TABLE 4.
Recommendations for A1C Targets in Older People With Type 2 Diabetes
| Guidelines/Position Statement | Patient Characteristics | A1C Goal, % |
|---|---|---|
| American Diabetes Association (11) Society for Post-Acute and Long-Term Care Medicine (27) |
Healthy (few coexisting chronic illnesses, intact cognitive and functional status) | ˂7.5* |
| Complex/intermediate health (multiple coexisting chronic illnesses† or two or more instrumental ADL impairments or mild to moderate cognitive impairment) | ˂8.0* | |
| Very complex/poor health (LTC or end-stage chronic illnesses‡ or moderate-to-severe cognitive impairment or two or more ADL dependencies) | ˂8.5*,§ | |
| American Diabetes Association (23) | Community-dwelling patients at skilled nursing facility for short-term rehabilitation | Avoid relying on A1C because of recent acute illness; follow current glucose trends |
| Patients residing in LTC facility | ˂8.5 | |
| Patients at end of life | No role for A1C | |
| International Diabetes Federation (50) | Functionally independent (no important impairments in ADL; no or minimal caregiver support; may have other medical comorbidities that may influence diabetes care) | 7.0–7.5 |
| Functionally dependent | 7.0–8.0 | |
| Frail/dementia | Up to 8.5 | |
| End of life care | None; avoid symptomatic hyperglycemia and minimize hypoglycemia | |
| Canadian Diabetes Association (2) | Healthy elderly | As for younger patients (˂7.0) |
| Frail elderly | ≤8.5% | |
| Diabetes Care Program of Nova Scotia and the Palliative and Therapeutic Harmonization Program (16) | Frail older adults | Maintain A1C ≥8% rather than below a specific level |
| European Diabetes Working Party for Older People (25) | Healthy (no other major comorbidities) | 7.0–7.5 |
| Frail (dependent; multisystem disease; care home residency, including those with dementia) | 7.6–8.5 |
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. “Multiple” means three or more illnesses, but many patients may have five or more illnesses.
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 = 8.5% equates to an estimated average glucose of 200 mg/dL (11.1 mmol/L). Looser A1C targets ˃8.5% are not recommended because they may expose patients to more frequent higher glucose values and acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.