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Published in final edited form as: Lancet Diabetes Endocrinol. 2025 Feb 17;13(5):427–437. doi: 10.1016/S2213-8587(24)00372-3

Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies

Medha Munshi 1, Anna R Kahkoska 2, Joshua J Neumiller 3, Anastasia-Stefania Alexopoulos 4, Nancy A Allen 5, Tali Cukierman-Yaffe 6, Elbert S Huang 7, Sei J Lee 8, Kasia J Lipska 9, Lisa M McCarthy 10, Graydon S Meneilly 11, Naushira Pandya 12, Richard E Pratley 13, Leocadio Rodriguez-Mañas 14, Alan J Sinclair 15, Sarah L Sy 16, Elena Toschi 17, Ruth S Weinstock 18
PMCID: PMC12178675  NIHMSID: NIHMS2086386  PMID: 39978368

Abstract

Treating older people with diabetes is challenging due to multiple medical comorbidities that might interfere with patients’ ability to perform self-care. Most diabetes guidelines focus on improving glycaemia through addition of medications, but few address strategies to reduce medication burden for older adults—a concept known as deprescribing. Strategies for deprescribing might include stopping high-risk medications, decreasing the dose, or substituting for less harmful agents. Accordingly, glycaemic management strategies for older adults with type 1 and type 2 diabetes not responding to their current regimen require an understanding of how and when to realign therapy to meet patient’s current needs, which represents a major clinical practice gap. With the gap in guidance on how to deprescribe or otherwise adjust therapy in older adults with diabetes in mind, the International Geriatric Diabetes Society, an organisation dedicated to improving care of older individuals with diabetes, convened a Deprescribing Consensus Initiative in May, 2023, to discuss Optimization of diabetes treatment regimens in older adults: the role of de-prescribing, de-intensification and simplification of regimens. The recommendations from this group initiative are discussed and described in this Review.

Introduction

Worldwide, more than 20% of people aged 65 years and older have diabetes. This group of older adults represents a large proportion of the overall diabetes population.1 By 2045, the global population of older adults living with diabetes is predicted to exceed 276 million.2 In this group, clinical characteristics, self-care abilities, goals, and priorities for care, and living situations differ widely within and across regions.1,3,4 Despite this heterogeneity, all older adults with diabetes—including older adults with type 1 and type 2 diabetes—need access to medication regimens that are safe, effective, and tailored to their individual needs.

Reducing the risk of hypoglycaemia is particularly important in the older population with diabetes, as low blood glucose can lead to injury, worsen cognitive impairment, and precipitate cardiac events.59 To address the risk of hypoglycaemia and other adverse outcomes, multiple guidelines recommend higher glucose targets, avoidance of overtreatment, and individualised glycaemic management regimens in older adults,1016 yet the recommendations often lack details on how best to modify treatments so that the benefits outweigh the risks. The term overtreatment conceptually refers to situations in which the intensity or risks of a medication regimen outweigh the benefits—a ratio that changes over the lifetime of an individual. As many older adults have multiple comorbidities, polypharmacy is often necessary. Studies based on medication count alone, without controlling for medical conditions or classes of medications, might not accurately reflect the totality of benefits and harms of the regimen. Nevertheless, polypharmacy can reflect potential for inappropriate prescribing and contribute to medication errors, drug related adverse events, and drug interactions, which might in turn increase the risks of cognitive impairment, frailty, malnutrition, depression, falls, fractures, weight loss, functional decline, disability, increased hospital admissions, and mortality.1719

Indeed, the varying needs of older adults with diabetes, combined with the accrual of comorbidities and declining functional status (cognitive, physical agility), medications, and habits over time, can make application of a single algorithm for medication decision making in this population challenging.4 Thus, the risks and benefits of any given regimen might fluctuate for the older individual with diabetes. Determining the risk–benefit ratio is key to determining when and how to intervene when a person is struggling with their current regimen (ie, identifying red flags that signal a problem with glycaemic management that should trigger re-evaluation of the individual’s treatment goals and strategy). These red flags can extend beyond clinical characteristics to include changes in the older adult’s personal circumstances that might adversely affect glycaemic management. Ensuring that therapeutic benefits outweigh risks is key. Therefore, an understanding of what information to collect and which specific steps to consider when realigning treatments to fit changing needs of the individual (including changes to increase safety or simplify the regimen) is essential.

