Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Diabetes targets in older adults
Medicine of older adults · UK scope · Sources checked 27 Aug 2026 · Clinical review pending
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Severe glucose emergency
Unconscious hypoglycaemia, recurrent seizure, diabetic ketoacidosis, hyperosmolar hyperglycaemic state, severe dehydration or infected ischaemic foot disease requires immediate emergency treatment.
Action: Use ABCDE and capillary glucose, treat hypoglycaemia immediately or activate DKA and HHS protocols with cautious fluid and electrolyte management, and obtain urgent diabetes, vascular or surgical input for persistent instability or foot sepsis.
Overview
Individualise glucose and cardiovascular targets around frailty, hypoglycaemia, cognition, organ function and life expectancy, while preventing symptomatic hyperglycaemia, foot disease and unsafe treatment simplification.
Ask what the person wants diabetes care to achieve: avoiding hypos and falls, maintaining vision, healing a wound, reducing thirst or simplifying injections. Establish diabetes type, duration, prior crises, vascular and microvascular disease, hypoglycaemia awareness and stable self-management. Determine who prepares meals, tests glucose, gives injections and recognises deterioration.
Review HbA1c in context. NICE targets 48 mmol/mol for many adults with type 2 diabetes managed by lifestyle or a medicine not associated with hypoglycaemia, and 53 mmol/mol when treatment can cause hypoglycaemia. NICE also supports relaxing targets individually in older or frail adults, those with reduced life expectancy, severe comorbidity or high consequence from hypoglycaemia.
Do not use one frailty target for everyone. A fit older adult with decades of expected benefit may choose standard prevention, whereas severe frailty and recurrent lows favour a higher target and simpler regimen. Avoid abrupt withdrawal that causes symptomatic glucose, weight loss, dehydration or HHS. In type 1 diabetes, basal insulin must not be stopped because of poor intake.
Aetiology
01
Progressive type 2 diabetes
Insulin resistance and beta-cell failure cause chronic hyperglycaemia, with organ disease and steroid exposure modifying control.
02
Treatment-related hypoglycaemia
Insulin and sulfonylureas produce low glucose when intake, renal clearance, dose or activity changes unexpectedly without timely regimen adaptation.
03
Frailty and self-management barriers
Cognitive, visual, dexterity, swallowing and carer limitations make complex testing and injection regimens unreliable during unsupervised daily care.
04
Acute illness destabilisation
Infection, dehydration, reduced intake, corticosteroids and hospital transitions cause rapid hyperglycaemia, ketosis or medicine accumulation over hours or days.
Pathophysiology
1
Hyperglycaemic osmotic loss
High glucose causes polyuria, dehydration, electrolyte loss and impaired cognition, with kidney impairment altering the phenotype.
2
Neuroglycopenia and adrenergic failure
Low glucose deprives the brain and triggers autonomic warning; repeated episodes can blunt awareness and delay rescue.
3
Microvascular and macrovascular injury
Chronic dysglycaemia damages retina, kidney, nerves and vessels while hypertension, lipids and smoking amplify cardiovascular risk.
4
Renal exposure amplification
Reduced clearance prolongs insulin and sulfonylurea action and alters the safety of metformin, SGLT2 and other medicines.
5
Competing time horizons
Tight control offers delayed microvascular benefit but creates immediate hypoglycaemia and treatment burden in limited reserve.
Clinical features and red flags
Neuroglycopenic hypoglycaemiaRed flag
Confusion, weakness, behaviour change, focal-appearing deficit or drowsiness occurs with low capillary glucose.
Hypoglycaemia unawareness
Autonomic warning fades after repeated lows, so cognitive impairment can occur before the person recognises danger.
Hyperosmolar patternRed flag
Profound dehydration and altered cognition accompany marked hyperglycaemia with little or no significant ketosis.
Ketotic illnessRed flag
Vomiting, abdominal pain, deep breathing and ketones require urgent DKA assessment regardless of age.
Overtight treatment pattern
Low HbA1c coexists with falls, nocturnal readings, weight loss or recurrent rescue carbohydrate.
Self-management mismatch
The prescribed testing and injections exceed cognition, vision, dexterity, meal reliability or carer availability.
Red flags requiring action
Reduced consciousness, seizure or inability to swallow with low glucose requires immediate parenteral hypoglycaemia treatment.
Ketones, acidosis, vomiting, deep breathing or abdominal pain suggests DKA even in an older adult with type 2 diabetes.
Investigations
01Glucose profile or sensor downloadFirst step
Why
Identify fasting, meal and nocturnal risk.
Interpretation and limitations
Assess time below range, variability and relation to meals, injections, activity and symptoms; one clinic value is insufficient.
