Special Considerations for Older Adults with Diabetes

Real Healthcare Debates from the Kitchen Table

Introduction

Managing diabetes is never one-size-fits-all — and this is especially true for older adults. In our house, this is a regular topic of conversation (yes, we’re that fun). I, Cory the pharmacist, tend to zoom in on medication safety, drug interactions, and dosing tweaks. Cassie, the nurse practitioner, leans into quality of life, independence, and realistic goals for the whole person.

When you’re 75, managing blood sugars looks very different than when you’re 45 — and it’s not just about the numbers. Let’s pull up a chair and talk about what makes diabetes care unique in our older patients.

Pharmacist Perspective (Cory)

My main priority? Keep elderly patients safe. In older adults, the risk of hypoglycemia can be much more dangerous than mild hyperglycemia. Low blood sugar can mean falls, ER visits, or worse.

Here’s what I’m watching closely:

• Hypoglycemia risk: Sulfonylureas (like glipizide) and insulin are common culprits. I’m quick to recommend scaling back doses or switching to lower-risk meds (like metformin, SGLT-2 inhibitors, DPP4 inhibitors or GLP-1s) when appropriate.
• Kidney function: As we age, kidney function can decline — sometimes without symptoms. Metformin and certain SGLT2 inhibitors especially require careful dose adjustments or discontinuation to avoid complications or lack of blood sugar lowering efficacy.
• Polypharmacy: It’s not unusual for my older patients to be on a dozen medications or more. At this point, drug-drug interactions are almost impossible to avoid, confusion from managing the many medications, as well as a side effect from the medications are possible, and duplicate therapies can be huge problems (raise your hand along with me if you have seen multiple GLP-1 agonists or 70/30 insulin paired with glargine before).
• Individualized A1C goals: The ADA suggests a target of <8% for many frail older adults — we want to avoid overtreatment at the risk of medication side effects. For severely complicated or much older individuals (90 or older), I sometimes just aim for a goal of less than 9%.¹
• Simplified regimens: The fewer the pills and injections, the better the adherence. I’ll often push for once-daily meds or combination pills to reduce complexity. This goes not only for their diabetes medications, but everything they are taking.

Nurse Practitioner Perspective (Cassie)

I’m with Cory on safety, but my focus starts with the human in front of me — not just their chart. My older patients often have more going on than diabetes: arthritis, vision changes, hearing loss, and sometimes cognitive decline on top of financial and social challenges.

Here’s what I prioritize:

• Quality of life over perfect control: I’d rather see stable blood sugars running a little above the standard ADA goal range than have a patient risk severe hypoglycemia chasing a “perfect” A1C. This is an education piece that can be hard to convince a patient of, especially if a “low A1C” has been drilled into them as a “must achieve” for decades.
• Nutrition without over-restriction: Have you ever tried to get an 80-year-old to change their eating habits? I am guessing the term “set in their ways” comes to mind? My goal is to help guide them on a path of nutrition modification that fits with their life goals at this stage in their health journey. My goal personally is a little medication with as much diet modification as possible, but sometimes convincing someone who has had a donut daily for 60 years to change is just not going to happen. For many patients, it can mean modifying just one meal a day to help reduce their dependence on diabetes medication.
• Functional fitness: Maintaining muscle mass with light resistance training is key for preventing falls and maintaining independence as well as improving blood sugar control by increasing glycogen storage capacity.
• Tools they can actually use: Arthritic hands and poor eyesight can make insulin pens or glucose meters tricky — sometimes the simplest devices work best. And sometimes the fanciest, newest ones like Continuous Glucose Monitors, are literal lifesavers.
• Social support: Isolation can worsen outcomes. I encourage family and friend involvement in meal prep, med checks, and doctor visits when the patient is agreeable.

Kitchen Table Consensus

We agree: older adults need a tailored, safety-first approach. The main goal is to avoid hypoglycemia, preserve independence, and maintain quality of life while minimizing the risks and problems from uncontrolled high blood sugars. Perfect blood sugar numbers aren’t worth sacrificing safety or well-being.

Practical Takeaways

• Aim for individualized A1C targets — often <8% is safer in frail older adults.¹
• Choose meds with a low hypoglycemia risk profile whenever possible.
• Adjust doses for kidney function and other comorbidities.
• Simplify regimens and devices whenever possible.
• Focus on adequate nutrition and functional movement
• Involve family or caregivers in care planning.

References

1. American Diabetes Association. Older Adults: Standards of Care in Diabetes—2024. Diabetes Care. 2024;47(Suppl 1):S195–S207. doi:10.2337/dc24-S013