To address how care providers might better recognise red flags and realign treatment strategies to address changing needs of older individuals with diabetes, a meeting of experts (geriatricians, endocrinologists, primary care physicians, pharmacists, educators, nurses, and researchers) convened on May 18–19, 2023. The meeting aimed to was to develop an approach to help care providers identify and address problems older adults with type 1 or type 2 diabetes face in managing their condition. Over several months after the meeting, the group developed the 4S Pathway (step 1: seeking triggers; step 2: shared decision making; step 3: setting and resetting goals; and step 4: simpler and safer medications), which aims to: help care providers identify changes in older adults’ clinical and functional status (cognitive, physical agility), lifestyle, social factors, available supports, and personal preferences, and determine through shared decision making an approach for establishing treatment modifications that should be made. The goal of the 4S Pathway is to make diabetes regimens not only safer but also more effective at meeting the individualised needs of older adults with diabetes. The 4S Pathway is not intended for older individuals with diabetes who are managing well, but for those experiencing difficulties with their current glycaemic management approach.

Conceptual basis of the 4S Pathway

The 4S Pathway involves four steps (figure 1): step 1—seeking triggers, that is, asking about and investigating possible causes or contributors to changes in health status, self-care capacity, or personal circumstances that might have led to a person’s difficulties with glycaemic management; step 2—shared decision making between the person with diabetes, their care partner(s), and their care provider(s) on changing goals, treatment, and other next steps; step 3—setting (or resetting) appropriate and realistic management goals; and step 4—simpler and safer antihyperglycaemic medication regimens (where actions taken to simplify regimens should also increase their safety). The first three steps are the same for all adults with diabetes, regardless of diabetes type or care setting. The specifics of step 4 differ according to the needs and characteristics of three different populations: community-dwelling older adults with type 1 diabetes, community-dwelling older adults with type 2 diabetes, and people with any form of diabetes who reside in post-acute and long-term care settings, such as skilled rehabilitation or long-term care facilities.

Figure 1:

Figure 1:

The 4S Pathway

Consensus discussion of terminology when developing the 4S Pathway

In developing the 4S Pathway, the authors sought not only to provide practical steps to address problems with glycaemic management of older adults with diabetes but also examined the geriatric medicine concepts of deprescribing or de-intensifying therapies as a response to overtreatment. The terms deprescribing and de-intensifying are commonly used to describe the process of modifying therapeutic regimens of older adults with burdensome treatment regimens. However, in the context of glycaemic management, some authors were concerned that these terms might carry negative connotations and falsely imply that care providers believe older individuals should abandon glycaemic management efforts or that most or all medications should be withdrawn. In seeking alternative terms, the authors of the 4S Pathway discussed how to best describe changes to the diabetes regimen that would lessen treatment burden, lower hypoglycaemia risk, and improve quality of life of older adults with diabetes—in sum, ensure that benefits outweigh the risks. After considering various terms, most of the group chose the term realign, which has been used throughout this document to describe treatment changes.

Realignment is not restricted to withdrawal of medications or to dose reductions, as connoted by the terms deprescribe or de-intensify. As described within the 4S Pathway, the total number of medications might be reduced, or the realignment might involve dose reductions or substitutions of medications with different potency or side-effect profiles. For example, many older patients who were diagnosed with type 2 diabetes in their 40s or 50s might have been started on a sulfonylurea and have responded well on their medication for many years, but when these individuals reach their 70s or 80s, any sign of hypoglycaemia warrants investigation and possibly a switch to a class of medication that does not cause hypoglycaemia.

Glycaemic pattern recognition as a key aspect of realignment

Glycaemic variability, or wide daily excursions into high and low glucose ranges, is a frequent problem across all age groups of individuals with diabetes and has also been linked with cardiovascular events and cognitive deficits.2022 To reduce these adverse outcomes in older adults, diabetes guidelines recommend avoiding or reducing medications that increase the risk of hypoglycaemia along with establishing higher HbA1c targets.1016 However, HbA1c has several limitations that reduce its usefulness as a metric in older adults, particularly those who might benefit from therapeutic realignment. Specifically, as a 3-month average of glycaemia, HbA1c cannot be used to detect hypoglycaemia (including that which occurs overnight) or glycaemic variability.23 In addition, because HbA1c cannot be used to evaluate daily glycaemic patterns, provides little guidance for the choice between different classes of anti-hyperglycaemic agents, and it cannot be used to evaluate the effects of changes in therapy over intervals shorter than 2–3 months. Another limitation of HbA1c is that values might not accurately represent the degree of hyperglycaemia in people with conditions that affect red blood cell lifespan and turnover, such as recent blood loss, chronic kidney disease, and anaemia.12,23 Anaemia is a particular concern, as it affects about 27% of people with diabetes, and its prevalence increases with age.24,25 A final and important drawback of relying solely on HbA1c for assessment of glycaemia in older adults is that relaxed HbA1c goals are not necessarily protective against hypoglycaemia. Thus, because of the limitations of HbA1c, glucose monitoring is recommended as a complimentary approach to guide therapy adjustements.26,27 This can be done with different antihyperglycaemic medications that target different aspects of hyperglycaemia based on their mechanism of action and timing of doses.23,28 Although CGM will provide the most robust information (appendix p 1), and evidence supports improved glycaemic management in CGM users versus non-users across the lifespan,26,29,30 glycaemic pattern assessment through the use of fingerstick BGM can also be informative. Ultimately, the tools that should be used are those that are available, acceptable to the individual older adult, and feasible within their care setting. Furthermore, the effect of the glucose monitoring approach on overall treatment burden and cost should be carefully considered.

