Scientific and reasonable treatment is based on a comprehensive and objective evaluation of diabetic patients, especially for elderly diabetic patients. Only with a thorough evaluation can safe and effective individualized treatment be achieved. There are many criteria for judging the health status of elderly diabetic patients, which are nothing more than judging based on the patient's age, course of diabetes, presence of diabetic complications and/or other lesions and the severity of their organ lesions, ability to take care of themselves, intelligence and education, economic conditions, family and social support, etc. On this basis, an individualized treatment plan suitable for the patient is proposed.
It should be noted that for any elderly diabetic patient who comes to the hospital, it is necessary to clarify whether the patient has had diabetes for many years before entering old age, or whether he or she has been diagnosed with diabetes after entering old age or even just discovered high blood sugar. For the former, it is more necessary to conduct examinations and evaluations of diabetic complications, metabolic control and drug treatment. On this basis, the patient is further classified and evaluated.
Patients without obvious diabetic complications or comorbidities and good self-management ability
To date, there are few long-term studies on the elderly, especially those over 75 years old, to prove the benefits of intensive control of blood sugar, blood pressure and blood lipids. The general consensus is that for elderly diabetic patients with long life expectancy, good cognitive and physical functions, no or only mild diabetic complications, and no comorbidities with important organ diseases such as the heart, brain, and kidneys, especially those who have a strong willingness and ability to manage themselves, they can be treated through joint decision-making between doctors and patients, with similar treatment targets and intervention measures as those for young diabetic patients, such as controlling glycosylated hemoglobin to <7.5%, or even ≤7.0%, and controlling fasting blood sugar and bedtime blood sugar to 5.0-7.2mmol/L and 5.0-10.0mmol/L.
With the guidance and help of medical staff, these patients have better self-management knowledge and skills, such as controlling diet, appropriate activities, and regular blood sugar monitoring, and can analyze and appropriately adjust treatment plans based on blood sugar monitoring results, and have a higher quality of life. The premise is that hypoglycemia does not occur, especially severe hypoglycemia.
The definition of severe hypoglycemia is that once hypoglycemia occurs, it requires help from others to correct hypoglycemia. When the patient's living habits change significantly or the individual's self-management ability decreases, medical staff should re-evaluate the patient's self-management knowledge and skills, adjust the treatment goals according to the condition, and ensure that the treatment is safe and effective.
Patients with diabetic complications and functional impairment
For elderly diabetic patients with advanced diabetic complications, comorbidities that shorten their lifespan (such as heart failure, renal failure), or severe cognitive impairment or functional impairment, it is reasonable to set lower-intensity blood sugar targets, such as controlling glycosylated hemoglobin at <8.0%, fasting blood sugar at 5.0-8.0mmol/L, and postprandial blood sugar at 5.6-10.0mmol/L.
Factors considered in achieving individualized blood sugar targets include the patient's life expectancy, the risk of hypoglycemia, adverse reactions of other combined drugs, existing vascular lesions, whether there are other serious lesions, the patient's willingness, the accessibility of medical and health resources, and their economic status. For patients who use hypoglycemic drugs with a risk of hypoglycemia, such as insulin, sulfonylureas, and glinides, the lower limit of blood sugar should not be lower than 5.0mmol/L.
Since the occurrence and development of microvascular disease requires a long time, for patients diagnosed with diabetes after the age of 75 to 80, if the fasting blood sugar is mostly lower than 8.0mmol/L, and sometimes lower than 10.0mmol/L; the postprandial blood sugar is mostly lower than 11.0mmol/L, and sometimes lower than 13.0mmol/L, it is not necessary to adopt active hypoglycemic treatment, especially it is not advisable to add drugs that are easy to cause hypoglycemia.
According to the patient's wishes, hypoglycemic drugs that are not easy to cause hypoglycemia and are simple to take (such as taking one pill or one tablet a day) can be added. It is necessary to remind these patients that it is not advisable to control blood sugar too strictly and increase exercise blindly. Malnutrition is a common phenomenon among elderly diabetic patients. Malnourished elderly people are more likely to suffer from some related diseases and have a poor prognosis.
On the one hand, it is necessary to ensure that these patients do not develop severe hyperglycemia that causes obvious symptoms and adverse results. Patients with severe hyperglycemia may develop acute complications of diabetes, such as dehydration, ketoacidosis, hyperglycemic hyperosmolar coma, and existing wounds are difficult to heal and infection is difficult to control. On the other hand, we must ensure that patients do not suffer from hypoglycemia. Through good communication between doctors and patients and joint efforts, we can ensure that patients' blood sugar control is within a safe range. This goal can be achieved.
