What is the target Hemoglobin A1c (HbA1c) level for a 90-year-old patient?

From the Guidelines

For a 90-year-old patient, the target Hemoglobin A1c (HbA1c) level should be less than 8%, as this acknowledges the increased risks of hypoglycemia in older adults and prioritizes safety over tight glucose control 1.

Key Considerations

• The American College of Physicians recommends that clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care 1.
• For patients with limited life expectancy or where the harms of treatment are greater than the benefits, less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate 1.
• The goal A1C should typically be less relaxed than for younger adults, with a target range of 7.5-8.5% or even higher depending on health status.
• Treatment should focus on avoiding hypoglycemia and hyperglycemic symptoms rather than achieving strict glycemic targets.
• 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.
• Regular monitoring for adverse effects is essential, and treatment goals should be reassessed frequently as the patient's health status changes.

Guidance Statements

• Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes 1.
• Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5% 1.
• Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary disease or congestive heart failure) because the harms outweigh the benefits in this population 1.

From the Research

Target Hemoglobin A1c (HbA1c) Level for a 90-year-old Patient

• The American Diabetes Association recommends different A1C targets in older adults based on comorbid health status 2
• For complex elderly patients, a moderate glycemic control with A1C levels between 7-8% is recommended 3
• However, the risk of hypoglycemia from some treatments may present a significant barrier to optimal glycemic control for the very old 3
• Liberating A1C goals in older adults may not protect against the risk of hypoglycemia 4
• The relationship between A1C and chronic complications of diabetes is curvilinear, and minor elevations of A1C above 7% have not been found to be associated with increased mortality 5
• A somewhat higher A1C level is appropriate in those who have previously experienced hypoglycemia or have potential high risk for hypoglycemia, have a long duration of diabetes, and have a short life expectancy, among other traits 5

Considerations for Individualized Glycemic Goals

• Individualized glycemic goals should be based on the patient's health status, risk of hypoglycemia, and life expectancy 5, 2
• The benefits of intensive therapy to lower A1C must be weighed against the greater risk of disabling and unpredictable hypoglycemia in the geriatric population 6
• A reasonable individualized glycemic goal is the lowest A1C that does not cause severe hypoglycemia and preserves awareness of hypoglycemia 5