Table 12.2

Considerations for treatment regimen simplification and deintensification/deprescribing in older adults with diabetes (56,82)

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

  • • During acute illness, patients may be more at risk for administration or dosing errors that can result in hypoglycemia, falls, fractures, etc.

  • • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate)

  • • If wide glucose excursions are observed

  • • If cognitive or functional decline occurs following acute illness

  • • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate)

  • • If wide glucose excursions are observed

  • • 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

  • • Long-acting medication formulations may decrease pill burden and complexity of medication regimen

  • • If severe or recurrent hypoglycemia occurs in patients on insulin therapy (even if A1C is appropriate)

  • • If unable to manage complexity of an insulin regimen

  • • If there is a significant change in social circumstances, such as loss of caregiver, change in living situation, or financial difficulties

  • • If severe or recurrent hypoglycemia occurs in patients on noninsulin therapies with high risk of hypoglycemia (even if A1C is appropriate)

  • • If wide glucose excursions are observed

  • • 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

  • • Hypoglycemia should be avoided

  • • Most important outcomes are maintenance of cognitive and functional status

  • • 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 the patient has an inconsistent eating pattern

  • • If on noninsulin agents with a high hypoglycemia risk in the context of cognitive dysfunction, depression, anorexia, or inconsistent eating pattern

  • • If taking any medications without clear benefits

Patients at end of lifeAvoid hypoglycemia and symptomatic hyperglycemia
  • • Goal is to provide comfort and avoid tasks or interventions that cause pain or discomfort

  • • Caregivers are important in providing medical care and maintaining quality of life

  • • If there is pain or discomfort caused by treatment (e.g., injections or fingersticks)

  • • If there is excessive caregiver stress due to treatment complexity

  • • If taking any medications without clear benefits in improving symptoms and/or comfort

  • 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.