Steps of the 4S Pathway

Step 1—seeking triggers

Many factors might trigger a change in an older person’s wellness and self-management capabilities (panel). Each time an older individual with diabetes visits the clinic, especially when there is a change in their glycaemic parameters, the evaluation should aim to detect these red flags and not just adjust doses of diabetes medications. Identifying triggers might require reassessment of—and should include—a medical and personal history; mood evaluation and cognition assessment; a physical exam with focus on mobility, balance, frailty, functional status, detrimental or unintentional weight loss, and infections; and assessment of glycaemic patterns to identify hypoglycaemia and glycaemic excursions.31 An important point about the examples listed in the panel is that they represent a new or worsening aspect of the person’s health status or living situation.

Figure 2 highlights key red flags—possible diabetes-related causes or contributing factors—and investigative actions that can be taken when seeking triggers. Many of the examples shown in figure 2 might have other causes, including geriatric syndromes, increasing frailty, comorbidities such as pre-existing cardiovascular disease or cardiovascular risk factors, cognitive impairment, or physical disabilities. The medication review should assess the effect of agents taken for the person’s comorbid conditions and their diabetes regimen. Social determinants of health, such as access to health-related services, medication affordability, housing stability, and food security, should also be investigated along with care partner support. Referrals to other specialists or mental health professionals should be considered if the person’s reduced wellbeing appears to be due to causes other than diabetes.

Figure 2: 4S Pathway step 1—seeking triggers.

Figure 2:

Selected examples of triggers that should prompt further investigation into diabetes-related contributions to declining health or wellbeing. CGM=continuous glucose monitoring.

Step 2—shared decision making

Shared decision making is well established as part of the standard of care in diabetes and geriatric medicine.32,33 People with diabetes and their care partners should participate in all management decisions to the extent they desire.34 Many older adults have been self-managing their diabetes for decades and might feel affronted by suggested simplifications to long-established treatment regimens. Others might feel relief with treatment simplification but still find the change in routine disruptive or confusing.35 In addition, many older adults might be transitioning management decisions to a care partner. There is, at present, no consensus about the optimal ways to frame the reasons for therapy realignment, although care providers might consider some suggested responses to possible concerns from older adults with diabetes as presented in the appendix (p 2). Some older adults and care partners might respond well to a discussion of decreasing treatment burden and improving overall wellness and quality of life. Others might respond favourably to risks of a current treatment regimen exceeding benefits due to the changing circumstances. Care providers should emphasise that realigning treatment does not mean the care team is giving up on the individual; but rather, the management regimen is being adapted to meet agreed-upon individualised goals aligned with the person’s priorities.36,37

