Target Blood Sugar for Elderly Patients
For elderly patients with diabetes, target blood glucose levels should be 140-180 mg/dL (7.8-10 mmol/L) in the hospital setting, with corresponding HbA1c targets of 7.5-8% for healthy elderly and 8-9% for those with multiple comorbidities or frailty in the outpatient setting. 1, 2
Hospital/Inpatient Setting
ICU Patients
- Target glucose: 140-180 mg/dL (7.8-10 mmol/L) for most elderly ICU patients 1
- Initiate insulin therapy when glucose exceeds 180 mg/dL 1
- More stringent goals of 110-140 mg/dL may be appropriate only for select patients (cardiac surgery, acute ischemic events) if achievable without hypoglycemia 1
Non-ICU Hospitalized Patients
- Target glucose: 140-180 mg/dL (7.8-10 mmol/L) similar to ICU targets 1
- These targets must be individualized based on clinical status, hypoglycemia risk, and presence of diabetes complications 1
- Elderly patients have impaired counterregulatory responses and may not perceive hypoglycemic symptoms, making them particularly vulnerable 1
Short-Term Rehabilitation/Skilled Nursing Facility
- Target glucose: 100-200 mg/dL (5.55-11.1 mmol/L) 1
- Avoid reliance on HbA1c in this setting 1
- Focus on recovery, wound healing, and infection prevention 1
Outpatient Setting: HbA1c Targets by Health Status
Healthy Elderly (Few Comorbidities, Intact Function)
- Target HbA1c: 7.0-7.5% 1, 2
- This applies to patients with good functional status, intact cognition, and life expectancy >10 years 2
- Tighter control reduces microvascular complications over time in this population 2
Complex/Intermediate Health Status
Very Complex/Poor Health or Frail Elderly
End of Life Care
- Avoid hypoglycemia and symptomatic hyperglycemia only 1
- Do not rely on HbA1c targets 1
- Goal is comfort, not glycemic control 1
Critical Evidence Supporting These Targets
The evidence strongly demonstrates that tight glycemic control (HbA1c <7%) in elderly patients increases hypoglycemia risk without mortality benefit 2. The ACCORD, ADVANCE, and VADT trials showed intensive control did not reduce cardiovascular events and increased hypoglycemia risk 1.5-3 fold, with ACCORD showing increased all-cause mortality 2. Elderly patients aged ≥80 years are more than twice as likely to visit emergency departments and nearly five times as likely to be hospitalized for insulin-related hypoglycemia compared to middle-aged adults 2.
Key Risk Factors for Hypoglycemia in Elderly
- Renal failure (decreased gluconeogenesis, impaired insulin clearance) 1
- Sepsis 1
- Low albumin level 1
- Impaired counterregulatory hormone responses 1
- Failure to perceive hypoglycemic symptoms 1
- Polypharmacy and drug-drug interactions 3
Common Pitfalls to Avoid
Never target HbA1c <6.5% in elderly patients - this is associated with increased mortality without clinical benefit 2, 4. A substantial proportion of elderly patients with complex health are potentially overtreated, with 60% of those with very complex/poor health achieving HbA1c <7% despite the harms likely exceeding benefits 5.
Avoid sliding scale insulin as sole regimen - it results in undesirable hypoglycemia and hyperglycemia with increased hospital complications 1. Use basal-bolus or basal-plus regimens instead 1.
Do not use first-generation sulfonylureas (chlorpropamide, tolazamide, tolbutamide) in elderly patients due to prolonged hypoglycemia risk 2, 3. Glyburide should also be avoided 3.
When to Simplify or Deintensify Treatment
Consider regimen simplification when 1:
- Severe or recurrent hypoglycemia occurs (regardless of HbA1c level) 1
- Wide glucose excursions are observed 1
- Cognitive or functional decline occurs 1
- Patient cannot manage complexity of insulin regimen 1
- Significant change in social circumstances (loss of caregiver, financial difficulties) 1
- Presence of polypharmacy 1