Patient-Centered Care of Older Adults With Diabetes

In 2016, approximately 9.5% of US adults had diabetes, representing 23 million adults.¹ Type 2 diabetes (T2D) accounted for more than 90% of cases.¹ Moreover, the prevalence of T2D increased to almost 20% for adults aged 65 years or older; this geriatric population is at increased risk of functional decline, frailty, malnutrition, and various other clinical comorbidities.

Currently, there is not a universally accepted glycemic goal and/or treatment standards for older adults with TD2. The purpose of this article is to discuss various factors to consider when prescribing TD2 medications in the geriatric population, with emphasis on the importance for providing patient-centered care to promote positive clinical outcomes and improved quality of care.

Frailty and Malnutrition

Frailty and malnutrition are important factors to consider in diabetes management in the older adult. Frailty is characterized by age-associated decline in physiologic reserve and function across all organ systems,² and it is commonly measured using the frailty index or, alternatively, the frailty phenotype.³ Similarly to TD2, the prevalence of frailty is known to increase with age. Using the frailty phenotype, the prevalence of frailty in older adults has been reported to be 7%, with a 4-year incidence rate of 7.2%.² Adults who met criteria for frailty with the frailty phenotype were 6 times more likely to die in a 3-year follow-up period.² Additionally, malnutrition is associated with increased frailty due to poor oral intake, involuntary weight loss, and advanced disease, and it is often underdiagnosed in older adults living in long-term care (LTC) facilities.⁴ Of further note, malnutrition rates are highest in hospitalized (35%-65%) and institutionalized (25%-60%) patients compared with ambulatory outpatients (15%).⁵

Hypoglycemia

The primary goal when prescribing diabetes treatment is to avoid hypoglycemia. In a retrospective cohort study,⁶ admissions to a hospital’s general ward were examined to determine the associations between frequency and severity of inpatient mortality, length of stay, and incidence of mortality 1 year following discharge. This study concluded that hypoglycemia is common in hospitalized diabetic patients, and that those who experienced hypoglycemia had an increased length of stay by 2.5 days, an 85.3% increase in inpatient death, and a 65.8% chance of death 1 year from discharge for each day with hypoglycemia.⁶ One major limitation of this study was that it examined a mixed population that was not limited to older adults. However, the conclusions of this study should still be considered significant based on the increased fragility and comorbidities of older adults. If the study had excluded patients younger than 65 years, a similar or even greater significance likely would have been seen.

In a cross-sectional study,⁷ older adults (mean age, 70.0 ± 17.3 years) admitted to an internal medicine unit were screened for malnutrition and hypoglycemia. The researchers found that a greater proportion of patients with at least 1 episode of hypoglycemia were at increased risk for malnutrition compared with patients without documented hypoglycemic events.⁷ Additionally, patients who experienced hypoglycemia had a higher score on a nutrition risk screening tool (NRS2002) for prehospitalization unintentional weight loss and reduced food consumed.⁷ The study concluded that malnutrition risk almost doubled the risk of hypoglycemia during hospitalization. Among the limitations for this study were that all adult admissions to the internal medicine unit were included regardless of having a diagnosis of diabetes, and the setting prior to admission (home, assisted-living facility, LTC facility) was not considered.

Establishing Hemoglobin A_1c Goals

There is growing concern that target glycosylated hemoglobin (A_1c) levels are too stringent for older adults, based on an increased risk of hypoglycemia, which in turn may result in traumatic fall with injury. The American Geriatrics Society (AGS) recommends an A_1c goal of 7.5% to 8.0% in older adults with moderate comorbidities and a life expectancy less than 10 years.⁸ The American Diabetes Association (ADA), on the other hand, recommends a more relaxed A_1c goal of 8.0% to 8.5% for patients with more complex medical issues.⁹ Wilcox and colleagues¹⁰ have reviewed these recommendations in correlation with outcomes from the VADT (Veterans Affairs Diabetes Trial), ADVANCE (Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation), and ACCORD (Action to Control Cardiovascular Risk in Diabetes) study and found that lower A_1c targets did not reduce the risk of macrovascular complications, and that strict glycemic control increased the risk of cardiovascular events in patients who had experienced hypoglycemic events. The American College of Physicians (ACP) reevaluated glycemic goals for patients with TD2 to provide treatment guidelines for specific populations.¹¹ To do so, the ACP examined the landmark trials ACCORD, ADVANCE, UKPDS (United Kingdom Prospective Diabetes Study), and VADT and synthesized recommendations from the ADA, the American Association of Clinical Endocrinologists (AACE), and the National Institute for Health and Care Excellence (NICE).¹¹

