Managing Diabetes in Older Adults

Diabetes care in older age is not simply the same care continued. The balance of risk changes, and treatment that was right at fifty can become the wrong treatment at eighty.

The central shift is from highs to lows. Complications from high blood sugar take years to develop. A severe hypoglycemia episode can cause a fall, a fracture, a hospital admission or worse — today. In a person in their eighties, the arithmetic favours avoiding lows over chasing a tighter average.

This is written into international guidance. Where the usual time-in-range target is more than 70% of the day between 70 and 180 mg/dL, for older or more fragile people the recommended goal is more than 50% in range, with less than 1% of the day below 70 mg/dL — a deliberately looser target on the top end and a stricter one on the bottom.

What changes in practice

• Targets are relaxed, deliberately and with your doctor. A rising HbA1c target in old age is often good medicine, not neglect.
• Medicines get reviewed for hypo risk. Sulfonylureas and insulin are the ones that cause lows.
• Hypo symptoms become harder to spot — confusion or a fall may be the first sign rather than sweating and shaking.
• Kidney function changes what is safe, and doses often need adjusting.
• Eating less becomes a risk, not a virtue. Appetite falls with age, and medicine doses set for larger meals then cause lows.

If an older relative is having falls, confusion or unexplained drowsiness, ask whether their diabetes medicines could be causing lows. It is a common and reversible cause that is easy to attribute to age instead.