For elderly patients with diabetes, the safe range of blood sugar is 5.0-10.0mmol/L. In some cases, blood sugar after meals can reach 13.0mmol/L. On this basis, patients maintain regular living habits, monitor blood sugar regularly, strengthen communication with medical staff, and adjust treatment plans in time when necessary. Now WeChat, video connection, email, information and other cross-time and space medical consultation services have provided great convenience for patients to seek medical treatment online.
For example, our diabetes center has a full-time nurse responsible for communicating with patients. At any time, if the patient's self-tested blood sugar shows a particularly abnormal value, he can send a message to us directly through WeChat. We provide timely and effective services to ensure that the patient's blood sugar is safe and effective.
Vulnerable patients at the end of life
For patients receiving palliative care and hospice care, the focus should be on avoiding hypoglycemia and symptomatic hyperglycemia, while reducing the burden of blood sugar management and the pain of patients. With the development of organ failure and the decrease in patients' food intake and the gradual loss of activity, some drugs that control sugar and lipid metabolism will be reduced or discontinued. There is no need to monitor blood sugar frequently for such patients.
Comprehensive assessment of elderly patients with diabetes from multiple dimensions
The comprehensive assessment of elderly patients with diabetes is complex and cannot be simply measured with one ruler. For example, the diagnosis and treatment guidelines divide the health level of elderly patients into good, moderate and poor, which are judged by whether the patients have comorbidities or several chronic diseases other than diabetes and whether the patients have impaired daily living ability and instrumental daily living activities; the diagnosis and treatment guidelines are divided into good control standards, intermediate transition stages and acceptable standards based on the different treatment targets of glycated hemoglobin, fasting blood sugar and postprandial blood sugar and the conditions for adapting to patients; the CDS guidelines stratify the health status of elderly patients with diabetes into healthy, complex or moderately healthy, very complex and poor health; the diagnosis and treatment standards divide elderly patients into three categories according to diabetic complications and functional conditions.
In general, patients with more complications and comorbidities of diabetes are in more serious conditions than those with fewer, but this is not necessarily the case. Although some patients have fewer complications and comorbidities, their lesions are serious; some patients have a short life expectancy but actually live a long time, while some patients have a long life expectancy but die suddenly. Therefore, it is important to combine individual conditions, analyze and discuss with doctors and patients, make an objective and comprehensive health assessment, and propose an individualized treatment plan suitable for patients on this basis. Moreover, this plan is a dynamic adjustment process, not fixed.
Blood sugar monitoring is one of the most important management methods both in the professional diagnosis and treatment of diabetes and in the daily monitoring of diabetics. In recent years, the continuous glucose monitoring system, which monitors the glucose concentration of the interstitial fluid of the subcutaneous tissue by wearing a glucose sensor (users call it a sensor or probe) to reflect the blood sugar level, has been increasingly recognized by diabetics.
With the continuous application, development and iteration of dynamic blood sugar monitoring technology, the blood sugar compliance rate of diabetics has been greatly improved. In particular, compared with the previous finger pricking to measure peripheral blood sugar, dynamic blood sugar monitoring technology covers a variety of evaluation indicators and can pre-set high blood sugar/low blood sugar threshold alarms, which has received widespread attention and welcome from diabetics.
As a daily blood sugar management method, dynamic monitoring is becoming a must-have weapon for the majority of type 1 diabetics to control blood sugar, and is also gradually accepted by type 2 diabetes patients and pre-diabetic people who pay attention to blood sugar. While dynamic blood sugar monitoring facilitates blood sugar control, it also brings many new problems to diabetics.
Frequent checking adds anxiety
While more and more diabetics use dynamic blood glucose monitoring devices as a tool for diabetes self-management, problems reported by patients in real-world use also arise. In particular, type 1 diabetics with large blood sugar fluctuations and parents (caregivers/guardians) of diabetics who have just started wearing dynamic blood glucose monitoring devices are often accustomed to the idea of spot-testing blood sugar in the past. They only look at the real-time blood sugar value displayed by the dynamic blood glucose monitoring, plus the arrow indicating the blood sugar change, and hastily take measures to increase insulin or eat. Various blood sugar control interventions are frequent, so that from the review of the single-day and multi-day blood sugar spectrum, it can be seen that blood sugar fluctuations show large peaks and valleys.
There are also diabetics with a long course of disease. With some accumulated self-regulation experience, in order to pursue a long-term blood sugar level as a straight line, they will also keep checking the dynamic monitoring of blood sugar and make frequent adjustments.