02HbA1c with reliability review
Why
Estimate longer-term glycaemia and trajectory.
Interpretation and limitations
Interpret against anaemia, CKD, transfusion and glucose data and apply an individual target rather than automatic intensification.
03Renal and urine albumin assessment
Why
Guide medicine safety and kidney protection.
Interpretation and limitations
Trend eGFR, creatinine and albuminuria; acute illness changes clearance and may require temporary treatment modification.
04Ketones, gas and osmolality
Why
Classify the type and severity of hyperglycaemic emergency.
Interpretation and limitations
Use blood ketones, pH, bicarbonate and calculated or measured osmolality under DKA or HHS protocols, including SGLT2 exposure.
05Foot examination
Why
Detect ulcer, infection, neuropathy and ischaemia.
Interpretation and limitations
Differential diagnosis
01
Hypoglycaemia
Sweating may be absent; delirium, fall, focal deficit, behavioural change or drowsiness can be the main presentation.
02
HHS or DKA
Dehydration and hyperglycaemia require ketone, gas and osmolality-informed assessment because type and age do not exclude either emergency.
03
Intercurrent infection
Pneumonia, urinary, skin and foot infection raises glucose and may present without classical fever or local symptoms.
04
Medicine and endocrine effects
Corticosteroids, missed insulin, enteral feeding, thyroid and pancreatic disease create distinct glucose patterns requiring cause treatment.
05
Non-diabetic cognitive decline
Stroke, delirium, medicines and dementia can mimic glucose symptoms and still require assessment after immediate glucose correction.
Management
01First-line target reviewBalance delayed benefit with immediate safetyFirst stepFirst lineFrailty, comorbidity or hypoglycaemia makes the current diabetes target uncertain.+
1Review diabetes type, complications, glucose data, renal function, cognition, function, life expectancy and personal priorities.
2Agree and document an HbA1c and glucose range that prevents symptoms and crisis while minimising low-glucose risk.
3Simplify or optimise treatment with a defined monitoring and complication-prevention plan and involve carers appropriately.
02Hypoglycaemia routeTreat now and prevent recurrenceGlucose is low or symptoms strongly suggest a low-glucose event.+
1Give rapid oral carbohydrate when swallowing is safe or parenteral glucose or glucagon when it is not, and recheck promptly.
2
Complications
01
Severe hypoglycaemia and injury
Seizure, arrhythmia, aspiration, falls and driving harm can follow low glucose, particularly with impaired awareness or absent rescue support.
02
Hyperglycaemic crisis
DKA and HHS cause dehydration, thrombosis, electrolyte disturbance, cerebral change, kidney injury and death without controlled specialist treatment.
03
Foot ulcer and amputation
Neuropathy, deformity, infection and peripheral arterial disease combine to cause tissue loss, amputation and lasting functional decline.
04
Visual and renal impairment
Retinopathy and nephropathy reduce self-management ability and increase medicine, cardiovascular and care complexity as disease advances.
05
Treatment burden and dependence
Multiple injections, tests, meal timing and rescue decisions can exceed personal or carer capacity and prompt unsafe omissions.
Monitoring and follow-up
Track severe, nocturnal and unrecognised hypoglycaemia and the circumstances around each event.
Review glucose pattern and HbA1c against the explicitly documented individual target and symptom burden.
Repeat renal function after acute illness and before restarting or escalating kidney-dependent medicines.
Monitor weight, appetite, hydration, falls and cognition after treatment simplification or intensification.
Complete foot surveillance, urine albumin, retinal screening, pressure, lipid and smoking review as appropriate.
Observe testing and injection technique and verify carer training, rescue treatment and supply.
Reassess targets after severe illness, new frailty, care transition, recurrent hypoglycaemia or major prognosis change.
Special situations
Low HbA1c may be a warning
Weight loss, CKD and recurrent hypoglycaemia can lower HbA1c while making treatment substantially less safe.
Relaxed is not unmonitored
A higher target still requires protection from thirst, dehydration, infection, ketosis and hyperosmolar crisis.
Basal insulin is different
A person with type 1 diabetes needs background insulin during poor intake to prevent ketone production.
Technology transfers work
A sensor helps only when the wearer or supporter can scan, interpret alarms and act correctly.
Meals are part of the dose
Insulin and sulfonylurea safety depends on reliable carbohydrate access and timing, not prescription alone.
Common pitfalls
01
Applying the same HbA1c target to every older adult.
02
Celebrating a low HbA1c despite falls, weight loss and recurrent hypoglycaemia.
03
Stopping basal insulin in type 1 diabetes during poor intake.
04
Using oral carbohydrate when consciousness or swallowing is impaired.
