Recommendations for A1C Targets in Older People With Type 2 Diabetes

Guidelines/Position StatementPatient CharacteristicsA1C Goal, %
American Diabetes Association (11)
Society for Post-Acute and Long-Term Care Medicine (27)
Healthy (few coexisting chronic illnesses, intact cognitive and functional status)˂7.5*
Complex/intermediate health (multiple coexisting chronic illnesses or two or more instrumental ADL impairments or mild to moderate cognitive impairment)˂8.0*
Very complex/poor health (LTC or end-stage chronic illnesses or moderate-to-severe cognitive impairment or two or more ADL dependencies)˂8.5*,§
American Diabetes Association (23)Community-dwelling patients at skilled nursing facility for short-term rehabilitationAvoid relying on A1C because of recent acute illness; follow current glucose trends
Patients residing in LTC facility˂8.5
Patients at end of lifeNo role for A1C
International Diabetes Federation (50)Functionally independent (no important impairments in ADL; no or minimal caregiver support; may have other medical comorbidities that may influence diabetes care)7.0–7.5
Functionally dependent7.0–8.0
Frail/dementiaUp to 8.5
End of life careNone; avoid symptomatic hyperglycemia and minimize hypoglycemia
Canadian Diabetes Association (2)Healthy elderlyAs for younger patients (˂7.0)
Frail elderly≤8.5%
Diabetes Care Program of Nova Scotia and the Palliative and Therapeutic Harmonization Program (16)Frail older adultsMaintain A1C ≥8% rather than below a specific level
European Diabetes Working Party for Older People (25)Healthy (no other major comorbidities)7.0–7.5
Frail (dependent; multisystem disease; care home residency, including those with dementia)7.6–8.5
  • * A lower A1C goal may be set for an individual if achievable without recurrent or severe hypoglycemia or undue treatment burden.

  • Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, congestive heart failure, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse chronic kidney disease, myocardial infarction, and stroke. “Multiple” means three or more illnesses, but many patients may have five or more illnesses.

  • The presence of a single end-stage chronic illness, such as stage 3–4 congestive heart failure or oxygen-dependent lung disease, chronic kidney disease requiring dialysis, or uncontrolled metastatic cancer, may cause significant symptoms or impairment of functional status and significantly reduce life expectancy.

  • § A1C = 8.5% equates to an estimated average glucose of 200 mg/dL (11.1 mmol/L). Looser A1C targets ˃8.5% are not recommended because they may expose patients to more frequent higher glucose values and acute risks from glycosuria, dehydration, hyperglycemic hyperosmolar syndrome, and poor wound healing.