The ACCORD trial,¹² a randomized controlled trial (RCT) of adults (mean age, 62 years), compared target A_1c levels of less than 6.0% with levels of 7.0% to 7.9%. The study found that intensive therapy led to small reductions in the onset of albuminuria but did not improve other clinical comorbidities such as kidney failure, neuropathy, and visual impairment. The trial was terminated early due to increased all-cause mortality, cardiovascular disease–related mortality, and hypoglycemic events.¹² The ADVANCE trial¹³ looked at A_1c goals of 6.5% or less compared with standard treatment. A_1c was levels were followed up for 5 years and found statistically significant reductions in microalbuminuria. Point estimates trended towards reduced macrovascular, cardiovascular related and all-cause mortality, however results were not statistically significant, and hypoglycemic events were increased in the intensive therapy group.¹³ The UKPDS trial14 enrolled participants with mean age of 54 who were newly diagnosed with TD2. After 10 years, the intensive control group showed a reduction in retinal finding and had nonsignificant trends toward decreased risk of macrovascular end points.¹⁴ The VADT trial¹⁵ compared patients with a mean age of 60 years with median achieved A_1c levels of 6.9% vs 8.4%. The intensive treatment group had fewer cardiovascular disease–related events, including MI and congestive heart failure (CHF), but had an increased risk of hypoglycemia.¹⁵

An important caveat about these trials is that they focused on sulfonylureas rather than newer medications such as dipeptidyl peptidase-4 (DPP-4) inhibitors, thiazolidinediones (TZDs), injectable glucagon-like peptide‐1 receptor agonists (GLP-1RAs), and sodium‐glucose cotransporter-2 (SGLT-2) inhibitors, which typically do not trigger hypoglycemic events.¹¹

To conclude, the ACP recommends A_1c goals to be individualized based on patient comorbidities and life expectancy, setting a standard goal of 7% to 8%. Older adults with a longer life expectancy (>15 y) may elect for a more stringent goal of below 6.5%. Additionally, those with a limited life expectancy of less than 10 years (80 years of age or older), or those who have significant comorbidities (dementia, kidney failure, cancer, nursing home resident, advanced COPD)¹¹ should focus on avoiding symptoms related to hyperglycemia and hypoglycemia rather than a specific A_1c goal. Assessment tools such as ePrognosis (https://eprognosis.ucsf.edu/) can be used to assist in estimating life expectancy to determine appropriate A_1c goals.

Kalra and Sharma¹⁶ summarized recommendations from the ADA and AGS regarding treatment of TD2 in older adults. Based on these recommendations, as well as recommendations from the ACP and results from National Health and Nutrition Examination Survey (NHANES) data on overtreatment of TD2 in the elderly, the guidelines in Table 1 are proposed.^11,16,17

Beers Criteria

The AGS has published the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults,¹⁸ which are guidelines for health care professionals to use to optimize medication selection, reduce polypharmacy, eliminate unnecessary medications, and control costs. The guidelines were developed by a multidisciplinary panel of geriatric experts and apply to adults aged 65 years or older in all settings, including ambulatory care, acute care, and institutionalized settings with the exception of hospice and palliative care. The AGS panel reviews and updates the criteria every 3 years. In 2019, glimepiride was added to the list of sulfonylureas with a higher risk of prolonged hypoglycemia in older adults.¹⁸ The Beers Criteria list also includes chlorpropamide, which has been found to have a prolonged half-life in older adults, thereby causing prolonged hypoglycemia.¹⁹

Antihyperglycemic Medications

It is well accepted that metformin is the first-line treatment when initiating pharmacologic therapy for patients with diabetes. Given the desirable adverse-effect profile of GLP-1RAs and DPP-4 inhibitors, the ADA currently recommends adding either a GLP-1RA and DPP-4 inhibitor to metformin if glycemic goals are not met, followed by insulin.²⁰ GLP-1RAs and DPP-4 inhibitors are currently expensive; if cost is prohibitive, older agents such as pioglitazone or glipizide can be added to metformin, followed by insulin.²⁰ Table 2 summarizes diabetes medications in older adults.

