Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with diabetes (93,128)
| Patient characteristics/health status . | Reasonable A1C/treatment goal . | Rationale/considerations . | When may regimen simplification be required? . | When may treatment deintensification/deprescribing be required? . |
|---|---|---|---|---|
| Healthy (few coexisting chronic illnesses, intact cognitive and functional status) | <7.0–7.5% (53–58 mmol/mol) | • Patients can generally perform complex tasks to maintain good glycemic control when health is stable • During acute illness, patients may be more at risk for administration or dosing errors that can result in hypoglycemia, falls, fractures, etc. | • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (regardless of A1C) • If wide glucose excursions are observed • If cognitive or functional decline occurs following acute illness | • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (regardless of A1C) • If wide glucose excursions are observed • In the presence of polypharmacy |
| Complex/intermediate (multiple coexisting chronic illnesses or two or more instrumental ADL impairments or mild-to-moderate cognitive impairment) | <8.0% (64 mmol/mol) | • Comorbidities may affect self-management abilities and capacity to avoid hypoglycemia • Long-acting medication formulations may decrease pill burden and complexity of medication regimen | • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate) • If unable to manage complexity of an insulin regimen • If there is a significant change in social circumstances, such as loss of caregiver, change in living situation, or financial difficulties | • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate) • If wide glucose excursions are observed • In the presence of polypharmacy |
| Community-dwelling patients receiving care in a skilled nursing facility for short-term rehabilitation | Avoid reliance on A1C, glucose target 100–200 mg/dL (5.55–11.1 mmol/L) | • Glycemic control is important for recovery, wound healing, hydration, and avoidance of infections • Patients recovering from illness may not have returned to baseline cognitive function at the time of discharge • Consider the type of support the patient will receive at home | • If treatment regimen increased in complexity during hospitalization, it is reasonable, in many cases, to reinstate the prehospitalization medication regimen during the rehabilitation | • If the hospitalization for acute illness resulted in weight loss, anorexia, short-term cognitive decline, and/or loss of physical functioning |
| Very complex/poor health (LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or two or more ADL impairments) | Avoid reliance on A1C and avoid hypoglycemia and symptomatic hyperglycemia | • No benefits of tight glycemic control in this population • Hypoglycemia should be avoided • Most important outcomes are maintenance of cognitive and functional status | • If on an insulin regimen and the patient would like to decrease the number of injections and fingerstick blood glucose monitoring events each day • If the patient has an inconsistent eating pattern | • If on noninsulin agents with a high hypoglycemia risk in the context of cognitive dysfunction, depression, anorexia, or inconsistent eating pattern • If taking any medications without clear benefits |
| At the end of life | Avoid hypoglycemia and symptomatic hyperglycemia | • Goal is to provide comfort and avoid tasks or interventions that cause pain or discomfort • Caregivers are important in providing medical care and maintaining quality of life | • If there is pain or discomfort caused by treatment (e.g., injections or finger sticks) • If there is excessive caregiver stress due to treatment complexity | • If taking any medications without clear benefits in improving symptoms and/or comfort |
| Patient characteristics/health status . | Reasonable A1C/treatment goal . | Rationale/considerations . | When may regimen simplification be required? . | When may treatment deintensification/deprescribing be required? . |
|---|---|---|---|---|
| Healthy (few coexisting chronic illnesses, intact cognitive and functional status) | <7.0–7.5% (53–58 mmol/mol) | • Patients can generally perform complex tasks to maintain good glycemic control when health is stable • During acute illness, patients may be more at risk for administration or dosing errors that can result in hypoglycemia, falls, fractures, etc. | • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (regardless of A1C) • If wide glucose excursions are observed • If cognitive or functional decline occurs following acute illness | • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (regardless of A1C) • If wide glucose excursions are observed • In the presence of polypharmacy |
| Complex/intermediate (multiple coexisting chronic illnesses or two or more instrumental ADL impairments or mild-to-moderate cognitive impairment) | <8.0% (64 mmol/mol) | • Comorbidities may affect self-management abilities and capacity to avoid hypoglycemia • Long-acting medication formulations may decrease pill burden and complexity of medication regimen | • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate) • If unable to manage complexity of an insulin regimen • If there is a significant change in social circumstances, such as loss of caregiver, change in living situation, or financial difficulties | • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate) • If wide glucose excursions are observed • In the presence of polypharmacy |
| Community-dwelling patients receiving care in a skilled nursing facility for short-term rehabilitation | Avoid reliance on A1C, glucose target 100–200 mg/dL (5.55–11.1 mmol/L) | • Glycemic control is important for recovery, wound healing, hydration, and avoidance of infections • Patients recovering from illness may not have returned to baseline cognitive function at the time of discharge • Consider the type of support the patient will receive at home | • If treatment regimen increased in complexity during hospitalization, it is reasonable, in many cases, to reinstate the prehospitalization medication regimen during the rehabilitation | • If the hospitalization for acute illness resulted in weight loss, anorexia, short-term cognitive decline, and/or loss of physical functioning |
| Very complex/poor health (LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or two or more ADL impairments) | Avoid reliance on A1C and avoid hypoglycemia and symptomatic hyperglycemia | • No benefits of tight glycemic control in this population • Hypoglycemia should be avoided • Most important outcomes are maintenance of cognitive and functional status | • If on an insulin regimen and the patient would like to decrease the number of injections and fingerstick blood glucose monitoring events each day • If the patient has an inconsistent eating pattern | • If on noninsulin agents with a high hypoglycemia risk in the context of cognitive dysfunction, depression, anorexia, or inconsistent eating pattern • If taking any medications without clear benefits |
| At the end of life | Avoid hypoglycemia and symptomatic hyperglycemia | • Goal is to provide comfort and avoid tasks or interventions that cause pain or discomfort • Caregivers are important in providing medical care and maintaining quality of life | • If there is pain or discomfort caused by treatment (e.g., injections or finger sticks) • If there is excessive caregiver stress due to treatment complexity | • If taking any medications without clear benefits in improving symptoms and/or comfort |
Treatment regimen simplification refers to changing strategy to decrease the complexity of a medication regimen (e.g., fewer administration times, fewer blood glucose checks) and decreasing the need for calculations (such as sliding-scale insulin calculations or insulin-carbohydrate ratio calculations). Deintensification/deprescribing refers to decreasing the dose or frequency of administration of a treatment or discontinuing a treatment altogether. ADL, activities of daily living; LTC, long-term care.