How do you adjust your HbA1c goal for managing diabetes in elderly patients with multiple chronic illnesses but no limitations in performing self-care tasks?

There is guidance from ADA, AACE and other organizations. Most agree that an A1c target of 8% is perfectly acceptable in advanced elders and/or people with multiple comorbidities and limited life expectancies. The critical issue is to understand what a reasonable timeline for the patient is. The natural history of diabetes and the temporal association of A1c and the development of advanced complications is complex, but a 1% higher A1c over 5-10 years is not associated with a substantive increase in clinically meaningful endpoints (i.e., developing retinopathy requiring intervention, end-stage kidney disease). However, some “elders” with multiple comorbidities have a life expectancy greater than 5-10 years where more intensive targets (7.5% or lower) are clearly desirable. That said, treatment of pre-existing complications, comorbidities, and cardiovascular needs to proceed. The key issue is avoiding hypoglycemia, better assessed with CGM than A1c, and recognizing that a higher A1c is not an automatic path to reduced risk of hypoglycemia. De-intensifying insulin and sulfonylureas in elders is probably an important goal, particularly the use of rapid-acting insulin and high-dose basal therapy with either insulin or sulfonylureas. It is a complex area of medical judgment without clear-cut trial support which requires further study.