Step 3—setting goals

An HbA1c of less than 7·0%—which is a target generally recommended for adults with diabetes who are younger than 65 years23—is often used as a proxy for overtreatment of older adults with diabetes using hypoglycaemic agents such as secretagogues and insulins. For example, in a cross-sectional study of 1288 participants in the National Health and Nutrition Examination Survey (NHANES 2001–10) who were 65 years or older and had diabetes, 56% of patients with poor health or complex disease had an HbA1c of less than 7·0%. 60% of the poor health group were treated with insulin or a sulfonylurea, increasing their risk of hypoglycaemia.38 Studies39,40 conducted in the US Veterans Affairs population of individuals aged 65 years or older found that more than 50% of veterans with diabetes, dementia, and a history of hypoglycaemia had an HbA1c of less than 7·0%. Similarly, in a study41 involving 7269 community-living older people with diabetes in Spain, 42·3% had an HbA1c of less than 7·0%, regardless of health status. In a Belgian study42 of hospital admissions between 2008 and 2015, 57% of adults aged 75 years or older with diabetes met criteria for overtreatment, which was defined as an HbA1c of less than 7·5% for patients with intermediate health status and less than 8·0% for those in poor health, based on guideline recommendations.12,14,42 The median HbA1c in the overtreated group was 6·7%, regardless of health status. Moreover, 71% of people in the poor health group met overtreatment criteria. As expected, mortality risk was 59% higher in adults with poor health relative to individuals with intermediate health status. Collectively, these data suggest that a high proportion of older adults might be at risk of overtreatment with hypoglycaemic agents. Overtreatment with glucose-lowering therapies was also associated with a 73% increased risk of mortality relative to appropriate glucose lowering (ie, HbA1c at target), whereas glycaemic undertreatment did not increase mortality risk.42 However, findings from the GERODIAB43 observational cohort in France found that targeting an HbA1c of less than 8·6% was associated with lower mortality, with the authors concluding that lower HbA1c targets might be acceptable in older adults with type 2 diabetes if the target can be achieved without hypoglycaemia.

With this evidence in mind, the 4S Pathway is intended to serve as a complement to existing guidelines for glycaemic management, all of which recommend individualising treatment targets.1215 When individualising glycaemic targets, the first priority in older adults is reducing the risk of hypoglycaemia, followed by decreasing glycaemic excursions, and maximising the amount of time the person spends in their individualised target range (ie, time in range). Finally, frequent or prolonged glucose values of more than 250 mg/dL should be avoided to minimise acute complications of hyperglycaemia, such as dehydration, infections, or cognitive decline. These priorities are the same for people with type 1 and type 2 diabetes and regardless of setting. As discussed, goal setting for older adults should consider glucose monitoring data along with HbA1c, because a higher HbA1c target alone is often not sufficient to reduce the risk of hypoglycaemia.44 For some older adults—particularly those living in long-term care—a more generous glucose target range with an upper target level of 200 mg/dL might be appropriate.45

Step 4—simpler and safer medication regimens

The final step in the 4S Pathway is to realign treatment regimens so they are simpler for older adults and care partners to manage and also reduce harm by decreasing risks for hypoglycaemia, detrimental weight loss or dehydration, or other undesirable adverse effects that undermine the person’s wellbeing. Here, regimens must be tailored to: the person’s type of diabetes; functional status, which is the main predictor of both total and healthy life expectancy; cognition; physical health; and comorbidities. In addition, any new treatment regimen that seeks to maximise benefits and minimise risks must also account for patient self-care capabilities and limitations of the care setting. Most overtreatment research in diabetes focuses on hypoglycaemia and use of hypoglycaemic agents (ie, insulin and sulfonylureas), because susceptibility to hypoglycaemia, and vulnerability to its effects, increases with age. As described earlier, hypoglycaemia increases the risks of cognitive impairment, cardiovascular events, falls, fractures, hospital admissions, and sudden death, and older people are particularly susceptible to hypoglycaemia and vulnerable to its consequences.58 For these reasons, use of insulin and sulfonylureas might become more problematic with increasing age, frailty, and multimorbidity.38,40,4649 However, in many instances (eg, in older adults with type 1or type 2 diabetes who are unable to tolerate), have contraindications, or unwilling to use other classes of glucose-lowering medications, insulin or sulfonylureas might need to be used. In these instances, realigned strategies can be used with help of glucose monitoring patterns to target hyperglycaemia and mitigate hypoglycaemia (figure 3). Overall, personalised treatment is recommended based on medication-specific and person-specific considerations to optimise the benefit–risk ratio,50 integrated with optimal lifestyle strategies such as nutrition and physical activity.45

Figure 3: Stepwise approach to lowering risk of hypoglycaemia based on CGM.

Figure 3:

CGM=continuous glucose monitoring. NPH=neutral protamine Hagedorn.

