What are the main challenges in the glycemic management of older adults?

Abstract

A1C targets for older adults should be individualized, primarily based on the patient's overall health status, the presence of coexisting chronic conditions, and cognitive and functional capacity. The goal is to balance the long-term benefits of glycemic control with the immediate risks, particularly hypoglycemia¹.

According to the 2026 Standards of Care, recommendations are categorized as follows:

• Healthy older adults: For those with few coexisting chronic conditions and intact cognitive and functional status, an A1C target of <7.0% to 7.5% is recommended. These individuals generally have a longer life expectancy and are able to safely perform complex self-management tasks.
• Older adults with complex or intermediate health: For patients with multiple coexisting chronic conditions, mild-to-moderate cognitive impairment, or two or more impairments in activities of daily living, less stringent glycemic targets are recommended, with an A1C <8.0%. In this group, avoiding hypoglycemia is a priority, as comorbidities may compromise the patient's ability to recognize and manage hypoglycemic events.
• Older adults with very complex or poor health: For patients residing in long-term care facilities, those with end-stage chronic illnesses, or those with moderate-to-severe cognitive impairment, reliance on A1C should be avoided. Instead, glycemic management should focus exclusively on preventing hypoglycemia and symptomatic hyperglycemia. These patients are expected to derive minimal benefit from intensive glycemic control, while the risk of treatment-related harm is substantially greater¹.

Early implementation of diabetes technology, such as continuous glucose monitoring (CGM), is also recommended for individuals with both type 1 and insulin-treated type 2 diabetes.

Pharmacologic Treatment and Comorbidities

In adults with type 2 diabetes who have cardiovascular or renal risk, treatment should include agents with proven cardiovascular and/or kidney benefits, such as SGLT2 inhibitors and GLP-1 receptor agonists, regardless of baseline A1C. In addition, obesity is recognized as a primary therapeutic target, with medications such as tirzepatide and semaglutide recommended for weight management².