What is the recommended A1C goal for a 92-year-old patient with type 2 diabetes (T2D), who is wheelchair-bound and dependent for all activities of daily living (ADLs), according to the American Diabetes Association (ADA) Standards of Care?

From the Guidelines

For SD, a 92-year-old with type 2 diabetes who is wheelchair-bound and dependent for all ADLs, I recommend an A1C goal of < 8 to 8.5%. This less stringent glycemic target is appropriate given SD's advanced age, significant functional limitations, and complex insulin regimen, as supported by the American Diabetes Association Standards of Care 1. The ADA Standards of Care specifically recommends less strict glycemic control for older adults with multiple comorbidities, limited life expectancy, and functional dependence, citing the importance of avoiding hypoglycemia and maintaining cognitive and functional status 1. With SD's current intensive medication regimen (insulin glargine 28 units daily, insulin lispro 8 units pre-meals, metformin 500 mg BID, and glipizide 10 mg BID), the risk of hypoglycemia is substantial, and targeting a higher A1C range helps balance diabetes management while minimizing the dangerous consequences of hypoglycemia, which can be particularly harmful in frail elderly patients 1. Key considerations for SD's care include:

• Avoiding hypoglycemia and symptomatic hyperglycemia to provide comfort and avoid tasks or interventions that cause pain or discomfort 1
• Simplifying SD's medication regimen to reduce hypoglycemia risk while maintaining reasonable glycemic control within the target range 1
• Regularly assessing SD's cognitive and functional status to adjust the treatment plan as needed 1
• Considering deintensification or deprescribing of medications if they are no longer providing a clear benefit or are causing undue burden on SD or their caregivers 1.

From the Research

Patient Profile

• SD is a 92-year-old patient with a history of type 2 diabetes.
• The patient is wheelchair-bound and impaired or dependent for all Activities of Daily Living (ADLs).
• Current medications for diabetes include insulin glargine, insulin lispro, metformin, and glipizide.

A1C Goal Recommendation

• According to the American Diabetes Association (ADA) Standards of Care, the recommended A1C goal for older adults with diabetes, such as SD, is less stringent than for younger adults 2, 3.
• Considering SD's age, disability, and comorbidities, a less stringent A1C goal may be appropriate to minimize the risk of hypoglycemia and other adverse effects.
• The ADA recommends an A1C goal of < 8% for older adults with diabetes, but this can be individualized based on the patient's health status and preferences 3.
• Based on the available evidence, a reasonable A1C goal for SD could be < 8 to 8.5% 2, 3.

Rationale

• The studies suggest that older adults with diabetes, such as SD, may require a more relaxed A1C goal due to the increased risk of hypoglycemia and other complications 2, 3.
• The use of metformin in patients over 80 years of age should be avoided due to declining kidney function 2.
• Insulin therapy is an option, but patients should be monitored carefully for the development of hypoglycemia 2.
• The choice of insulin regimen, such as insulin lispro mixture or insulin glargine, can affect glycemic control and hypoglycemia risk 4, 5, 6.