A study involving nearly 90,000 patients uncovers discrepancies between treatment changes and individualised glycaemic targets in older adults, raising concerns over overtreatment and undertreatment in diabetes management.
Among older adults with type 2 diabetes, treatment changes often do not match where haemoglobin A1c levels actually fall relative to guideline targets, according to research led by Phuc Le of the Cleveland Clinic and reported in JAMA Internal Medicine. The analysis of electronic health records from nearly 90,000 patients found that many people whose blood glucose control was either too high or too low did not have their medicines adjusted in the expected direction, even though professional guidance says targets should be set according to a patient’s overall health.
The American Diabetes Association and other clinical guidance recommend a more individualised approach in older people, with looser HbA1c targets for those with frailty, major illness or limited life expectancy and tighter control for healthier patients. A systematic review in Age and Ageing and separate guidance from the American Geriatrics Society both note that targets commonly range from about 7% to 7.5% in healthier older adults to 8% to 9% in those with more serious health problems, largely to reduce the risk of hypoglycaemia and other harms. Other reviews have made the same point: glycaemic goals should reflect health status, medication burden and treatment preferences, not age alone.
In the Cleveland Clinic analysis, 37.8% of patients were at goal, 48.4% were below goal and 13.8% were above goal. Just 16.9% of those below target had their therapy deintensified, while 32.8% of those above target had treatment intensified. The study also found that intensification was happening even in some patients with poor health and already low HbA1c values, a pattern the authors said was worrying because overly aggressive glucose lowering in frail or medically complex older adults can raise the risk of hypoglycaemia and other adverse outcomes.
The findings suggest that clinicians may need to be more deliberate about matching treatment intensity to the intended goal. Le said that reducing medication burden can be appropriate care in some older adults, while patients in good health who remain above target may need closer follow-up and more active treatment. The study authors said the results should not be read as a rule that every out-of-range HbA1c demands a medication change, but rather as evidence that individualised goals are not always being translated into day-to-day prescribing decisions.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
