From the Guidelines
For a 90-year-old patient with dementia, the target Hemoglobin A1c (HbA1c) level should be individualized, but a less stringent goal of 8.0-8.5% is generally appropriate, rather than the standard target of 7.0% or lower, as stated in the American College of Physicians guidance statement 1. This approach prioritizes minimizing hypoglycemia risks, which are particularly dangerous in elderly patients with cognitive impairment, and focuses on preventing acute complications like severe hyperglycemia, dehydration, and hyperosmolar states. The primary goal is to balance diabetes control while avoiding hypoglycemia, which can worsen confusion and increase fall risk, and acknowledging the patient's limited life expectancy, prioritizing quality of life over intensive glycemic control. Regular blood glucose monitoring by caregivers is essential, with particular attention to symptoms that might indicate hypoglycemia, as the patient may not be able to recognize or communicate these symptoms themselves. Some key points to consider when managing diabetes in this population include:
- Individualizing glycemic targets based on patient characteristics, such as life expectancy, comorbidities, and risk of hypoglycemia 1
- Focusing on simple regimens with lower hypoglycemia risk, such as metformin, DPP-4 inhibitors, or GLP-1 receptor agonists, while avoiding sulfonylureas and complex insulin regimens when possible 1
- Prioritizing quality of life and minimizing treatment burden, as the benefits of intensive glycemic control may not outweigh the risks in patients with limited life expectancy 1
- Regularly reassessing and adjusting glycemic targets as patient factors change over time 1
From the Research
Target Hemoglobin A1c (HbA1c) Level for Older Adults with Diabetes
- The American Diabetes Association recommends different A1C targets in older adults based on comorbid health status 2
- For older adults with complex/intermediate or very complex/poor health, an A1C target of <8% may be more appropriate, while for healthy older adults, an A1C target of <7% may be suitable 2
- A study found that older adults with A1C ≥8% had higher mortality risk and more hospitalizations compared to those with A1C <7% 2
Considerations for Older Adults with Dementia
- There is limited evidence on the optimal HbA1c target for older adults with dementia 2, 3, 4, 5
- However, considering the potential benefits of tighter glycemic control on cognitive function and the risk of hypoglycemia, a target HbA1c level of <8% may be considered for older adults with dementia 2, 3
- Sodium-glucose cotransporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RAs) may be effective in reducing HbA1c levels and have potential benefits on cardiovascular and renal outcomes in older adults with diabetes 3, 4
Specific Considerations for a 90-year-old Patient with Dementia
- Given the limited evidence and potential risks of hypoglycemia, a target HbA1c level of <8% may be considered for a 90-year-old patient with dementia 2, 3
- The choice of glucose-lowering medication should be individualized based on the patient's comorbidities, renal function, and risk of hypoglycemia 6, 3, 4