Adapted from The Johns Hopkins Diabetes White Papers. For in-depth information from Johns Hopkins physicians, purchase your own copy of the White Paper today. The minimum goal of blood glucose control for all people with diabetes is to avoid the acute symptoms of high blood glucose�that is, excessive thirst, frequent urination, unintended weight loss, fatigue, ketoacidosis, and hyperosmolar nonketotic states. To achieve this goal, fasting blood glucose levels should generally be 200 mg/dL or lower. However, to reduce the risk of developing long-term complications from diabetes�neuropathy, retinopathy, and nephropathy�it is often recommended that patients maintain tight glucose control with a hemoglobin A1c level under 7%. Yet, for some elderly people, the risks of tight glucose control may outweigh the benefits. Consequently, the extent of blood glucose control should be individualized. The main risk of glucose control that is too tight is hypoglycemia, which can lead to sweating, palpitations, fainting, double vision, confusion, and even coma. Some of these effects are of particular concern to older people who are at high risk for falls and subsequent disability. Nighttime hypoglycemia is also a serious concern for people who live alone and have no one to help them in the event of a hypoglycemic episode. Life expectancy and general health status also should be taken into account when considering tight glucose control, which is meant to prevent complications that usually take 10 to 20 years to develop. Very old or very ill patients who have a limited life expectancy may not require strict control. Tight glucose control is more relevant to patients who are expected to live long enough to put themselves at risk for developing complications. People with hypoglycemia unawareness�that is, an inability to recognize or feel the symptoms of a hypoglycemic reaction�should also have their blood glucose control targets relaxed. Studies have shown that awareness of hypoglycemia can be regained by preventing episodes of significant hypoglycemia for several months. Tight glucose control may be dangerous for people who cannot or will not actively participate in the management of their condition. It may not be recommended for older people with a history of stroke or transient ischemic attacks, individuals with advanced diabetes complications, or people who take numerous medications for other illnesses that could interact with drugs used for glucose control. Tight glucose control may not be practical for some older people who may have difficulty giving themselves insulin injections because of arthritis, poor vision, or cognitive impairment. Lastly, for people who have had diabetes for 20 to 25 years after puberty with minimal or no complications, a tightening of glucose control may not be needed because complications are unlikely to develop after this time. From The 2002 edition of the Johns Hopkins Diabetes White Paper.
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