Older adults with type 2 diabetes

The table in the appendix (pp 3–4) describes key attributes of antihyperglycaemic medication classes, including general mechanisms by which they lower glycemia.11,12,51,52 Although most agents lower both fasting and postprandial (eg, after meal) glycaemia to some extent, some classes have a relatively greater effect on fasting or postprandial glycaemia, respectively. Agents such as metformin, sulfonylureas, thiazolidinediones, and basal insulin improve glycaemia through pronounced reductions in fasting and between-meal glucose levels. In contrast, dipeptidyl peptidase-4 (DPP-4) inhibitors, glinides (short-acting insulin secretagogues), and prandial insulin have relatively robust effects on postprandial glucose excursions. GLP-1 receptor agonists, dual glucose-dependent insulinotropic polypeptide (GIP) and GLP-1 receptor agonists, and sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce both fasting and postprandial glucose. For older people with type 2 diabetes, metformin, GLP-1 receptor agonists, dual GIP and GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors, and thiazolidinediones carry a lower risk of hypoglycaemia compared with sulfonylureas, glinides, and all forms of insulin. Moreover, agents with proven benefits in comorbid conditions (eg, atherosclerotic cardiovascular disease, heart failure, and chronic kidney disease) are preferred as long as adverse effects do not reduce the person’s overall wellbeing.11,53,54 For example, if an older adult taking a GLP-1 receptor agonist to reduce their risk of cardiovascular events begins to lose a harmful amount of weight, it might be better to stop than continue the GLP-1 receptor agonist. SGLT2 inhibitors are now considered standard of care for people with heart failure or chronic kidney disease independent of diabetes, but recurrent genitourinary infections, inability to consume fluids adequately (or dependence on caregivers for feeding and hydration needs), or chronic volume depletion might be serious enough to outweigh the benefits in older adults with these comorbid conditions. Sliding scale insulin regimens, unless used as correction dose regimens, should be avoided.

Older adults with type 1 diabetes

For adults with type 1 diabetes, choosing a basal insulin analogue over neutral protamine Hagedorn and a rapid-acting prandial insulin analogue or inhaled insulin over regular human insulin will reduce the risk of hypoglycaemia.11 Innovations in continuous subcutaneous insulin infusion, especially automated insulin delivery, greatly reduce the risk of hypoglycaemia for people with type 1 diabetes, but access to this technology and the dexterity and cognitive needs to manage it (especially if there is inadequate care partner support) might be a challenge for many older adults with type 1 diabetes.12,26

Older adults with type 1 or type 2 diabetes on complex insulin regimens

Matching medication characteristics to an individual’s glycaemic pattern permits care providers to replace medications that are causing hypoglycaemia or are ineffective in controlling hyperglycaemia with a safer choice. As an example, figure 3 shows selected actions that might be taken in response to hypoglycaemic patterns in older adults using basal-bolus insulin regimens, and the supplemental table 3 (appendix p 5) provides examples of actions that can be helpful for older adults managed on complex insulin regimens experiencing hypoglycaemia. Sliding scale insulin regimens are not recommended due to increased risk for hypoglycaemia.

Applying step 4 of the 4S Pathway to promote simpler and safer treatment

Based on the principles just discussed, figures 4 and 5 detail application of step 4 of the 4S Pathway for older adults with type 2 and type 1 diabetes, respectively.

Figure 4: 4S Pathway step 4 for type 2 diabetes.

Figure 4:

CGM=continuous glucose monitor. DPP-4=dipeptidyl peptidase-4. eGFR=estimated glomerular filtration rate. GIP=glucose-dependent insulinotropic polypeptide; GLP-1=glucagon-like peptide 1. NPH=neutral protamine Hagedorn. SGLT2=sodium-glucose co-transporter-2. *Basal insulin analogues preferred over NPH due to lower risk of hypoglycaemia. †Fasting glucose goal: 90–150 mg/dL, measured over 1 week with fingerstick blood glucose monitor or CGM. ‡Might be prescribed for chronic kidney disease or heart failure independent of type 2 diabetes or eGFR; monitor for adverse events. §Evaluate for gastrointestinal adverse events as possible cause of weight loss. ¶Includes dual GIP and GLP-1 receptor agonists. ||Monitor for oedema and other adverse events. **Selection based on person-specific considerations (table 3).

Figure 5: 4S Pathway step 4 for type 1 diabetes.

Figure 5:

BGM=blood glucose monitoring. CGM=continuous glucose monitor. CV%=coefficient of variation. *Any recurrent hypoglycaemia is detrimental, including level 1 (≤70 mg/dL), level 2 (<54 mg/dL), or level 3 (requiring help from another person).