Biguanides

Biguanides work by decreasing glucose absorption and hepatic glucose production. Data are limited on the use of biguanides in older adults, but Masoudi and colleagues²¹ found that the biguanide metformin is associated with a significantly lower risk of death from all causes in this population. The retrospective cohort study concluded that metformin is contraindicated in patients with CHF because it increases the risk of potentially fatal lactic acidosis. Metformin should also be used with caution in patients with decreased kidney function, dehydration, and/or chronic disease with tissue hypoxia.²² Notable side effects include vitamin B₁₂ deficiency,²² adverse gastrointestinal tract effects, and weight loss.

GLP-1RAs

GLP-1RAs have shown to have benefits in postprandial hyperglycemia and hypertension. The LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) trial²³ demonstrated that the GLP-1RA liraglutide was associated with lower rates of nephropathy and death from cardiovascular causes. In this trial, individuals on liraglutide had an average 2.3-kg weight loss, 1.2-mm Hg decrease in systolic blood pressure, 0.6-mm Hg increase in diastolic blood pressure, and a 3.0-beats/min increase in heart rate. Limitations of using liraglutide in the geriatric population include increased risk of weight loss, the need for subcutaneous injection, and a higher rate of gallstone disease.²³ The SUSTAIN-6 (Trial to Evaluate Cardiovascular and Other Long-term Outcomes With Semaglutide in Subjects With Type 2 Diabetes) trial²⁴ also supported the cardiovascular benefits of the GLP-1RA semaglutide, as well as the reduced incidence of nonfatal stroke. The most common adverse effect of semaglutide in the trial was nausea.²⁴

DPP-4 Inhibitors

DPP-4 inhibitors decrease the inactivation and degradation of GLP-1. They are effective for fasting and postprandial hyperglycemia management and are known to be well-tolerated in older adults. They are recommended as a second agent to metformin for patients whose glucose level is not well-controlled on metformin alone.²⁵ DPP-4 inhibitors also have been shown to protect against worsening cognitive function in older adults.²⁶ Kim and colleagues²⁷ concluded that the risk of all-cause dementia was lower in the DPP-4 inhibitor group compared with the sulfonylurea group, and that DPP-4 inhibitors were associated with a significantly lower risk of Alzheimer disease.²⁷ Notable drawbacks of DPP-4 inhibitors include the need for subcutaneous administration and their relatively high cost.

Sulfonylureas

Sulfonylureas are oral hypoglycemic drugs that function by increasing insulin release from β cells in the pancreas. The risk of hypoglycemia may be worse with longer-acting sulfonylureas such as glyburide,²⁸ as well as when a sulfonylurea is combined with another agent. The DUAL IV (Dual Action of Liraglutide and Insulin Degludec)²⁹ RCT investigated the safety and efficacy of adding combination insulin degludec and liraglutide for patients on a sulfonylurea at baseline (with or without metformin). The study found that patients who added the degludec/liraglutide combination to their regimen had triple the risk of hypoglycemia (42% vs 17%).²⁹ Sulfonylureas should be used with caution in older adults at risk for malnutrition, renal insufficiency, and decreased liver function.

Meglitinides

Meglitinides stimulate insulin release but are more rapid acting than sulfonylureas. Wu and colleagues³⁰ reviewed a panel of 2793 patients in Taiwan with TD2 and advanced chronic kidney disease (CKD) who had recently been started on a meglitinide. The review concluded that compared with the control group, starting meglitinide was associated with an increased risk of hypoglycemia and increased mortality, especially when combined with insulin.³⁰ On the contrary, meglitinides and α-glucosidase inhibitors have demonstrated low hypoglycemic risk in older adults when calorie intake is sufficient.³¹ When comparing meglitinides and sulfonylureas, meglitinides are less effective in lowering blood glucose but have a lower risk of hypoglycemia and a greater effect on controlling postprandial hyperglycemia.³² Limitations of meglitinides include decreased liver function, malnutrition, and an increased risk of hypoglycemia with advanced CKD.³⁰

