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Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes[1]

Framework for considering treatment goals for glycemia, blood pressure, and dyslipidemia in older adults with diabetes[1]
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 <7.5% (58 mmol/mol) 90 to 130 mg/dL (5.0 to 7.2 mmol/L) 90 to 150 mg/dL (5.0 to 8.3 mmol/L) <140/90 mmHg Statin unless contraindicated or not tolerated
Complex/intermediate (multiple coexisting chronic illnesses or 2+ 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 to 150 mg/dL (5.0 to 8.3 mmol/L) 100 to 180 mg/dL (5.6 to 10 mmol/L) <140/90 mmHg Statin unless contraindicated or not tolerated
Very complex/poor health (LTC or end-stage chronic illnessesΔ or moderate-to-severe cognitive impairment or 2+ ADL dependencies) Limited remaining life expectancy makes benefit uncertain <8.5%◊ (69 mmol/mol) 100 to 180 mg/dL (5.6 to 10 mmol/L) 110 to 200 mg/dL (6.1 to 11.1 mmol/L) <150/90 mmHg Consider likelihood of benefit with statin (secondary prevention more so than primary)
This 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.
A1C: glycated hemoglobin; 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, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. By "multiple," we mean at least 3, but many patients may have 5 or more[2].
Δ The presence of a single end-stage chronic illness, such as stage 3-4 congestive 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.
◊ A1C of 8.5% (69 mmol/mol) equates to an estimated average glucose of approximately 200 mg/dL (11.1 mmol/L). Looser A1C targets above 8.5% (69 mmol/mol) are not recommended, as they may expose patients to more frequent higher glucose values and the acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.
Reference:
  1. Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care 2012; 35:2650.
  2. Laiteerapong N, Iveniuk J, John PM, et al. Classification of older adults who have diabetes by comorbid conditions, United States, 2005-2006. Prev Chronic Dis 2012; 9:E100.
From: American Diabetes Association. 11. Older adults: Standards of medical care in diabetes – 2018. Diabetes Care 2018; 4:S119. American Diabetes Association, 2017. Copyright and all rights reserved. Material from this publication has been used with the permission of American Diabetes Association.
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