Table 12.2

Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with diabetes (39,55)

Patient characteristics/ health statusReasonable A1C/treatment goalRationale/considerationsWhen may regimen simplification be required?When may treatment deintensification/deprescribing be required?
Healthy (few coexisting chronic illnesses, intact cognitive and functional status)A1C <7.5% (58 mmol/mol)• Patients can generally perform complex tasks to maintain good glycemic control when health is stable• If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate)• If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate)
• During acute illness, patients may be more at risk for administration or dosing errors that can result in hypoglycemia, falls, fractures, etc.• If wide glucose excursions are observed• If wide glucose excursions are observed
• If cognitive or functional decline occurs following acute illness• In the presence of polypharmacy
Complex/intermediate (multiple coexisting chronic illnesses or 2+ instrumental ADL impairments or mild-to-moderate cognitive impairment)A1C <8.0% (64 mmol/mol)• Comorbidities may affect self-management abilities and capacity to avoid hypoglycemia• If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate)• If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate)
• Long-acting medication formulations may decrease pill burden and complexity of medication regimen• If unable to manage complexity of an insulin regimen• If wide glucose excursions are observed
• If there is a significant change in social circumstances, such as loss of caregiver, change in living situation, or financial difficulties• In the presence of polypharmacy
Community-dwelling patients receiving care in a skilled nursing facility for short-term rehabilitationAvoid reliance on A1C• Glycemic control is important for recovery, wound healing, hydration, and avoidance of infections• If treatment regimen increased in complexity during hospitalization, it is reasonable, in many cases, to reinstate the prehospitalization medication regimen during the rehabilitation• If the hospitalization for acute illness resulted in weight loss, anorexia, short-term cognitive decline, and/or loss of physical functioning
Glucose target: 100–200 mg/dL (5.55–11.1 mmol/L)• Patients recovering from illness may not have returned to baseline cognitive function at the time of discharge
• Consider the type of support the patient will receive at home
Very complex/poor health (long-term care or end-stage chronic illnesses or moderate-to-severe cognitive impairment or 2+ ADL dependencies)A1C <8.5% (69 mmol/)• No benefits of tight glycemic control in this population• If on an insulin regimen and the patient would like to decrease the number of injections and fingerstick blood glucose monitoring events each day• If on noninsulin agents with a high hypoglycemia risk in the context of cognitive dysfunction, depression, anorexia, or inconsistent eating pattern
• Hypoglycemia should be avoided• If the patient has an inconsistent eating pattern• If taking any medications without clear benefits
• Most important outcomes are maintenance of cognitive and functional status
Patients at end of lifeAvoid hypoglycemia and symptomatic hyperglycemia• Goal is to provide comfort and avoid tasks or interventions that cause pain or discomfort• If there is pain or discomfort caused by treatment (e.g., injections or fingersticks)• If taking any medications without clear benefits in improving symptoms and/or comfort
• Caregivers are important in providing medical care and maintaining quality of life• If there is excessive caregiver stress due to treatment complexity
  • Treatment regimen simplification refers to changing strategy to decrease the complexity of a medication regimen, e.g., fewer administration times, fewer fingerstick readings, decreasing the need for calculations (such as sliding scale insulin calculations or insulin-carbohydrate ratio calculations). Deintensification/deprescribing refers to decreasing the dose or frequency of administration of a treatment or discontinuing a treatment altogether. ADL, activities of daily living.

  • Consider adjustment of A1C goal if the patient has a condition that may interfere with erythrocyte life span/turnover.