Applying step 4 in community-dwelling older adults with type 2 diabetes

Stopping or reducing the dose of the antihyperglycaemic agent most likely associated with the trigger identified in Step 1 of the 4S Pathway is the first decision to be made in transitioning to simpler and safer regimens (figure 4). In case hypoglycaemia is part of the problem, medications associated with hypoglycaemia should be stopped or adjusted. Complex insulin regimens for individuals with type 2 diabetes should be simplified to use of basal insulin taken in the morning rather than at bedtime and titrated to a fasting blood glucose of 90–150 mg/dL, as recommended by the American Diabetes Association.45 Prandial insulin might need to be replaced with a non-insulin agent that does not cause hypoglycaemia.12 Likewise, sulfonylureas or glinides should generally be replaced with an antihyperglycaemic agent that does not promote hypoglycaemia. The choice of replacement medication depends first on the patient’s kidney function as measured by estimated glomerular filtration rate (eGFR). Patients with an eGFR of less than 30 mL/min/1·73 m2 should not be given metformin or an SGLT2 inhibitor for glycaemic management. SGLT2 inhibitors might be prescribed for the treatment of chronic kidney disease in people with low eGFR, but the class is not effective for reducing glucose when eGFR is less than 30 mL/min/1·73 m2, and a different agent might be needed for glycaemic management in people with comorbid type 2 diabetes and chronic kidney disease. The next decision should be based on the patient’s appetite and weight. GLP-1 receptor agonists, which reduce weight along with glucose levels, might need to be avoided in older adults with low appetite or individuals at risk from weight loss. DPP-4 inhibitors might be given regardless of kidney function, appetite, or weight status, but some agents within this class require dose adjustment based on eGFR. For older adults with eGFR of at least 30 mL/min/1·73 m2 and who are at risk from weight loss, agents that reduce weight, including GLP-1 receptor agonists and SGLT2 inhibitors, might need to be stopped or avoided. Metformin often has gastrointestinal side-effects that might lead to weight reduction; on this basis the medication might need to be stopped or avoided in people who are experiencing weight loss or those with sarcopenia. DPP-4 inhibitors do not have a risk of weight loss; thiazolidinediones might be considered but carry an increased risk of heart failure and fractures and patients taking it should be monitored for adverse effects such as oedema. For older adults with type 2 diabetes with normal kidney function and who are not at risk from weight loss, the preferred agent might depend on other comorbidities (appendix pp 3–4). In all cases, the final choice of agent should be made through shared decision making between the older adult with diabetes, their care partner(s), and the care provider.

Applying step 4 in community-dwelling older adults with type 1 diabetes

Figure 5 provides some general guidelines for identifying type 1 diabetes-specific treatment distress or challenges and making appropriate adjustments to type 1 diabetes regimen. Avoiding hypoglycaemia is of paramount importance and daily target glucose ranges (but not necessarily HbA1c targets) might need to be adjusted upward (eg, to 5·6–10·0 mmol/L [100–200 mg/dL]) to help prevent hypoglycaemia. Use of alarm-enabled CGM should be offered, if available.

Overarching recommendations for older adults with type 1 and type 2 diabetes

Involving care partners in day-to-day management is important so that partners can step in and help, or if necessary, take over tasks such as insulin administration and lifestyle management. Diabetes education should be reinforced (or provided) to both the older adult and care partner(s), in addition to nutrition education and counselling, and support to adopt and maintain optimal nutrition and physical activity.45 Insulin regimens should be tailored to fit not only the older individual’s medical needs but also the management capabilities of both the individual and their care partner(s).

Considerations for older adults with diabetes living in skilled rehabilitation or long-term care facilities

Overtreatment of diabetes is common in long-term care facilities. For example, in a cohort study among residents in Veterans Affairs nursing homes, 17% of participants met study criteria for overtreatment (HbA1c <6·5% with any insulin use) and an additional 23% met criteria for possible overtreatment (HbA1c <7·5% with any insulin use or <6·5% on any glucose-lowering medication other than metformin alone). When evaluating factors associated with deintensification of the diabetes treatment strategy, severe functional impairment (minimum dataset activities of daily living score ≥19) was associated with decreased odds of continued overtreatment.55 In a study56 involving 32 Swedish nursing home residents with type 2 diabetes, a third of the study population had an HbA1c of 6·0% or less at baseline and were offered medication withdrawal; in this group, completely withdrawing oral antihyperglycaemics and reducing or discontinuing insulin led to a modest increase in mean HbA1c (from 5·2% to 5·8%), and only four patients went back to their previous regimens due to hyperglycaemia. A recent retrospective study57 published in 2022involved 2082 patients aged 65 years or older with diabetes and either limited life expectancy or dementia who were admitted to Veterans Affairs nursing homes with an HbA1c of 7·5% or less. Glucose-lowering therapies were reduced or discontinued in 27% of this population, and this deintensification was not associated with increased risk of 60-day all-cause emergency department visits, hospitalisation, or death.

