Table 1. A Framework for Considering Treatment Goals for Glycemia, Blood Pressure, and Dyslipidemia in Older Adults with Diabetes.
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/caregiver preferences is an important aspect of treatment individualization. Additionally, a patient’s health status and preferences may change over time.
| Patient Characteristics/ Health Status |
Rationale | Reasonable A1C Goal (A lower goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden) |
Fasting or Preprandial glucose (mg/dl) |
Bed- time glucose (mg/dl) |
Blood Pressure (mm Hg) |
Lipids |
|---|---|---|---|---|---|---|
| Healthy (Few co-existing chronic illnesses, intact cognitive and functional status) |
Longer remaining life expectancy | <7.5% | 90–130 | 90–150 | < 140/80 | Statin unless contraindicated or not tolerated |
| Complex/Intermediate (Multiple co-existing chronic illnesses* or 2+ instrumental ADL impairments or mildmoderate cognitive impairment) |
Intermediate remaining life expectancy, high treatment burden, hypoglycemia vulnerability, fall risk | <8.0% | 90–150 | 100–180 | <140/80 | Statin unless contraindicated or not tolerated |
| Very Complex/Poor Health (Long-term care or end-stage chronic illnesses** or moderate-severe cognitive impairment or 2+ ADL dependencies) |
Limited remaining life expectancy makes benefit uncertain. | <8.5%† | 100–180 | 110–200 | < 150/90 | Consider likelihood of benefit with statin (secondary prevention> primary) |
Co-existing 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 (136).
The presence of a single end-stage chronic illness such as stage III–IV 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% equates to an estimated average glucose of ~200 mg/dl. Looser glycemic targets than this may expose patients to acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor would healing.