TZDs

TZDs improve insulin sensitivity by decreasing fasting and postprandial glucose, without evidence of hypoglycemia. They also have been found to reduce triglyceride levels and improve high-density lipoprotein levels.²² According to Masoudi and colleagues,²¹ TZDs and metformin were found to have a significantly lower risk of all-cause mortality, whereas sulfonylureas and insulin showed no significant mortality benefit. TZDs, however, were associated with a higher rate of readmission for CHF.²¹ Lu and colleagues,³³ in a study including 51,415 adults aged 65 years or older with TD2, found that the use of a TZD (pioglitazone more so than rosiglitazone) when used with metformin had a protective effect on the development of dementia (vascular and Alzheimer-related) compared with the use of metformin and a sulfonylurea. ADOPT (A Diabetes Outcome Progression Trial)³⁴ supported this association when rosiglitazone was used but revealed that rosiglitazone was associated with a higher risk of myocardial ischemic events compared with placebo, metformin, and sulfonylureas. Limitations of TZDs include an increased risk of CHF and increased risk of fracture.^22,34,35

SGLT-2 Inhibitors

SGLT-2 inhibitors function by preventing glucose absorption in the kidneys. One RCT showed that patients taking teneligliptin and canagliflozin were more likely to achieve an A_1c level below 8.0%, as well as an A_1c level below 7.0%, compared with patients in the control group.³⁶ Hypoglycemic events were not observed, highlighting the attractiveness of the use of these medications for older adults.³⁶

Additionally, several trials have identified cardiovascular mortality reductions with SGLT-2 inhibitors. The largest trial, EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients),³⁷ randomly assigned patients to 10 mg or 25 mg of empagliflozin or placebo once daily. The study examined 7020 patients with TD2 and cardiovascular complications and found that patients treated with either dose of empagliflozin had a 14% reduction in 3-point major adverse cardiovascular events (nonfatal MI, nonfatal stroke, or cardiovascular death) and a 35% reduction in hospitalization for CHF complications.³⁸ The study also found a 39% reduction in composite kidney end points.³⁸ Similar trends were found in CANVAS (Canagliflozin Cardiovascular Assessment Study),³⁹ which looked at 10,142 patients who were randomly assigned to 100 mg or 300 mg of canagliflozin or placebo. Januzzi and colleagues⁴⁰ conducted a 2-year randomized double-blind placebo-controlled trial of 666 older adults with TD2 (baseline A_1c, 7%-10%) and found that the addition of canagliflozin to existing diabetes medication regimens resulted in a 27% relative decrease in high-sensitivity troponin I and N-terminal pro–B-type natriuretic peptide levels for the canagliflozin group.

Insulin

Insulin therapy is very effective in treating patients with diabetes; however, it is associated with an increased risk of hypoglycemia and weight gain. Based on the Beers Criteria, sliding-scale insulin should be avoided in the absence of basal or long-acting insulin, since it does not improve the management of hyperglycemia.¹⁸ Jovanovič and colleagues⁴¹ compared glycemic control with twice-daily insulin lispro mix 75/25 (LM75/25) with once-daily insulin glargine in older adults with TD2. The study concluded that reduction in A_1c from baseline was greater when using the LM75/25 compared with glargine and was more effective in maintaining this A_1c reduction for a longer period. Postprandial glucose was noted to be lower with LM75/25 with no significant difference in frequency of hypoglycemia. However, LM75/25 requires a higher dosage and is associated with a greater weight gain compared with insulin glargine.⁴¹

A regimen with the least variability in plasma glucose may protect against hypoglycemic and hyperglycemic events.^21,42 Heller and colleagues⁴³ conducted an RCT comparing insulin or sulfonylureas with metformin and other non–insulin-secreting oral antihyperglycemic medications such as GLP-1RAs. Outcomes showed that all regimens were equally efficacious, but the group on insulin and sulfonylureas were more likely to experience a hypoglycemic event.⁴³ These results were highlighted in a meta-analysis of 6 studies involving 14,685 older adults with diabetes, noting that individuals were 64% more likely to experience a fall, and the group with the highest risk for fall were those who had been prescribed insulin.⁴⁴

The capability and capacity of a patient to effectively self-administer insulin should be considered when prescribing insulin therapy to older adults, carefully considering cognition, dexterity, vision, and other factors.

Table 3 summarizes the key recommendations for antihyperglycemic treatment in older adults presented above.

