From the Guidelines
For older adult patients with moderate comorbidity and a life expectancy of less than 10 years, an appropriate hemoglobin A1c goal is generally between 7.5% and 8.0%. This recommendation is based on the most recent and highest quality study, which suggests that less stringent glycemic control is appropriate for older adults with multiple coexisting chronic illnesses or functional dependence 1. The focus in managing diabetes in these patients should shift from preventing long-term complications to improving quality of life and avoiding acute complications.
When managing diabetes in older adults, it is essential to consider the patient's functional status, cognitive abilities, support system, and personal preferences. Medication choices should prioritize those with low hypoglycemia risk, such as metformin (if kidney function permits), DPP-4 inhibitors, or certain GLP-1 receptor agonists, while avoiding sulfonylureas which carry higher hypoglycemia risk.
Some key points to consider in managing diabetes in older adults include:
- Avoiding reliance on A1C for glucose control decisions in very complex or poor health patients, and instead focusing on avoiding hypoglycemia and symptomatic hyperglycemia 1
- Considering the potential benefits and harms of tight glycemic control, and recognizing that the microvascular benefits of strict glycemic control typically take 8-10 years to manifest 1
- Individualizing treatment decisions based on the patient's health status, preferences, and life expectancy
- Prioritizing medications with low hypoglycemia risk and avoiding those with high risk, such as sulfonylureas.
Overall, the goal of diabetes management in older adults with moderate comorbidity and limited life expectancy should be to improve quality of life, avoid acute complications, and minimize the risks associated with tight glycemic control.
From the Research
Hemoglobin A1c Goal for Older Adults with Moderate Comorbidity
- The American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults based on comorbid health status 2.
- For older adults with moderate comorbidity and a limited life expectancy, a hemoglobin A1c goal of 7.5% to 8% may be appropriate.
- A study published in Diabetes Care found that older adults with A1C ≥8% had higher mortality risk and more hospitalizations compared to those with A1C <7% 2.
- However, the study also suggests that a goal of <7% may be reasonable for some older adults with diabetes, depending on their individual health status and life expectancy.
- Other studies have found that metformin-based dual therapies with sulfonylurea, pioglitazone, or DPP4-inhibitor can be effective in achieving glycemic control in patients with type 2 diabetes 3, 4, 5.
- A study published in the American Journal of Epidemiology found that Medicare claims data can be used to predict life expectancy and risk of death in older adults, which can inform decisions about glycemic control goals 6.
Key Considerations
- The patient's individual health status, comorbidities, and life expectancy should be taken into account when determining a hemoglobin A1c goal.
- The ADA guidelines recommend considering the patient's risk of hypoglycemia, disease duration, and presence of cardiovascular disease when setting a glycemic control goal.
- The choice of antihyperglycemic therapy should be based on the patient's individual needs and characteristics, as well as the potential benefits and risks of each therapy.