From the Guidelines
For adults over 75 years old, the A1c target should be individualized, but generally a less stringent goal of <8.0% is appropriate when deciding to stop intensive treatment, as suggested by the most recent guidelines 1. When considering whether to de-intensify diabetes treatment in patients over 75, factors such as frailty, limited life expectancy, cognitive impairment, and history of severe hypoglycemia should be taken into account.
- The primary goal shifts from preventing long-term complications to improving quality of life, reducing treatment burden, and avoiding acute complications like hypoglycemia.
- Medications that carry high hypoglycemia risk (insulin, sulfonylureas) should be reduced or discontinued first, while metformin and newer agents with lower hypoglycemia risk may be continued if well-tolerated, as recommended by recent studies 1. This approach recognizes that the benefits of strict glycemic control take years to manifest, while the harms of hypoglycemia are immediate and potentially catastrophic in older adults with reduced physiologic reserve.
- The 2023 guidelines from Diabetes Care 1 provide a framework for individualizing treatment goals and simplifying treatment regimens in older adults with diabetes, emphasizing the importance of avoiding hypoglycemia and symptomatic hyperglycemia in this population. The A1c cutoff for stopping treatment in adults over 75 should be based on individual patient characteristics, health status, and treatment goals, with a focus on minimizing harm and improving quality of life 1.
From the Research
A1C Cut Off for Older Adults
The American Diabetes Association (ADA) recommends different A1C targets for older adults based on their comorbid health status 2.
- For healthy older adults, an A1C target of <7% is recommended.
- For those with complex/intermediate health, an A1C target of <8% is suggested.
- For older adults with very complex/poor health, an A1C target of <8% may not be necessary, and treatment goals should be individualized.
Stopping Treatment in Older Adults
There is no specific A1C cut off for stopping treatment in older adults. However, studies suggest that treatment intensity should be reduced as health status declines 3.
- Insulin use was most prevalent among older adults with poor health, but subsequent insulin discontinuation was most likely in healthier patients.
- The decision to stop treatment should be based on individual patient factors, such as comorbidities, life expectancy, and treatment goals.
Glycemic Control in Older Adults
Maintaining A1C levels within individualized target ranges is associated with lower risk of mortality and cardiovascular disease in older adults with diabetes 4.
- A1C time in range (A1C TIR) is a measure of glycemic control that can be used to evaluate the effectiveness of treatment.
- Increasing A1C TIR is associated with reduced risk of adverse health outcomes, including mortality and cardiovascular disease.