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Insulin remains the standard of care for the elderly person with T1DM (I discuss insulin use in full detail in Chapter 10). It may not be possible to achieve excellent blood glucose control, though. Attempting to force a hemoglobin A1c of 7 percent or less on the patient at this age may lead to a significant reduction in the quality of life, with multiple episodes of hypoglycemia. You and your doctor have to decide whether you're going to try for basic or intensive care with your insulin administration.

i Basic care means avoiding excessive urination and thirst. This allows you to get a good night's sleep and feel rested. An elderly person with multiple significant medical conditions who isn't expected to live very long should receive this level of care. The goal of the treatment is to keep the blood glucose under 200 mg/dl. This can be done with a single shot of insulin glargine in the morning and moderate amounts of rapid-acting insulin before meals. An even simpler regimen may be two shots of a mixture of short- and intermediate-acting insulin daily. These come in insulin pens and are easy to administer.

i Intensive care means trying to lower the hemoglobin A1c below

7 percent to prevent microvascular complications. This is done for the elderly person with T1DM who's expected to live long enough to develop microvascular complications (eye, kidney, and nerve disease) if not treated intensively. These days, that could include the 80- or 90-year old. It may be necessary to accept some hypoglycemia in order to accomplish this level of care.

An insulin pump (see Chapter 11) may be useful in intensive care because it reduces the amount that you have to remember in order to administer the right amount of insulin.

You must test your blood glucose if you use insulin. Study after study has concluded that the more a person with T1DM tests, the better their blood glucose control. In addition, your doctor should regularly test your hemoglobin A1c (every three months), your microalbumin (at least annually), your weight and blood pressure (every visit), and your blood fats (at least annually). I describe all these tests in Chapter 7.

In view of the increasing insulin resistance in the elderly, consideration should be given to using the drug metformin, which lowers the release of glucose from the liver. It's given at a dose of 500 to 1000 mg three times daily with meals.

Other drugs said to be insulin sensitizers (that is, they make you more sensitive to your insulin), such as the thiazoledinedione class that includes rosiglitazone and pioglitazone, are associated with a number of side effects that, I believe, make them dangerous. They cause weight gain, anemia, and osteoporosis, and rosiglitazone has been shown to cause early heart attacks. I don't recommend their use.

It's a good idea to bring your medications to the doctor's office every time you go and to keep a list of your medicines with you at all times in case you find yourself in an emergency room unexpectedly. When you see your doctor, don't hesitate to take all your medications out and ask the doctor whether you still need to take each one or if you can lower your dose. Any time you can accomplish either, you will benefit.

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