Management of Older Adults with Diabetes

Glycemic Targets

• For older adults (≥70 years), glycemic targets should be less stringent than for younger patients, with an HbA1c goal of 8.0-8.5% being appropriate to minimize risk of hypoglycemia while providing reasonable control 3
• The American Geriatrics Society recommends relaxing glycemic targets in older adults with multiple comorbidities, with an HbA1c target of approximately 8.0-9.0% 4
• Tight glycemic control (HbA1c <7.0%) is not recommended in older patients due to increased risk of hypoglycemia, which can lead to falls, fractures, and cardiovascular events 2

Initial Pharmacological Management

• Check renal function before starting metformin; if eGFR is <60 mL/min, dose adjustment is needed, and metformin is contraindicated if eGFR is <30 mL/min 1
• If metformin is contraindicated or not tolerated, consider a DPP-4 inhibitor as they have minimal hypoglycemia risk and are well-tolerated in older adults 1

Stepped Approach Based on HbA1c Response

• If HbA1c remains >8.5% despite metformin, consider adding a second agent with low hypoglycemia risk, such as a DPP-4 inhibitor 1, 6
• Avoid sulfonylureas if possible due to increased hypoglycemia risk in older adults 1, 2

Monitoring and Follow-up

• Initiate self-monitoring of blood glucose (SMBG), focusing on fasting levels initially, with frequency based on medication regimen and hypoglycemia risk 1
• Monitor for hypoglycemia symptoms, which may be atypical in older adults (confusion, dizziness) 3
• Schedule follow-up within 1-2 months of treatment initiation to assess tolerance and effectiveness 8

Special Considerations for Older Adults

• Assess cognitive function, as impairment may affect ability to manage medications and recognize hypoglycemia 3
• Consider medication burden and simplify regimen when possible to improve adherence 4
• Evaluate for geriatric syndromes (falls, frailty, polypharmacy) that may influence treatment decisions 9
• Avoid setting overly aggressive targets that might lead to treatment burden without clear mortality benefit 2

Common Pitfalls to Avoid

• Targeting HbA1c <7% in older adults can increase risk of hypoglycemia without providing additional benefit 2
• Failing to consider medication costs and complexity, which can affect adherence in older adults 4