before a meal. If that doesn’t work either, the patient builds up to insulin injections before every meal. But again, following ADA recommendation, clinicians will opt for tighter blood sugar control only in healthy elderly patients with 10 or more years of life expectancy. For the over 85 and 90 set, with a more reduced life expectancy, “we can be more flexible. We want to treat them with the least amount of medicine,” Lewy-Alterbaum adds.

As Sloane’s case exemplifies, seniors who have type 2 for years can be the hardest patients to treat. The challenge is finding the precise amount to keep blood sugar under control. Too much insulin can cause blood sugar to nosedive. Low blood sugar symptoms include shakiness, anxiety, fast heartbeat, clamminess and nausea. But hypoglycemia can also cause confusion and dizziness, leading to falls. Though all diabetics run the risk of hypoglycemia, the elderly are more vulnerable to the effects. They may already suffer from balance issues or dementia.

Doctors recommend that patients regularly check their blood glucose level and keep glucose tablets on hand in case it’s too low.

Endocrinologist have found that older patients benefit when their insulin regimen is simplified. Not only is it easier and less confusing to follow, but it also improves the quality of their lives. Quinteros reports that Sloane, who also suffers from hepatic encephalopathy (loss of brain function) as a result of non-alcoholic liver cirrhosis, is more energetic these days, and he is less stressed.

“It’s going beautifully and it’s a big break for both of us,” he says. “Sometimes more does not mean better.”