Relaxing the targets

Many people with type 1 diabetes spend their whole diabetes-lives trying to achieve the best control they can in order to prevent them from running into problems and complications. 

As people get older, it can be difficult for them to accept that the levels of glucose they have always strived for may not be appropriate anymore, particularly if other medical problems develop. People can become more frail as they grow older and sometimes quality of life and avoiding low glucose levels is much more important than worrying about high glucose levels. 

It is reasonable to suggest that the sugars should be no lower than 6 mmol/l and no higher than 15mmol/l

See some advice below about relaxing the targets as people get older: 

A blood sugar of 4-5 may be OK when we are young, fit and agile…… 

Older gentleman carrying out finger prick test

…… As we get older, our body’s counter-regulatory response (hormonal response) and symptom awareness of hypos doesn’t always work as well, which can increase the risk of hypoglycaemia. 

Problems with mobility, memory or vision can make it more of a challenge to get to carbohydrate quickly and therefore it may be safer to keep glucose levels a bit higher – nearer 8-9 (or even higher). This idea may take some getting used to! 

It is certainly true that as we get older we may be more at risk of hypoglycaemia than high glucose levels…… 

…… it is reasonable to accept glucose levels up to about 15, as long as levels like that don’t make someone feel unwell. 

We tend to try to put an upper limit on glucose levels around this, as any higher can lead to dehydration and risk of falls. People may also want to urinate more often and running to the bathroom as you get older may be a challenge! 

How to relax target

As people get older, quality of life and avoiding low glucose levels is much more important than worrying about high glucose levels. 

There are several ways to relax the targets – the suggestions below are only ideas and an individualised programme should be devised with the diabetes team. This plan should be reviewed regularly to make sure it is working. 

Learn about ways people can relax their targets: 

Carbohydrate counting
If someone is carbohydrate counting then the ratio can be changed so that they take less insulin with each carbohydrate meal. If using a smart meter, the ratio can be changed on the meter/ app. If manually calculating, the ratio can be changed in a similar way, for example from 1 unit per 10 grammes to 0.5 units per 10 grammes.

Reduce fixed doses
If someone is on fixed doses of insulin then the dose with each meal can be reduced.

Reduce long acting dose
Reducing the long acting dose of insulin can allow the average glucose level to drift up a bit. It may be necessary to reduce the long acting and the short acting insulin as above.

Stop mealtime insulin
If someone’s appetite has reduced and they are eating very little carbohydrate and becoming quite frail, it may be acceptable to stop the meal time insulin altogether. Long acting insulin with one or two extra meal time injections per day if the glucose is rising may be sufficient. However, it is strongly recommended that this is decided with a diabetes team. Stopping mealtime insulin may mean that blood glucose tests are needed in the morning and at night to make sure the sugars aren’t creeping too high.

If blood glucose tends to rise, on occasion, whilst on long acting insulin only, it is possible to give occasional small corrections of short acting insulin when required. A sensible, written scale can be devised to help work out those correction doses.

Reduce the number of blood tests
It may be acceptable to reduce the number of glucose tests taken each day. This may cause some distress in people who are used to paying very close attention to their diabetes. It may be OK to test just once or twice a day if the doses of insulin have reduced significantly and someone is becoming progressively more unwell and frail.

It is important to aim for a higher average blood glucose level – the HbA1c. Levels of 8.5% (69mmol/mol) or even higher may be appropriate.

Targets may need to be continually reviewed, particularly if someone is becoming increasingly unwell and frail. However, age itself is not necessarily a reason to relax diabetes control – there are plenty of eighty-year-olds touring Europe and overseas!

It is very important to remember that someone with type 1 diabetes should not stop their insulin altogether, however, it may be sensible to relax the demands that are put on them as they become older and more frail.

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