From the Guidelines
For a 91-year-old patient with type 2 diabetes, a less stringent hemoglobin A1c (HbA1c) target range of less than 8% is generally recommended. This more relaxed goal acknowledges the increased risks of hypoglycemia in elderly patients and prioritizes safety over strict glycemic control, as suggested by the most recent guidelines 1. When managing diabetes in very elderly patients, the focus shifts toward preventing acute complications like hypoglycemia, which can lead to falls, confusion, and hospitalization, rather than preventing long-term complications that may take years to develop.
Key Considerations
- Treatment should be individualized based on the patient's overall health status, functional abilities, life expectancy, and personal preferences.
- Medication choices should favor those with lower hypoglycemia risk, such as metformin (if kidney function permits), DPP-4 inhibitors, or certain GLP-1 receptor agonists, while using insulin or sulfonylureas more cautiously with appropriate dose adjustments, as recommended by recent guidelines 1.
- Regular blood glucose monitoring is important, especially if the patient is on insulin or sulfonylureas, to detect and prevent hypoglycemic episodes.
Evidence-Based Recommendations
The American College of Physicians suggests that clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes 1. However, for patients with limited life expectancy, such as those over 80 years old, less stringent targets may be appropriate, with a focus on minimizing symptoms and avoiding hypoglycemia 1. The most recent guidelines from Diabetes Care suggest that less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy or where the harms of treatment are greater than the benefits 1.
Individualized Care
Given the patient's age and the potential risks associated with tight glycemic control, a target HbA1c range of less than 8% is a reasonable goal, prioritizing the prevention of acute complications and maintaining quality of life, as supported by the latest evidence 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Target Hemoglobin A1c (HbA1c) Range for a 91-year-old Patient with Diabetes Mellitus Type 2
The target HbA1c range for a 91-year-old patient with diabetes mellitus type 2 can vary depending on several factors, including the patient's life expectancy, comorbidities, and risk of hypoglycemia.
- According to the American Diabetes Association (ADA) 2013 guidelines, a reasonable HbA1c goal for many nonpregnant adults with diabetes is less than 7.0% 2.
- However, for patients with a history of severe hypoglycemia, limited life expectancy, advanced macrovascular and microvascular complications, extensive comorbidities, and long-standing diabetes, an HbA1c level less than 8.0% may be appropriate 2.
- The American College of Physicians (ACP) published a guideline in 2018 recommending an HbA1c target level between 7% and 8% for most patients with type 2 diabetes, and deintensification of therapy for patients with an HbA1c level lower than 6.5% 3.
- For elderly patients, a less-aggressive goal may be considered due to the increased risk of hypoglycemia and its complications 4, 5.
- A study published in 2011 suggested that a glycosylated hemoglobin (HbA1c) goal of <7% is reasonable for most patients, but a less-aggressive goal may be considered for patients at high risk of hypoglycemia or high risk of complications from hypoglycemia 5.
Considerations for Elderly Patients
When determining the target HbA1c range for a 91-year-old patient with diabetes mellitus type 2, several factors should be considered, including:
- Life expectancy: Patients with a limited life expectancy may not benefit from tight glycemic control 3, 4.
- Comorbidities: Patients with extensive comorbidities may be at higher risk of hypoglycemia and its complications 2, 5.
- Risk of hypoglycemia: Elderly patients are at higher risk of hypoglycemia due to factors such as renal insufficiency, polypharmacy, and irregular meal patterns 4, 5.
- Glycemic control: The benefits of intensive therapy to lower HbA1c must be weighed against the risk of hypoglycemia and its complications 2, 3, 4, 5.