Dose Adjustments for CKD

Hahr and Molitch⁴⁵ examined diabetic treatment in patients with CKD, highlighting medications that are considered safe for use in patients with impaired kidney function. Metformin and glipizide can be used until the glomerular filtration rate (GFR) is less than 30 mL/min/1.73 m². If the GFR is between 30 and 44 mL/min/1.73 m², metformin should not be added as a new medication and/or the dose should not exceed 1000 mg/d. Glipizide can be used without a dose adjustment until GFR is less than 30 mL/min/1.73 m², while longer-acting sulfonylureas such as glyburide should be avoided. TZDs and DPP-4 inhibitors can safely be used without dose adjustment even when GFR is less than 30 mL/min/1.73 m². GLP-1RAs should be used with caution in patients with reduced kidney function, since long-term safety and efficacy are unknown.⁴⁵

Treatment in LTC Facilities

The ADA suggests that diabetes management in LTC facilities requires an interdisciplinary team and a patient-centered approach.⁹ In LTC, simplified treatment regimens and the elimination of sliding-scale insulin as sole treatment are recommended, since the risks of overtreating diabetes outweigh the benefits.⁴⁶ Pharmacists have stressed the importance of shifting from sliding-scale insulin to a scheduled regimen.⁴⁶

In addition to medication management, emphasis is placed on diet. The ADA recognizes liberal diet plans to be associated with improved food and beverage intake, reducing the risk of dehydration and unintentional weight loss, as opposed to a diabetic diet.⁹ The use of small frequent feedings is recommended to optimize total daily nutrient consumption and to prevent medication-induced hypoglycemia. It is also good practice to incorporate adequate fibrous foods to avoid postprandial glucose spikes, which may lead to overtreatment when using sliding-scale insulin. Clinicians should also implement routine evening snacks for older adults who are known to skip meals or to have frequent episodes of morning hypoglycemia.

Artificial Nutrition

Older adults with TD2 who are dependent on artificial nutrition represent a unique challenge, because they are often cognitively and/or physically impaired, increasing the risk of malnutrition and pressure injuries. Enteral nutrition (EN) is preferred over total parenteral nutrition (TPN) because EN decreases infection risks, requires less monitoring, allows patients to maintain function of their gastric mucosa, and has lower costs. Despite its benefits, EN does have complications. In a study of 30 older adults receiving EN, there was a high rate of gastrointestinal tract complications (up to 63%), an average weight loss of more than 2 kg, and inadequate recommended water intake.⁴⁷

A study of 1004 hospitalized patients who received EN examined the predictors of mortality.⁴⁸ This group included patients with and without diabetes, as well as patients without diabetes who were hyperglycemic in the hospital. Nondiabetics with normal glucose levels were on average younger, had a higher albumin level, and were less likely to be admitted to the intensive-care unit (ICU). The strongest predictor of mortality in both univariate and multivariate analysis was a low albumin level, followed by newly diagnosed hyperglycemia.⁴⁸

Diabetes-Specific Enteral Formula

As of 2018, the American Society for Parenteral and Enteral Nutrition had not made a recommendation for the specific type of enteral formula to be used for patients with diabetes.⁴⁹ Current diabetes-specific formulas contain an increased percentage of monounsaturated fats, low-glycemic carbohydrates, and fiber to help minimize blood glucose response. The prevalence of older adults with diabetes who receive EN may be as high as 50%. For that reason, diabetes-specific formula should strongly be considered for improving overall clinical outcomes.

A retrospective study evaluating patients receiving EN showed that use of a diabetes-specific enteral formula reduced mortality by more than 50%.⁵⁰ In this case, the diabetes-specific formula included a slowly digestible carbohydrate and higher proportion of monounsaturated fatty acids. However, the study lacked information on glucose or A_1c levels over time.⁵⁰

Furthermore, diabetes-specific formulas may reduce complications from respiratory infections when given to mechanically ventilated ICU patients, although data on morbidity and mortality are lacking.⁵¹ Diabetes-specific enteral formula may also reduce hospital admissions and lower overall health care costs.⁵¹

Mesejo and colleagues⁵² conducted a double-blind RCT of 157 mechanically ventilated patients with T2D in an ICU who received EN. The patients on diabetes-specific formula had statistically significantly reduced capillary glucose on ICU day 1, glycemic variability, and incidences of ventilator-associated tracheobronchitis or pneumonia compared with patients on the standard formula.⁵²

An RCT by Lansink and colleagues,⁵³ as well as a small study conducted by Alish and colleagues,⁵⁴ found that diabetes-specific formula had superior glycemic control compared with standard formulas. Furthermore, Vaisman and colleagues⁵⁵ enrolled 25 patients in a double-blind RCT and found better glycemic control among a soy protein–based diabetes-specific enteral formula.

