Nearly one in three Americans age 65 and older lives wiht diabetes,according to the Centers for Disease control and Prevention. But our healthcare system often approaches diabetes care as if every adult’s metabolism and physical capabilities are identical, a frustrating reality for both patients and their doctors.
I recall vividly, during two years at a geriatric primary care clinic in Philadelphia, watching well-intentioned patients inadvertently harm themselves. Some would take excessive medication doses, or skip meals altogether, all in pursuit of an A1c of 7.0. These actions frequently led to emergency room visits and complicated their ongoing care. It was a stark lesson: preventive care, when misapplied, can be profoundly detrimental.
A1c Targets: One Size Doesn’t Fit All
Currently, quality metrics used by the Centers for Medicare & Medicaid Services (CMS) and many other health systems incentivize physicians to maintain an A1c below 7.0. While appropriate for a healthy adult in their 40s, this target can be counterproductive-even perilous-for a senior citizen in their 80s grappling with frailty and cognitive decline. Standardized guidelines are valuable for consistency and research, but modified A1c ranges that consider a patient’s overall health could significantly improve diabetes care and open new research avenues.
The American Diabetes Association (ADA) and American Geriatrics Society (AGS) now recommend individualized A1c targets between 7.5 and 8.5 for geriatric patients with multiple health conditions. Though, financial incentives haven’t caught up. Physicians are often compelled to prioritize rigid quality standards over personalized care that reflects the physiological and social changes of aging, leading to increased medication prescriptions and more emergency room visits.
A 2023 analysis in JAMA Internal Medicine revealed that up to 40 percent of older adults are “over-treated”-receiving medications with no proven benefit that significantly increase the risk of debilitating hypoglycemic episodes and other adverse effects, ultimately diminishing their quality of life.
Prioritizing Quality of Life Over Lab Numbers
Managing diabetes in older adults should prioritize function, comfort, and independence, rather than rigidly pursuing a specific lab value. This requires a systemic shift, moving away from the assumption that an A1c of 7.0 equates to optimal health. CMS could update its quality-reporting programs to financially reward clinicians for achieving individualized targets. A system of patient-specific A1c ranges, adjusted for frailty and comorbidities, would better align incentives with evidence-based care. Hos
