How low is too low for older people with diabetes?

Since the ACCORD (Action to Control Cardiovascular Risk in Diabetes) and ADVANCE (Action in Diabetes and Vascular disease: Preterax and Diamicron MR Controlled Evaluation) studies highlighted the risk in pursuing very low HbA_1c values, as clinicians we have all been more mindful of individualised targets for the older person with diabetes. We have rightly considered the effects of low glucose levels on safety and daily living, and have been de-prescribing or reducing sulphonylureas or insulin doses where appropriate to reduce hypoglycaemia risk and avoid exacerbating mental dysfunction. However, there is balance needed in all things, as the retrospective analysis by McGovern et al (2016) reveals.

Their retrospective cohort analysis was of 19 000 people aged ≥65 years with diabetes, with their infection rates stratified by glycaemic control. After adjustment for confounders, they found that poor glycaemic control (HbA_1c>69 mmol/mol [8.5%]) was a significant predictor of rates of pneumonia, urinary tract infections, and skin and soft tissue infections. This is particularly relevant given that people with diabetes are at an increased risk of death from pneumonia and other infectious diseases, with older people being especially vulnerable.

While the researchers acknowledge that further research is needed, their findings emphasise the effect of poor glycaemic control on rates of potentially life-threatening infections in older people with diabetes. The trend away from diabetes targets that are deemed too low for the older person may result in increased infection rates, with the potential of increased hospital admissions. This reminds us to factor in the increased risk of infection when we relax glycaemic targets.

Another aspect to consider is the rise in chronic conditions in older people, which will be relevant in those with diabetes and their additional risks. The University of Leicester studied 15 000 people in England and found an increasing trend in people over 50 years developing a second or third chronic condition (Dhalwani et al, 2016). They suggest that the number of older people living with more than one chronic condition has risen by 10% in the past 10 years. This will have direct effects on the NHS, as multimorbidity becomes one of the main challenges to both patients and healthcare providers.

The two articles in this section consider two relevant aspects of care in the older person; the state of diabetes care in care homes and an update on how effective team working can improve diabetes care. Although finances limit our services, research informs our practice and can help us to improve how we work. How we provide care to the most vulnerable remains a challenge for us all.