Table 13.2.

Considerations for treatment plan simplification and deintensification/deprescribing in older adults with diabetes

Characteristics and health status of person with diabetes	Reasonable A1C/treatment goal	Rationale/considerations	When may medication plan 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)	• Individuals can generally perform complex tasks to maintain good glycemic management when health is stable • During acute illness, individuals 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 individuals 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 indviduals 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 plan	• If severe or recurrent hypoglycemia occurs in individuals on insulin therapy (even if A1C is appropriate) • If unable to manage complexity of an insulin plan • 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 individuals 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 individuals receiving care in a skilled nursing facility for short-term rehabilitation	Avoid reliance on A1C, glucose goal 100–200 mg/dL (5.55–11.1 mmol/L)	• Glycemic management is important for recovery, wound healing, hydration, and avoidance of infections • Individuals recovering from illness may not have returned to baseline cognitive function at the time of discharge • Consider the type of support the individual will receive at home	• If treatment plan increased in complexity during hospitalization, it is reasonable, in many cases, to reinstate the prehospitalization medication plan 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 management in this population • Hypoglycemia should be avoided • Most important outcomes are maintenance of cognitive and functional status	• If on an insulin plan and the individual would like to decrease the number of injections and finger-stick blood glucose monitoring events each day • If the individual 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 plan simplification refers to changing strategy to decrease the complexity of a medication plan (e.g., fewer administration times and 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. Created using information from Munshi et al. 2016 (102) and 2017 (138). ADL, activities of daily living; LTC, long-term care.