Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes
| Patient characteristics/health status . | Rationale . | Reasonable A1C goal‡ . | Fasting or preprandial glucose . | Bedtime glucose . | Blood pressure . | Lipids . |
|---|---|---|---|---|---|---|
| Healthy (few coexisting chronic illnesses, intact cognitive and functional status) | Longer remaining life expectancy | <7.0–7.5% (53–58 mmol/mol) | 80–130 mg/dL (4.4–7.2 mmol/L) | 80–180 mg/dL (4.4–10.0 mmol/L) | <130/80 mmHg | Statin, unless contraindicated or not tolerated |
| Complex/intermediate (multiple coexisting chronic illnesses* or two or more instrumental ADL impairments or mild-to-moderate cognitive impairment) | Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk | <8.0% (64 mmol/mol) | 90–150 mg/dL (5.0–8.3 mmol/L) | 100–180 mg/dL (5.6–10.0 mmol/L) | <130/80 mmHg | Statin, unless contraindicated or not tolerated |
| Very complex/poor health (LTC or end-stage chronic illnesses** or moderate-to-severe cognitive impairment or two or more ADL impairments) | Limited remaining life expectancy makes benefit uncertain | Avoid reliance on A1C; glucose control decisions should be based on avoiding hypoglycemia and symptomatic hyperglycemia | 100–180 mg/dL (5.6–10.0 mmol/L) | 110–200 mg/dL (6.1–11.1 mmol/L) | <140/90 mmHg | Consider likelihood of benefit with statin |
| Patient characteristics/health status . | Rationale . | Reasonable A1C goal‡ . | Fasting or preprandial glucose . | Bedtime glucose . | Blood pressure . | Lipids . |
|---|---|---|---|---|---|---|
| Healthy (few coexisting chronic illnesses, intact cognitive and functional status) | Longer remaining life expectancy | <7.0–7.5% (53–58 mmol/mol) | 80–130 mg/dL (4.4–7.2 mmol/L) | 80–180 mg/dL (4.4–10.0 mmol/L) | <130/80 mmHg | Statin, unless contraindicated or not tolerated |
| Complex/intermediate (multiple coexisting chronic illnesses* or two or more instrumental ADL impairments or mild-to-moderate cognitive impairment) | Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk | <8.0% (64 mmol/mol) | 90–150 mg/dL (5.0–8.3 mmol/L) | 100–180 mg/dL (5.6–10.0 mmol/L) | <130/80 mmHg | Statin, unless contraindicated or not tolerated |
| Very complex/poor health (LTC or end-stage chronic illnesses** or moderate-to-severe cognitive impairment or two or more ADL impairments) | Limited remaining life expectancy makes benefit uncertain | Avoid reliance on A1C; glucose control decisions should be based on avoiding hypoglycemia and symptomatic hyperglycemia | 100–180 mg/dL (5.6–10.0 mmol/L) | 110–200 mg/dL (6.1–11.1 mmol/L) | <140/90 mmHg | Consider likelihood of benefit with statin |
This table represents a consensus framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient and caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time. ADL, activities of daily living; LTC, long-term care.
A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.
Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. “Multiple” means at least three, but many patients may have five or more (66).
The presence of a single end-stage chronic illness, such as stage 3–4 heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. Adapted from Kirkman et al. (3).