Diabetes is extremely common among older adults: up to 25% of older adults in the United States have diabetes. Intensive glucose lowering in older adults with diabetes increases hypoglycemia and potentially falls; in addition, many older adults do not have enough remaining life expectancy to benefit from microvascular risk reduction. Therefore, for many older adults, the harms of intensive glucose lowering may outweigh the benefits. The “sweet spot” of safe management of diabetes in older adults should consider hemoglobin A1c (A1c) goals that are individualized based on age, comorbid conditions, and remaining life expectancy.
The Quick Guide to Diabetes Management in Older Adults introduces a five
step framework for diabetes management in older adults, and is based on recommendations from the American Diabetes Association and the American Geriatrics Society. It is adapted from Finding the Sweet Spot: an interactive workshop on diabetes management in older adults (Triantafylidis LK, Phillips SC, Hawley CE, Schwartz AW. Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults. MedEdPORTAL . 2019;15:10845. Published 2019 Oct 18. doi:10.15766/mep_2374 8265.10845). This guide will help clinicians caring for older adults with diabetes to:
- Develop individualized glycemic goals for the treatment of older adults with diabetes
- List safety and efficacy characteristics of antihyperglycemic agents in older adults
- Implement geriatric prescribing and deprescribing principles for antihyperglycemic agents
The five step approach to “Finding the Sweet Spot” in diabetes management for older adults builds off the AGS approach to multimorbidity and is detailed in this guide, along with a case example. The content in this app is also available as a downloadable printer-friendly pocketcard at https://GeriatricsCareOnline.org/ProductAbstract/AGS-Quick-Guide-to-Diabetes-Management-in-Older-Adults/PC0011.
Step 1. Review Diabetes Regimen
- Identify medications with a high risk of hypoglycemia
- Monitor adherence
If insulin is required:
- Simplify regimens
- Minimize use of sliding scales
Step 2. Individualize A1C Goal
Individualize Hemoglobin A1c goal based on:
- Hypoglycemia risk
- Disease duration/complications
- Life expectancy
- Comorbidities
- Preference/support
Step 3. Discuss Patient Preferences
- Self monitoring blood glucose
- Injections
- Medication burden
- Regimen complexity
- Cost/affordability
Step 4. Determine What is Feasible
- Alternative medication regimens
- Monitor for contraindications
- Ability to follow instructions
- Support available
Step 5. Deprescribe or Prescribe
- Deprescribe medications with a high risk of hypoglycemia when possible
- Prescribe medications with a glucose dependent mechanism of action to minimize risk of hypoglycemia