For all older adults with diabetes, an individualized A1c goal should be established to effectively guide deprescribing and prescribing.
Stringent A1c goals may be appropriate for healthier older adults, if they can be achieved without hypoglycemia or adverse treatment effects, including polypharmacy.
Consider an A1c goal of <7.5% for patients with:
- Type 2 diabetes mellitus treated with lifestyle changes or metformin only
- Longer remaining life expectancy
- No significant cardiovascular disease
- Intact cognition and function
Relaxed A1c goals may be appropriate for patients with complex or intermediate health status.
Consider an A1c goal of <8% for patients with:
- Intermediate remaining life expectancy
- Multiple chronic illnesses (≥3)
- Instrumental ADL impairment(s)
- Mild moderate cognitive impairment
- High treatment burden
- Increased risk of hypoglycemia
- Fall risk
Less stringent A1c goals may be appropriate for very complex patients with multiple or end stage comorbidities.
Consider an A1c goal of <8.5%-9% for patients with:
- History of severe hypoglycemia
- Limited life expectancy
- Advanced macro and microvascular complications
- Extensive comorbidities, including moderate to severe cognitive impairment
- ADL dependency
- Long term care status
- Long standing diabetes that remains difficult to manage despite intensive education, appropriate glucose monitoring, and maximal antihyperglycemic therapy including insulin
Key Points:
- Individualized A1c goals will help to guide both blood glucose goals and medication choices
- A1c may not be an accurate measure of glycemic control in frail older adults with multiple comorbidities1
- Higher A1c goals do not protect against hypoglycemia for older adults on insulin therapy2
- When the A1c goal is less stringent, fasting, prandial, and nocturnal glucose targets should also be relaxed
1Munshi et al. Shortfalls of the use of HbA1C derived eAG in older adults with diabetes. Diabetes Res Clin Pract . 2015 Oct;110(1): 60 65.
2Munshi et al. Liberating A1c goals in older adults may not protect against the risk of hypoglycemia. J Diabetes Complication s. 2017 Jul;(7):1997 1999.