Q: Should my older patients with diabetes have the same treatment goals as younger patients?

About 20% of the population over 65 years old has diabetes. Caring for older adults with diabetes must be personalized to each individual. This heterogenous group can include those who have had diabetes for many years and have coexisting illnesses such as heart disease, stroke, or hypertension, or significant complications like retinopathy, neuropathy, and nephropathy. Other active, older adults may have just been diagnosed and have little comorbidity. Still others may have underlying conditions that limit physical and cognitive functioning. The American Diabetes Association (ADA) Guidelines (2014) include a framework to help providers and patients in considering glycemic, blood pressure, and lipid goals for older patients with diabetes, although not every patient will fall clearly into a category.

Characteristics of the healthy older patient with diabetes include individuals with good cognitive and physical functioning, few coexisting chronic illnesses, and a longer remaining life expectancy. Patients in this category may be treated with interventions similar to younger adults with diabetes and would include glycemic targets of A1c 7% to 7.5%. Fasting (FBS) or preprandial blood glucose (BG) target range for this group is 90 to 130 mg/dL with a bedtime BG target between 90 and 150 mg/dL. These patients should strive for a blood pressure (BP) of <140/80 mmHg and should consider lipid management that would include a statin if not contraindicated (ADA, 2014).

The complex or intermediate group has at least three multiple coexisting chronic illnesses defined as conditions that require medications and/or lifestyle management. Some examples include arthritis, cancer, depression, emphysema, falls, incontinence, heart failure, and stroke. This group may experience impairment in activities of daily living (ADL), mild-to-moderate cognitive impairment, an intermediate remaining life expectancy (<10 years), and/or high treatment burden, hypoglycemia vulnerability, and fall risk. For this group, an A1c of 8%, 90 to 150 mg/dL FBS/preprandial, and 100 to 180 mg/dL bedtime BG are recommended. BP and lipid management is the same as the healthy group parameters (ADA, 2014).

The last patient group are individuals with complex/poor health. This group may be in long-term care or have end-stage chronic illnesses such as stage 3-4 heart failure, oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or metastatic cancer. There may be moderate-to-severe cognitive impairment or ADL dependencies with limited remaining life expectancy. The BG targets include A1c 8.5%, FBS 100 to 180 mg/dL, and bedtime glucose 110 to 200 mg/dL. These more relaxed glycemic goals still need to prevent glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing. The BP target for this group is <150/80. These individuals should also consider the benefit of a statin for secondary prevention (ADA, 2014).

Patients and caregivers should be included in shared decision making. A lower goal can be considered if the treatment to reach target does not cause recurrent or severe hypoglycemia or undue treatment burden. Tighter glycemic control may result in higher rates of hypoglycemia that can cause falls and subsequent injuries for the older adult. Glycemic targets should be a reflection of patient goals, health status, and life expectancy. Evaluation of the known targets for BG, BP, and lipids should be compared for appropriateness and may need to be discussed with the primary care provider to ensure safe and effective management for the older adult with diabetes.

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