The appendix (p 6) outlines considerations for people with either type 1 or type 2 diabetes who reside in skilled rehabilitation or long-term care facilities. Avoiding hypoglycaemia is the primary goal in these populations. Hypoglycaemia-reduction strategies outlined in figures 4 and 5 should be applied, with the understanding that data and experience to inform use of SGLT2 inhibitors and GLP-1 receptor agonists in this setting are scarce. Sliding scale insulin (ie, correction or supplemental insulin without basal insulin) should be avoided in all settings; correction dosing with a prandial insulin in addition to basal insulin might be used to optimise glucose values.58 In skilled rehabilitation facilities, the primary goal is to restore the person’s health and wellbeing so that they can return home and resume their normal routines. For these older adults, managing hyperglycaemia is important to facilitate wound healing and prevent diabetes complications. Furthermore, many of these patients might be starting a physical activity or rehabilitation programme that might affect glycaemic management, resulting in the need for different medications and doses. Quality of life considerations take precedence for older adults living in long-term care facilities; in that regard, glucose goals and dietary regimens should be relaxed. For those receiving end of life care, maintaining comfort is the primary goal.

Conclusions

Older adults with diabetes are growing in number. Care providers for older adults must be equipped to respond to the changes that come with ageing, from increasing frailty, cognitive impairment, and comorbidities to transitions in living situations and personal circumstances, all of which might affect glycaemic management. Most algorithms focusing on glucose management in people with diabetes focus on stepwise addition of pharmacological agents to improve glycaemic control. To help care providers determine whether and how to realign diabetes treatment strategies to meet changing needs of older adults with diabetes, we designed the 4S Pathway—a series of four practical algorithms to enable care providers to ensure the optimal therapeutic benefit—risk ratio for each older individual. Although further research is needed to empirically validate these algorithms across broad populations of older adults, this framework offers a set of holistic strategies that can be tailored to individual older adults in their present health status and altered according to their medical, functional, and social circumstances over time.

Supplementary Material

SM

Panel: Examples of signs, symptoms, or factors that might trigger re-evaluation of treatment goals and the treatment strategy in older adults with diabetes.

Medical event

  • Fall, accidental injury, emergency medical services call, emergency department visit, or hospitalisation for any reason

Life-altering event

  • Change in living situation, death of a spouse, loss of care partner, new financial difficulties, change in insurance coverage, or natural disaster

Change in physical, cognitive, or mental health status

  • New or worsening frailty

  • New diagnosis, disability, or comorbidity (eg, renal failure or chronic pancreatic disease)

  • New or progressing cognitive impairment

  • New-onset depression, anxiety, stress, or substance abuse

Medication red flags

Possibly inappropriate prescriptions

  • High numbers of medications, complex regimens

  • Missed prescription refills or confusion over type of insulin, or administration time

Medication adverse effects

  • Symptomatic and asymptomatic hypoglycaemia, unintended weight loss or loss of muscle strength, urinary incontinence or infections, hypotensive episodes, impairment of kidney function, or signs or symptoms of volume depletion

Signs of unrecognised hypoglycaemia

  • Increased confusion, falls, new or worsening cognitive impairment, or lethargy

Signs and symptoms of excessive hyperglycaemia

  • Increase in diabetes symptoms (polyphagia, polydipsia, and polyuria), or signs of repeated infection

Acknowledgments

Amanda M Justice provided medical writing (including assistance in preparation of the initial draft of the manuscript and incorporation of revisions) and editorial support in the preparation of this manuscript, which was funded by the International Geriatric Diabetes Society.