When the parents of diabetics share and view remotely, they feel anxious and nervous. No wonder many diabetics and their families say that now they can't live without dynamics. Inappropriate and excessive psychological dependence has led to the fact that the results of blood sugar control have not improved as expected, and the unsatisfactory feedback results at the stage have increased the psychological frustration. Therefore, complaints continue, and it seems that the expensive blood sugar monitoring tool has become a burden.
Let's analyze whether it is scientific and reasonable for diabetics to use dynamic blood sugar monitoring equipment on a daily basis through several cases reported by diabetics.
Wearing a "blood sugar electrocardiogram"
Xiao Liu is a type 1 diabetic who has been using insulin pump therapy for 6 years. In the past, because he was unwilling to prick his finger to measure blood sugar, he controlled blood sugar by feeling most of the time, resulting in his self-management being good and bad. The results of glycated hemoglobin measured every 3 months were mostly between 7.0% and 8.0%, and the occasional fingertip blood sugar was also high and low.
Since wearing a dynamic blood sugar monitoring sensor, he can easily check his blood sugar at any time. Whenever he sees an upward arrow on the blood sugar graph, Xiao Liu will get up and walk up and down the stairs quickly. If it is not convenient to move, he will take out the insulin pump and press the tonic; on the contrary, when he sees the arrow showing a drop in blood sugar on the applet, he will add sweets to his meal, which often leads to increased blood sugar. In this way, the blood sugar trend graph fluctuates greatly every day. It is really worrying to look at it, and it is uneasy not to look at it. In Xiao Liu's words, he is simply wearing a "blood sugar electrocardiogram".
Xiao Liu's situation is not uncommon among diabetics. Too frequent operation not only wastes energy, but often causes problems, and blood sugar is difficult to control satisfactorily.
Beautiful-looking blood sugar graph
So, those old diabetics with a long course of illness have accumulated a lot of experience in blood sugar control. Are they handy when using new blood sugar management equipment? The real situation is not always the case.
I often see several "god" diabetics in WeChat groups share their dynamic monitoring graphs. A straight line is very pleasing to the eye. But behind the beautiful straight line, is there a real healthy life to support it? Once, I talked about daily life with several diabetics and their parents. They said: When sitting or working, attending classes, or even playing with mobile phones, blood sugar is stable for a few hours, but I didn't expect that after get off work, get out of class, or getting up to move, blood sugar will change instantly. Eat some food, and your blood sugar will be high. Infuse more insulin, and your blood sugar will be low again. Therefore, some diabetics would rather not eat food or inject insulin to maintain a beautiful blood sugar graph. I once heard a doctor introduce that a young type 1 diabetics can flexibly use insulin pumps to adjust a nearly straight blood sugar graph for a day.
Success is dynamic, failure is also dynamic
More and more clinical studies have shown that dynamic continuous blood sugar monitoring helps blood sugar management, especially the high or low blood sugar alarm function in it, which is indispensable for type 1 diabetics to achieve safe blood sugar control. As mentioned above, the seemingly perfect blood sugar graph obtained with the blessing of dynamic monitoring equipment, under careful examination, does it improve the quality of life of diabetics, or does it do more harm than good? If it is the latter, what is the reason?
The problems that diabetics are entangled in daily use reflect that we still lack a comprehensive understanding of new medical devices.
In recent years, the "Type 1 Diabetes Diagnosis and Treatment Guidelines" and clinical physicians at home and abroad have reminded diabetics to pay attention to the indicator of glucose time in the target range (TIR), and to set blood sugar at 3.9-10.0mmol/L as the daily control target. Although this target range is different from the blood sugar range of normal people, it is a commonly used blood sugar target range in clinical practice.
The dynamic blood sugar monitoring equipment programs for personal applications that have been launched on the market also use this range as an important indicator. Reasonable regulation of blood sugar fluctuations within this range is the relatively scientific and healthy life norm and pursuit of type 1 diabetics.
The author has repeatedly proposed that diabetics and their families should follow the three stages of "starting point, advanced, and synchronization" to control blood sugar. The first stage: learning the basic knowledge of diabetes prevention and control, which is an indispensable and important starting point. The second stage: learning diabetes prevention and control knowledge and sugar control practices, standardizing blood sugar management on the basis of new medical equipment assistance, and then achieving comprehensive compliance with various indicators. The third stage: sharing experiences in resisting blood sugar, helping fellow diabetics, and making collaborative progress.
I hope that type 1 diabetics can scientifically control blood sugar with the help of new technologies and new equipment, and gain more freedom and happiness.
