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TABLE 13.1

Framework for Considering Treatment Goals for Glycemia, BP, and Dyslipidemia in Older Adults With Diabetes

Patient Characteristics/Health StatusRationaleReasonable A1C GoalFasting or Preprandial GlucoseBedtime GlucoseBPLipids
Healthy (few coexisting chronic illnesses, intact cognitive and functional status) Longer remaining life expectancy <7.0–7.5% (53–58 mmol/mol) 80–130 mg/dL (4.4–7.2 mmol/L) 80–180 mg/dL (4.4–10.0 mmol/L) <130/80 mmHg Statin, unless contraindicated or not tolerated 
Complex/intermediate (multiple coexisting chronic illnesses* or two or more 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) 90–150 mg/dL (5.0–8.3 mmol/L) 100–180 mg/dL (5.6–10.0 mmol/L) <130/80 mmHg Statin, unless contraindicated or not tolerated 
Very complex/poor health (LTC or end-stage chronic illnesses** or moderate-to-severe cognitive impairment or two or more ADL impairments) Limited remaining life expectancy makes benefit uncertain Avoid reliance on A1C; glucose control decisions should be based on avoiding hypoglycemia and symptomatic hyperglycemia 100–180 mg/dL (5.6–10.0 mmol/L) 110–200 mg/dL (6.1–11.1 mmol/L) <140/90 mmHg Consider likelihood of benefit with statin 
Patient Characteristics/Health StatusRationaleReasonable A1C GoalFasting or Preprandial GlucoseBedtime GlucoseBPLipids
Healthy (few coexisting chronic illnesses, intact cognitive and functional status) Longer remaining life expectancy <7.0–7.5% (53–58 mmol/mol) 80–130 mg/dL (4.4–7.2 mmol/L) 80–180 mg/dL (4.4–10.0 mmol/L) <130/80 mmHg Statin, unless contraindicated or not tolerated 
Complex/intermediate (multiple coexisting chronic illnesses* or two or more 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) 90–150 mg/dL (5.0–8.3 mmol/L) 100–180 mg/dL (5.6–10.0 mmol/L) <130/80 mmHg Statin, unless contraindicated or not tolerated 
Very complex/poor health (LTC or end-stage chronic illnesses** or moderate-to-severe cognitive impairment or two or more ADL impairments) Limited remaining life expectancy makes benefit uncertain Avoid reliance on A1C; glucose control decisions should be based on avoiding hypoglycemia and symptomatic hyperglycemia 100–180 mg/dL (5.6–10.0 mmol/L) 110–200 mg/dL (6.1–11.1 mmol/L) <140/90 mmHg Consider likelihood of benefit with statin 

This table represents a consensus framework for considering treatment goals for glycemia, BP, 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.

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, HF, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, MI, and stroke. “Multiple” means at least three, but many patients may have five or more.

**

The presence of a single end-stage chronic illness, such as stage 3–4 HF or oxygen-dependent lung disease, CKD requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy. ADL, activities of daily living. Adapted from Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes Care 2012;35:2650–2664.

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