In Diabetes Care, a Push to Simplify

Alfrieda Goterch, 82, found it increasingly hard to manage four daily injections of insulin to control her diabetes, along with a cascade of other age-related problems she was experiencing. In frail health after two major surgeries and a hospitalization following a fall, Ms. Goterch also had a worsening case of glaucoma, and she had developed a wound on her foot.

Older diabetics often struggle to manage the disease, and with their numbers growing fast, diabetes experts are stepping up efforts to improve care. They are screening older patients for physical and mental problems, simplifying complex medication schedules, monitoring them between office visits and teaching them how to manage their disease.

[image]Sara Friedrich

In a study of the care of older diabetes patients including Alfrieda Goterch, left, her daughter Susan Friedrich, right, has weekly calls with a dietitian.

The efforts can be more time-consuming and expensive but often pay off by preventing problems that might have gone untreated and keeping blood-sugar levels under control.

More than a quarter of Americans 65 and older have Type 2 diabetes, according to the Centers for Disease Control and Prevention, and roughly another 50% have a condition known as prediabetes. By 2050, as many as 1 in 3 adults in the U.S. could have diabetes if current trends hold, compared with 1 in 10 now, the CDC says, citing the increased odds of developing Type 2 diabetes with age, population growth of minority groups at higher risk and people with diabetes living longer.

Older diabetics have higher rates of amputation, heart attack, visual impairment and kidney disease. They seek emergency care for blood-sugar crises at twice the rate of the general diabetes population.

But physicians often lack time to assess, educate and manage older patients. Last fall, a consensus panel convened by the American Diabetes Association and the American Geriatrics Society warned that while doctors know how to help middle-aged patients prevent and manage diabetes, far less is known about managing older adults. The panel recommended more individualized treatment, starting with categorizing older adults as healthy, complex or very complex and adjusting regimens accordingly.

Diabetes patients may be active and otherwise healthy, but “on the other end of the spectrum are very frail, sick older patients with other major health problems,” says panel member Jeffrey Halter, director of the geriatrics center at the University of Michigan in Ann Arbor. “If doctors are prescribing 10 medications, and a patient has a significant cognitive disorder, that is asking for a lot of trouble.”

At Joslin Diabetes Center in Boston, where Ms. Goterch receives care, staffers do initial patient screenings to assess health status and functional ability and offer coping strategies and advice. They may provide simpler medical devices and medication schedules to patients with vision or dexterity problems, and refer some to a memory clinic. Between visits, staffers follow up with regular phone calls. In a study published in the March issue of Diabetes Care, a group of patients at Joslin who received regular phone calls offering advice and strategies for diabetes issues had better blood-sugar control than a group that got equal attention but with whom staffers discussed only life events unrelated to diabetes.

“Considering the number of patients who are aging and how many more we are going to see, we have to look for the barriers this population encounters and what we can do to help them overcome them,” says lead author Medha Munshi, who served on the consensus panel and heads Joslin’s Geriatric Diabetes Clinic.

Ms. Goterch, a widow in Salem, N.H., was assessed at Joslin in July 2011, after her daughter Susan Friedrich, a financial adviser, became concerned that oral medications weren’t enough to manage her mother’s disease. Dr. Munshi put Ms. Goterch on a regimen of one insulin injection in the morning and oral medications at mealtimes. That enabled Ms. Goterch to undergo hip surgery in June 2012. In December, though, after a fall requiring two months of inpatient rehabilitation, doctors at the hospital put her on a regimen of four daily injections.

Ms. Goterch lives with her daughter, and the whole family pitches in to help. But after she returned home in February she found it hard to manage the injections during the day when everyone was at work. In March, a blister on her heel became a serious wound. And she had to use eye drops daily for her glaucoma.

At Ms. Goterch’s next visit to Joslin, Dr. Munshi was concerned about the excessive highs and lows in her blood sugar. The good news, Dr. Munshi said, was that she qualified to return to one injection a day, as part of a new study, called Simple. The study aims to determine if fewer injections of a longer-acting insulin can reduce dangerous episodes of hypoglycemia, or low blood sugar, in older patients.

When monitoring diabetes, doctors generally focus on a test called A1C, which measures average blood-sugar levels over two to three months, and may set goals for patients in the range of 6% to 8%. But for elderly patients, the focus is less on hitting those numbers than on getting “the best blood glucose numbers you can get without the risk of hypoglycemia,” Dr. Munshi says. Simpler medication regimens can improve quality of life and decrease the frequency of low blood-sugar episodes, she notes, and they also are associated with better A1C numbers.

As part of the study, Ms. Friedrich reports on her mother’s blood-sugar levels in regular weekly calls with Nora Saul, a Joslin diabetes educator and dietitian, and they discuss adjustments to her diet and medications that may be needed. Ms. Goterch, for her part, says she is grateful for the care at Joslin and says the simplified regimen is keeping her blood sugar under control.

Joslin, an affiliate of Harvard Medical School, contracts with clinics and hospitals to establish diabetes-care programs around the country. The geriatric clinic holds educational webinars for primary-care doctors.

Other groups are running patient classes at hospitals, clinics and pharmacies, with reimbursement by Medicare and most insurers. Programs accredited by the American Association of Diabetes Educators have grown from 72 in 2009 to 573 serving primarily patients over 65 at 1,480 sites. Leslie Kolb, the association’s director of accreditation and quality initiatives, says the programs helped reduce A1C levels among participants in 2012 to an average 7.15 from 8.37.

A program at Presbyterian College School of Pharmacy in Clinton, S.C., gets referrals from physicians who may lack time to educate older diabetes patients, says Kayce Shealy, an assistant professor who runs a wellness clinic at the school. “We can assess their needs, review their medications, make recommendations and send them back to the doctors, who have been very receptive,” she says.

Write to Laura Landro at