What is a reasonable A1c (hemoglobin A1c) goal for a 73-year-old patient with diabetes?

A1c Goals for a 73-Year-Old with Diabetes

For a 73-year-old with diabetes, the appropriate A1c goal should be <7.5-8.0% if they are relatively healthy with few comorbidities, and <8.0-8.5% if they have multiple chronic conditions or functional limitations.

Individualized A1c Targets Based on Health Status

The American Diabetes Association (ADA) provides clear recommendations for A1c targets in older adults based on their health status:

For Healthy Older Adults (73 years old)

• A1c target: <7.0-7.5% 1
• Applies to those with:
  • Few coexisting chronic illnesses
  • Intact cognitive function
  • Good functional status

For Complex/Intermediate Health Status

• A1c target: <8.0% 1, 2
• Applies to those with:
  • Multiple coexisting chronic illnesses
  • Instrumental ADL impairments
  • Mild-to-moderate cognitive impairment

For Very Complex/Poor Health Status

• A1c target: Avoid reliance on A1c 1
• Focus on avoiding hypoglycemia and symptomatic hyperglycemia
• Applies to those with:
  • End-stage chronic illnesses
  • Moderate-to-severe cognitive impairment
  • Long-term care residence

Rationale for Less Stringent Goals in Older Adults

1. Hypoglycemia Risk: Older adults have greater risk of hypoglycemia than younger adults 1

   • Hypoglycemia causes recurrent morbidity and can be fatal 3
   • Risk increases with insulin, sulfonylureas, or glinides

2. Diminishing Returns: The relationship between A1c and complications is curvilinear 3

   • Minor elevations above 7% have not been associated with increased mortality
   • A1c is a relatively weak predictor of cardiovascular disease

3. Life Expectancy Considerations: Benefits of tight control may not be realized in those with limited life expectancy 4

   • A stringent goal was not cost-effective when an individual had less than 7 years of life remaining

Important Considerations When Setting A1c Goals

• Medication Regimen: Consider simplification if:

  • Severe or recurrent hypoglycemia occurs
  • Wide glucose excursions are observed
  • Cognitive or functional decline occurs
  • Significant change in social circumstances 1

• Monitoring Approach:

  • Check A1c every 3 months until target is reached, then at least twice yearly if stable 2
  • For those on insulin (especially Type 1), consider continuous glucose monitoring to reduce hypoglycemia risk 1

• Avoid Overtreatment:

  • Recent research supports that A1c <7% is not associated with elevated mortality risk in older adults, regardless of health status 5
  • However, this must be balanced against hypoglycemia risk

Treatment Approach

When selecting medications to achieve the appropriate A1c target:

• First-line: Metformin remains the cornerstone of therapy unless contraindicated 2
• Avoid high hypoglycemia risk agents: Use caution with sulfonylureas, especially long-acting ones like glyburide (contraindicated in older adults) 1
• Preferred second-line agents: Consider SGLT2 inhibitors or GLP-1 receptor agonists, especially in those with cardiovascular disease 2
• DPP-4 inhibitors: Have minimal hypoglycemia risk but cost may be a barrier 1

Key Pitfalls to Avoid

1. Setting overly aggressive targets that increase hypoglycemia risk
2. Failing to adjust targets when health status changes
3. Ignoring functional status when setting glycemic goals
4. Overlooking medication burden and complexity in treatment decisions
5. Relying solely on A1c without considering hypoglycemia risk or quality of life

Remember that the ultimate goal is to achieve the lowest A1c that does not cause severe hypoglycemia, preserves awareness of hypoglycemia, and maintains quality of life for the individual patient 3.