Older adults with type 2 diabetes face heightened risks of hypoglycemia, frailty, and falls due to the common practice of intensive glucose-lowering therapy that exceeds clinical necessity.
Medical organizations are now pushing for individualized treatment plans to prevent overtreatment in patients aged 65 and older.
Risks of Intensive Glucose Management
Intensive glycemic control often persists even as patients age, develop comorbidities, or experience cognitive decline. While a treatment regimen might be appropriate for a younger, healthier patient, it can become dangerous if the patient’s health status changes, according to Scott Isaacs, an adjunct assistant professor of medicine at the Emory University School of Medicine in Atlanta and immediate past president of the American Association of Clinical Endocrinology (AACE).
“A regimen that worked years earlier is continued, even after the patient becomes frail, develops kidney disease, eats less, or experiences cognitive decline,” Isaacs told Medscape Medical News. This misalignment between medication and physical reality increases the likelihood of severe hypoglycemia, which can further accelerate physical and cognitive deterioration.
Prevalence of Overtreatment
Data indicate that overtreatment is a widespread issue across various care settings. Approximately one third of adults aged 65 or older in the United States live with type 2 diabetes, a figure that rises to nearly one fifth globally. Research involving 133,773 older adults in British Columbia showed that nearly one third of those with an A1c level of 7.0% or less were being overtreated.
Similar trends appear in institutional care. An Ontario-based study of 15,034 nursing home residents found that over half were treated to intensive glycemic targets, with those suffering from severe cognitive impairment most frequently subjected to this approach. In a recent analysis of nearly 90,000 patients at the Cleveland Clinic, researchers found that medication adjustments rarely aligned with the individualized goals recommended by the American Diabetes Association (ADA).
Shifting Toward Safer Glycemic Targets
Both the ADA and the AACE have updated their 2026 guidance to emphasize safe prescribing over rigid A1c targets. Clinicians are encouraged to consider person-specific characteristics, such as frailty and life expectancy, rather than applying a one-size-fits-all approach. For frail patients, the AACE 2026 algorithm supports a more moderate A1c goal of 7%-8%.
“The most appropriate target isn’t the lowest possible A1c, but the safest A1c for that particular patient, and hypoglycemia avoidance is the first safety priority,” Isaacs said. When patients are medically complex, deintensification of therapy should be considered, particularly for those receiving medications with a high risk for hypoglycemia, such as insulin or sulfonylureas.
Implementing Deprescribing Strategies
The process of deprescribing requires a deliberate, supervised approach rather than an ad hoc response to adverse events. Lisa McCarthy, a pharmacist and associate professor at the University of Toronto, notes that as frailty increases, the clinical focus must shift from achieving a specific A1c number to preventing symptomatic hyperglycemia and hypoglycemia.
To assist clinicians, McCarthy helped develop the 4S Pathway, which is now incorporated into ADA standards. The framework guides providers through four steps: seeking triggers for medication changes, shared decision-making, setting goals, and devising simpler, safer regimens.
“to avoid treating A1c as a 'one-size-fits-all' number in older adults,” Phuc Le, PhD, MPH, associate professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, said.
Why A1c Monitoring Changes for Frail Older Adults
Why is A1c monitoring sometimes limited for frail older adults?
As patients age and experience frailty, the physiological significance of A1c levels can change, making traditional targets less relevant or even misleading for guiding safe care. Experts increasingly emphasize that monitoring for hypoglycemia and functional decline often provides a more accurate picture of a patient’s health and safety needs.
What medications are considered lower risk for older patients?
According to AACE guidance, clinicians are encouraged to favor medications with a lower risk of hypoglycemia. These include metformin, DPP-4 inhibitors, GLP-1 receptor agonists, SGLT2 inhibitors, and pioglitazone, provided they are appropriate for the patient’s specific comorbidities.
What happens if a patient’s glucose levels rise after deintensification?
Deprescribing is a monitored process, not a permanent withdrawal of care. If a patient develops symptomatic hyperglycemia or if glucose levels exceed the newly established, safer targets, clinicians may consider dose adjustments or switching to alternative medications that carry a lower risk of hypoglycemia.
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