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October 25, 2016
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Ethics and the Elders

Occasionally my mailbox or follow-the-link browsing will come up with something discussing whether (and if so, when) to ease the restrictions on treatment goals when the patient is elderly, arguing either to favor a higher quality of remaining life (lifestyle choices less limited by chronic illness) or to take into consideration geriatric cognitive decline (aka "senility") and simplify, as much as possible, the regimen.

While the goal of medicine is, obviously, not to kill the patient (doh!), when we start talking about people in their 80s and 90s, the uncertainty of their remaining lifespans magnifies the ethical dilemma of treating to extend the duration of one's full-facultied life or to minimize the restrictions against "living as one d---- pleases".

There are a number of issues involved in these decisions above and beyond the two I've discussed above.

While many of us are most concerned about the levels of care our elders might get in an institutionalized setting (such as a nursing home), diabetes-care issues transcend even to those of our elderly who are able to live on their own, with or without assistance such as Meals on Wheels and visiting nurses and social workers.

The big issue that comes to mind where diabetes is concerned is diet versus medication load.

I'm among the first to admit that institutional cooking usually looks terrible, tastes terrible, and has cost-per-person rather than Food Pyramid goals in mind. It's usually high on starches, sodium, and added sugars, and low on fresh produce, lean protein, whole grains, and protein-rich legumes. I can certainly understand why many folk in nursing homes and eating Meals on Wheels might not want to eat everything on their calorie-controlled plates or drink their Boost, Ensure, or Glucerna nutritional supplement.

If the medical issue were hypertension or arthritis or something like that, there might not be an issue beyond stomach irritation or the proper absorption of medications — but when one's pre-loaded diabetes medication is predicated upon the meal as served, not eating one's broccoli (or drinking one's Ensure) could result in serious lows a few hours out. Meanwhile, eating only the bread, pasta, and carbs on the plate might result in short term glycemic spikes.

I've seen a few pieces associating lows with age-related cognitive decline. If this is the case, overmedicating for diabetes is something we might want to avoid — but without hourly (or more frequent) testing or a CGM, how do we know if our parents' and grandparents' "senior moments" are moments of senility, or moments of low? That is, perhaps, another argument in favor of relaxing treatment guidelines (to a higher HbA1c) for elderly PWD.

As with everything medical, though, the choices need to depend on what the PWD is willing and able to do, and what his healthcare providers believe is the best therapy for that person, and the conversation between them that determines (or should determine) the regimens, medications, and goals of their diabetes care.

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