The Shift Towards Individualised Care
For many years, the standard approach to managing type 2 diabetes involved aiming for a single, low HbA1c target for all adults. However, extensive research and clinical experience have shown that in older adults, particularly those who are frail, this can be counterproductive. Intense treatment to achieve very low HbA1c levels significantly increases the risk of hypoglycemia (dangerously low blood sugar), falls, and hospital admissions, with limited long-term benefit. As a result, NICE and other major diabetes organisations now recommend a person-centred approach, setting different HbA1c goals based on an individual's overall health and circumstances.
Categorising Health and Setting Appropriate Targets
The individualized approach to setting HbA1c targets for older adults typically categorises patients based on their overall health status. This provides a framework for clinicians to make informed decisions that balance the risks and benefits of therapy. The primary health categories considered are:
Healthy Older Adults
For older adults who are otherwise healthy, with a few stable comorbidities and intact cognitive and functional status, a tighter glycaemic control is generally appropriate. This group has a longer life expectancy and can therefore benefit from the long-term reduction in microvascular and macrovascular complications that good glycaemic control provides. The recommended HbA1c target for this group is often similar to that for younger adults, around 7.0–7.5% (53–58 mmol/mol), as long as it can be achieved safely.
Complex or Intermediate Health
This group includes older adults with multiple coexisting chronic illnesses, mild to moderate cognitive impairment, or two or more instrumental limitations in their daily activities. In these cases, the risk of hypoglycemia and the burden of intensive treatment start to outweigh the potential long-term benefits of tight control. For this reason, NICE, in line with ADA and other guidelines, suggests a less stringent HbA1c target, typically around <8.0% (<64 mmol/mol). The focus here shifts from aggressive long-term prevention to managing the current health state and preventing immediate complications from poor glucose control, such as infections or symptomatic hyperglycemia.
Very Complex or Poor Health (Frail)
At the other end of the spectrum are older adults with advanced illness, severe frailty, limited life expectancy, or significant cognitive or functional disability. For these individuals, aiming for a specific HbA1c target provides minimal benefit and poses significant risks. The priority is to avoid symptomatic hyperglycemia (which can cause discomfort, dehydration, and infections) and, most importantly, prevent hypoglycemia. The guidelines recommend avoiding strict reliance on HbA1c targets altogether, with decisions based on maintaining comfort and quality of life. Medication should be de-escalated or simplified to reduce treatment burden and the risk of adverse events.
A Framework for Individualised Glycaemic Targets
Implementing individualized care involves considering a range of factors beyond HbA1c levels. A comprehensive assessment is key to determining the most appropriate and safest therapeutic goals. Key factors include:
- Life Expectancy: The potential long-term benefits of tight glycaemic control may not be relevant for someone with a limited life expectancy due to advanced illness.
- Risk of Hypoglycemia: Certain diabetes medications, like insulin and sulfonylureas, carry a higher risk of causing low blood sugar. This risk must be carefully balanced against the potential benefits, especially as older adults may not experience the typical warning signs of hypoglycemia.
- Comorbidities: The presence of other health conditions, such as kidney disease or heart failure, can impact both diabetes management and overall prognosis.
- Cognitive Function: Cognitive impairment can affect a person's ability to manage a complex medication regimen and recognise symptoms of hypoglycemia.
- Functional Status: A person's independence in daily activities is a major determinant of their ability to manage their diabetes and cope with any side effects of treatment.
- Treatment Burden: The number of medications and complexity of the diabetes regimen can be overwhelming, impacting quality of life and adherence.
Comparison of Glycaemic Targets by Health Status
| Health Status Category | HbA1c Target | Priority Focus |
|---|---|---|
| Healthy Older Adults | <7.0–7.5% (<53–58 mmol/mol) | Long-term prevention of complications. |
| Complex/Intermediate Health | <8.0% (<64 mmol/mol) | Balancing risk and benefit; minimizing hypoglycemia. |
| Very Complex/Poor Health | Avoid reliance on A1c | Avoidance of hypoglycemia and symptomatic hyperglycemia. |
Steps in Adopting an Individualised Approach
- Assess Overall Health: Perform a comprehensive geriatric assessment to determine frailty, comorbidities, cognitive function, and functional status.
- Establish Goals: Involve the patient and their caregivers in setting realistic and achievable glycaemic goals that align with their overall health and life priorities.
- Adjust Treatment: Tailor the treatment plan, including medication and lifestyle recommendations, to support the agreed-upon goals while minimising risks.
- Monitor Regularly: Continuously monitor the patient's HbA1c, blood glucose, and overall well-being. Adjust targets and treatment as health status changes over time.
- Educate Patients and Caregivers: Provide clear information about symptoms of hypoglycemia and hyperglycemia, and what to do if they occur.
Conclusion: More than Just a Number
The NICE guidelines for HbA1c in the elderly reflect a modern, patient-centered approach to diabetes care. It's not about achieving a specific number at all costs, but rather about promoting health, maintaining independence, and ensuring quality of life for older adults. By individualizing glycaemic targets based on health status, clinicians can protect vulnerable patients from the risks of overly aggressive treatment while still managing their diabetes effectively. Understanding this nuanced approach is crucial for both healthcare professionals and families caring for older adults with diabetes. For more details on these and other diabetes management strategies, you can refer to authoritative sources like the American Diabetes Association.
Important Considerations for Clinical Practice
- Glycemic Legacy Effect: Recognize that the benefits of tight control can take years to manifest, making it less relevant for those with limited life expectancy.
- Medication De-intensification: Actively simplify and reduce medications for older, frail patients to decrease treatment burden and reduce side effects.
- Hypoglycemia Risk: Be particularly vigilant about the risk of hypoglycemia in older adults, as its consequences can be severe.
- Beyond HbA1c: Focus on avoiding symptomatic hyperglycemia and hypoglycemia, especially in the very frail, rather than just hitting a number.