Declaration of interests

MM receives grant funding from the US National Institutes of Health (NIH) and Dexcom; was a consultant and has received scientific advisory board fees from Sanofi and Medtronic; and declares royalties from UpToDate for writing and editing. ARK is supported by the National Institutes on Aging, NIH (grant K01-AG084971-01); and was supported by the National Center for Advancing Translational Sciences, NIH (grant K12TR004416). JJN is supported by NIH research grant (OT2OD032581); and receives compensation from Bayer, Sanofi, Novo Nordisk, Boehringer Ingelheim, Eli Lilly, Proteomics International, and Dexcom outside the submitted work. ASA was supported by the Duke Clinical and Translational Science Institute (award number KL2TR002554). NAA reports receiving consulting fees from Diathrive Health. TC-Y reports grant funding from Medtronic and Novo Nordisk and speaker honoraria from AstraZeneca, Boehringer Ingelheim, Sanofi, Eli Lilly, Medtronic, Geffen Medical, and Novo Nordisk. ESH is supported by grants from the National Institutes of Health (K24AG069080, P30 DK092949, R01 AG063391). SJL reports support to his institution from the National Institute on Aging (K24AG066998), travel reimbursement from the International Geriatric Diabetes Society, and unpaid board membership on the International Geriatric Diabetes Society. KJL receives grant support from NIH, other support from Centers for Medicare and Medicaid Services to develop and evaluate publicly reported quality measures, and royalties from UpToDate to write and edit content. LMM declares grants from the Canadian Institutes of Health Research and funding support from the Ontario Centres for Learning, Research and Innovation in long-term care at Bruyere and Health Canada; consulting fees from United Hospital Fund; speaker fees from Dalhousie University and Medisystem Pharmacy; travel support from the International Geriatric Diabetes Society and European Association of Hospital Pharmacy; unpaid membership on the Executive Committee of the Canadian Medication Appropriateness and Deprescribing Network; and position as Co-Lead of the deprescribing. org Team. NP reports support to her institution from HRSA (U1QHP33074); speaker fees from the Florida Osteopathic Medical Association, travel support from the International Geriatric Diabetes Society, and unpaid board membership on the International Geriatric Diabetes Society. REP has received speaker fees from Eli Lilly, Merck, and Novo Nordisk; consulting fees from AbbVie, Bayer, Bayer HealthCare Pharmaceuticals, Corcept Therapeutics Incorporated, Dexcom, Endogenex, Gasherbrum Bio, Genprex, Getz Pharma, Hanmi Pharmaceutical, Hengrui, Intas Pharmaceuticals, Eli Lilly, Merck, Novo Nordisk, Pfizer, Rivus Pharmaceuticals, Sanofi, and Sun Pharmaceutical Industries; and received grants from Biomea Fusion, Carmot Therapeutics, Dompe, Endogenex, Fractyl, Eli Lilly, Novo Nordisk, and Sanofi (directed to his institution through 12/31/2023 and directed to Dr. Pratley personally as of 1/1/2024). LR-M reports grants from DIABFRAIL-LATAM, Horizon Europe Program funded by the European Union (grant agreement number 825546); speaker fees from Abbott Laboratories, Nestle Health Science, and Sandoz Pharm; and travel support from the International Geriatric Diabetes Society. ET reports consulting fees from Vertex and Sequel. RSW reports clinical trial support to her institution from Tandem, Insulet, Diasome, Eli Lilly, Amgen, and MannKind Corporation; and received DexCom metres at reduced cost for use in some studies. ARK, GSM, AJS, SLS declare no competing interest.

Footnotes

See Online for appendix

Contributor Information

Medha Munshi, Joslin Diabetes Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Anna R Kahkoska, Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Joshua J Neumiller, Department of Pharmacotherapy, College of Pharmacy and Pharmaceutical Sciences, Washington State University, Spokane, WA, USA.

Anastasia-Stefania Alexopoulos, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.

Nancy A Allen, College of Nursing, University of Utah, Salt Lake City, UT, USA.

Tali Cukierman-Yaffe, Division of Endocrinology, Diabetes and Metabolism, Sheba Medical Center, Department of Epidemiology and Preventive Medicine, School of Public Health, Faculty of Medicine, Herczeg Institute on Aging, Tel-Aviv University, Tel Aviv, Israel.

Elbert S Huang, Department of Medicine, The University of Chicago, Chicago, Il, USA.

Sei J Lee, Division of Geriatrics, University of San Francisco, CA, USA.

Kasia J Lipska, Department of Medicine, Yale School of Medicine, New Haven, CT, USA.

Lisa M McCarthy, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada; Institute for Better Health, Trillium Health Partners, Mississauga, Canada.

Graydon S Meneilly, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.

Naushira Pandya, Department of Geriatrics, Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA.

Richard E Pratley, Advent Health Translational Research Institute, Orlando, FL, USA.

Leocadio Rodriguez-Mañas, Servicio de Geriatria, Hospital Universitario de Getafe, Getafe, Spain.

Alan J Sinclair, Foundation for Diabetes Research in Older People, King’s College London, London, UK.

Sarah L Sy, Division of Geriatric Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.

Elena Toschi, Joslin Diabetes Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

Ruth S Weinstock, Department of Medicine, Upstate Medical University, Syracuse, NY, USA.

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