In a trial of 74 hospitalized patients who required EN during their stay,⁵⁶ patients were either assigned to the default admitting physician or to specialized diabetes admitting physician and team. The patients managed by the specialized diabetes admitting team had lower rates of in-hospital mortality and hyperglycemia, whereas the occurrence of hypoglycemia was similar among the two groups. Study limitations included a lack of blinding and a resulting selection bias for assigning patients to the admitting team.⁵⁶

Insulin Regimen With EN

Data are limited on specific regimens for tube-fed patients with diabetes. A study in 2005 of 25 patients receiving artificial nutrition (TPN or EN) confirmed the safety and efficacy of long-acting insulin glargine in hospitalized patients.⁵⁷ Murphy and colleagues58 examined 46 patients in an LTC facility over 18 months for differences in glycemic control over EN regimens. Three regimens were compared: a 20-hour feed using a 30:70 premixed insulin; 3 bolus (4-hour) feeds combined with short-acting insulin and a basal long-acting insulin; and a 24-hour feed combined with long-acting insulin. Glycemic control did not vary among the 3 groups, with the exception of decreased episodes of hypoglycemia in the intermittent group. Although the results were surprising, the authors postulated that there was a decrease in the amount of feed interruptions for interventions such as tests or attending scans. These interruptions may have then predisposed the patients to hypoglycemia.⁵⁸

Conclusion

Managing diabetes in older adults is often challenging given clinical comorbidities, frailty, malnutrition, and cost. This article reviews various factors that should be considered when determining appropriate diabetic treatment, with emphasis on patient-centered care.

For frail patients who are at risk of malnutrition, the primary goal is to reduce the risk of hypoglycemia by avoiding the use of medications that may exacerbate weight loss. In addition to pharmacy-induced weight loss, work with speech-language pathologists and dietitians to liberalize diets when possible. Initiate small frequent feedings to optimize total daily nutrient consumption, thereby reducing the risk of weight loss and sarcopenia. Additionally, providers should be mindful of prescribing TZDs for older adults who are at increased risk of fracture. For older adults receiving EN, use a diabetes-specific formula.

Impaired kidney function and cardiac complications should be given careful consideration when prescribing diabetes treatment, and use of the Beers Criteria is encouraged to help promote better treatment and clinical outcomes. Noteworthy recommendations include avoiding chlorpropamide and glimepiride in older adults, given the medications’ association with prolonged hypoglycemia. The Beers Criteria also discourage the use of sliding-scale insulin without the use of long-acting insulin for individuals who are at high risk for hypoglycemia. Despite these guidelines, many patients in LTC facilities remain on sliding-scale insulin regimens. Treatments should be reviewed every 3 months, between hospital transfers, and/or when there is a significant change with the patient, eliminating medications such as sliding-scale insulin at the earliest opportunity to minimize the detrimental effects of such medications in this age group.

In addition to diet and medication management, improvement is needed in providing adequate training and continued reinforcement to direct-care staff in LTC facilities for recognizing the signs and symptoms of hypoglycemia. Implementing protocols for patients with diabetes when changes in appetite or weight are observed can further reduce the risk of adverse outcomes. Furthermore, registered dietitians and physicians should actively communicate and document malnutrition and malnutrition risk when appropriate to be proactive in diabetes care planning.

There remains no standard A_1c goal for older adults, although a patient-centered approach is recommended to reduce the risk of hypoglycemia. When determining an A_1c goal for a specific patient, it is important to consider frailty, comorbid illnesses, cognitive status, and functional status. Using clinical judgment, patients who are at low risk should have a goal A_1c below 6.5%; patients who are at moderate risk should have a goal A_1c of 7.0% to 8.0%; and patients at high risk should not have an A_1c goal, but instead the focus is on preventing hypoglycemia and hyperglycemia. As frailty progresses, medications should be discontinued gradually based on adverse effects and comorbid illnesses, weighing the benefits and adverse effects of each medication in an aim to treat the patient rather than a goal A_1c.

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