Do no harm
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Yesterday, I saw a feisty 97-year-old woman. She lives on her own and still drives her car on short errands. Im busy! I have things to do! She is very physically active, swimming three or more times a week at the local swim center. She is proud of the fact that she has taught more than 1,000 people how to swim. Dont we all wish to be like her someday?
She has been frustrated about her diabetes however. She was diagnosed at age 90. Her blood sugars were initially well controlled on oral medications. Metformin has been stopped due to chronic renal insufficiency, but she remains on glipizide 5 mg per day. When control deteriorated two years ago, insulin glargine was added. Despite the dose being increased to 55 units a day, her home blood glucoses have recently ranged between 200-300 mg/dL. An HgA1c in May was 12.4%. She worries that her concerns are not being taken seriously because of her age.
She may be correct. Subconscious ageism seems pervasive not only in medicine but in our society in general. It may be unintentional but can affect our medical decision-making. Rather than looking only at someones chronological age, we need to consider other factors, such as current state of health and future prognosis.
How much longer will this woman live? I have no idea. Except for her diabetes, however, she is in better health than many of my 50- and 60-year-old patients. One thing is for certain, she has absolutely no intention of going to the funny house. She was adamant, If they put me there, Ill run away! I believe her.
I agreed that we need to do something about her uncontrolled diabetes. I discussed concerns about potentially inducing a severe hypoglycemic event if we too tightly attempt to control blood glucoses. A severe but nonfatal hypoglycemic event resulting in a disabling complication frightens us both more than the unlikely possibility of developing a new microvascular complication.
She will check a few 1 a.m. to 3 a.m. blood glucoses for us. She only weighs 99 lbs, and I am worried that the glargine dose is higher than it should be. She has had no documented hypoglycemia. However, there was one suspicious episode where she was confused, fell in the middle of the night and woke up on the floor.
We added low-dose premeal fast-acting insulin and stopped the glipizide. Severe hypoglycemia can occur in elderly patients with chronic renal failure on sulfonylurea. Our goals for glycemic control will not be as aggressive as those we might target in others. We are thinking of fasting blood glucoses of 110-150 mg/dL and an HgA1c of around 8% but only if we can do so without hypoglycemia. The treatment must not be worse than the disease. As the medical aphorism goes, we must do no harm.