Optimization of type 2 diabetes care in adults aged 65 or older

Clinical question

What considerations are required and what strategies are available for deintensifying type 2 diabetes mellitus (T2DM) treatment in adults aged 65 years or older, particularly for those with multimorbidity or frailty?

Bottom line

Effective diabetes management, particularly in older and frail adults, requires a nuanced approach that balances the benefits of antihyperglycemic medications with the risks of intensive glycemic control. While certain diabetes medications are important to the prevention of chronic complications of diabetes, intensive glycemic management can increase the risk of hypoglycemia, potentially leading to serious adverse outcomes (eg, falls, seizures, hospitalizations, death). In patients aged 65 or older and those with frailty, a tailored approach to diabetes care is crucial. A patient-centred approach might include individualizing glycemic targets and reducing the intensity of both pharmacologic treatment and routine monitoring to prioritize patient safety and quality of life. Implementing such patient-centred care requires clinicians to thoroughly consider each patient’s overall health, preferences, and social context, thus ensuring that treatment decisions align with the patient’s personal goals of care and life circumstances.

Approach to patients

In managing T2DM in adults aged 65 years or older, a comprehensive approach is essential to account for the complex health needs of patients, including psychological, functional, social, and geriatric aspects. These factors not only influence the risks of side effects and the expected benefits of diabetes treatment but also affect patient capacity for effective self-management.^11,13 We thus suggest a practical approach, including several steps described below and in Figure 1,¹³ that the health care team—which might include physicians, nurses, pharmacists, and long-term care staff—can use in their everyday practices to implement deintensification of treatment for patients with T2DM.

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Figure 1.

Flowchart for deintensification of diabetes care in adults aged 65 years or older

Assess overall health status. The first step is to perform a detailed assessment of the patient’s overall health status. The health care team should categorize the patient’s health status as “good,” “intermediate,” or “poor” by evaluating comorbidities, cognitive function, and functional status. Such an assessment guides the decision-making process, particularly in determining the suitability of deintensification strategies. Patients in “good” health might still benefit from tighter glycemic control, while less stringent goals could be more appropriate for those with limited life expectancy, low cognitive or functional status, a history of hypoglycemia, or a history of multiple comorbidities, as described in Table 1.¹³

Determine deintensification strategies. The next phase involves tailoring the patient’s T2DM treatment plan based on their overall health status. This process may include loosening goals related to blood glucose or HbA_1c levels, carefully reviewing current medications, and considering reduction or deprescribing of medication where appropriate. All these steps are aimed at minimizing the burden of T2DM treatment, with clinicians balancing the benefits of each medication against potential risks.

Determine medication(s) to deprescribe. When a decision is made to deprescribe an antihyperglycemic medication, priority should be given to those that can cause hypoglycemia (ie, sulfonylurea and insulin). When considering alternatives it is important to understand the benefits and limitations of each option. Switching to medications with lower-risk profiles, such as metformin or dipeptidyl peptidase 4 inhibitors, may be considered. Even if they have not shown a direct cardiovascular benefit, dipeptidyl peptidase 4 inhibitors can help reduce hyperglycemia without provoking hypoglycemia.¹⁴

Monitor patient post-deintensification. Acknowledging that patients are unlikely to develop symptomatic hyperglycemia following moderate deprescribing, we recommend a cautious approach that involves monitoring blood glucose or HbA_1c levels during the weeks and months following deintensification. It is essential to engage in comprehensive discussions that might involve, in addition to the patient and their health care team, the patient’s informal caregivers and relatives, respecting the patient’s wishes and mental capacity. For patients receiving end-of-life care, intensifying the standard monitoring frequency for T2DM is generally not advised. By doing this, we can reduce the necessity of frequent routine monitoring and align with the objective of minimizing the overall burden of care. Additionally, for patients not taking sulfonylureas or insulin, reducing or even discontinuing home blood glucose monitoring is recommended because there is no risk of hypoglycemia.¹⁵ Furthermore, too much monitoring can lead to increased costs and patient discomfort.¹⁶ However, it remains important to continue monitoring in cases where HbA_1c measurements may be misleading, such as in patients with increased erythrocyte turnover disorders.¹⁷

Reduce diabetes-specific assessments. Finally, for patients receiving end-of-life care or with severe frailty or dementia, discontinuation of nonessential T2DM-specific assessments is emphasized.¹⁸ Assessments such as those for peripheral artery disease or chronic kidney disease should be discontinued to prioritize the patient’s comfort and quality of life.