05
Ignoring SGLT2-associated ketosis because glucose is not markedly elevated.
06
Prescribing a complex correction scale no carer can deliver reliably.
07
Using frailty to stop foot, retinal and kidney care without discussing likely benefit.
08
Failing to communicate an intentionally relaxed target across care settings.
Practice
Two practice questions
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Question 1 of 2
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Medicine of older adultsOriginal SBA
Individualising an HbA1c target
An 87-year-old with severe frailty, recurrent hypoglycaemic falls and limited life expectancy has an HbA1c of 45 mmol/mol while using insulin. What is the best response?
Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources
Sources and review status
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Interrogate glucose patterns rather than HbA1c alone. Ask fasting, pre-meal, post-meal and night readings, variability, symptoms, missed meals, alcohol and activity. Anaemia, CKD, transfusion and haemoglobin variants can distort HbA1c. Continuous monitoring can reveal hidden nocturnal lows but requires training, alarm settings and someone able to respond.
Treat low glucose immediately. If conscious and able to swallow, use 15 to 20 g rapid carbohydrate, recheck after 10 to 15 minutes and repeat until above the treatment threshold, then provide longer-acting carbohydrate or the next meal when appropriate. If unable to swallow, use IV glucose in clinical care or glucagon when suitable, place safely and reassess because sulfonylurea or long-acting insulin can cause recurrence.
After every severe or recurrent hypo, identify cause: excess insulin or sulfonylurea, renal decline, lost weight, reduced appetite, missed carers, alcohol, increased activity, injection error or duplicate dose. Review awareness and driving. Reduce the causal regimen promptly and use a less hypoglycaemic treatment where possible. A rescue kit is ineffective if no trained person is available.
During acute illness, check glucose and ketones according to type, treatment and symptoms. Type 1 diabetes and SGLT2 inhibitors can produce ketotic illness at lower glucose. Follow a written sick-day plan: continue basal insulin, adjust other insulin with specialist advice, maintain fluids and carbohydrate, and temporarily withhold specified medicines such as metformin or SGLT2 inhibitors during dehydration or serious illness under current guidance.
Choose type 2 medicines for cardiovascular and kidney benefit, hypoglycaemia, weight, frailty, renal function, infection and administration. SGLT2 inhibitors may benefit heart and kidney disease but require genital-infection, volume and ketoacidosis education. GLP-1 receptor agonists can reduce weight, which may be undesirable in malnutrition. Sulfonylureas and insulin need cautious dosing and meal reliability.
Continue complication prevention proportionately. Inspect feet and footwear; assess pulses and sensation; refer active foot disease urgently under NICE NG19. Check eGFR and urine albumin, arrange retinal screening and review blood pressure, lipid and smoking care. Sensory or cognitive impairment can make appointment and medicine systems inaccessible, requiring reasonable adjustments.
Simplify without losing safety. Move from complex sliding or correction regimens to a stable pattern when appropriate, use pens and large-print or talking meters, align administration with reliable care visits and reduce unnecessary testing in people not using hypoglycaemia-causing treatment. Care-home plans must specify targets, rescue threshold, ketone actions and who can administer.
Monitor outcomes beyond HbA1c: severe and nocturnal hypo, thirst, infections, falls, cognition, weight, foot condition and burden. Communicate intentional target relaxation so future clinicians do not intensify automatically. Review after illness, renal change, weight loss, steroid initiation, care transition or any severe glucose event.
Key points
Set targets from diabetes type, frailty, comorbidity, hypoglycaemia, cognition, life expectancy and what the person can safely manage.
For many adults with type 2 diabetes, NICE uses HbA1c 48 mmol/mol with lifestyle or non-hypoglycaemia therapy and 53 mmol/mol with hypoglycaemia-associated medicines.
Relax HbA1c targets case by case when frailty, limited life expectancy, severe comorbidity or hypoglycaemia risk makes tight control harmful.
A relaxed target is not neglect: prevent symptomatic hyperglycaemia, dehydration, infection and crisis while reducing severe low-glucose risk.
Prioritise reducing insulin and sulfonylurea exposure when recurrent hypoglycaemia occurs, while preserving enough insulin to avoid ketosis where relevant.
Continuous or flash glucose monitoring can reveal nocturnal and unrecognised lows, but alarms, scanning and data interpretation must be practically supported.
Use sick-day guidance for vomiting, reduced intake, dehydration and infection, including ketone testing and specific medicine holds or dose actions.
Foot examination, renal albumin assessment, retinal screening, blood pressure, lipids and smoking treatment remain important when consistent with goals.
Profound dehydration, marked hyperglycaemia and altered cognition suggests HHS and requires controlled specialist correction.
Hot swollen foot, spreading infection, tissue loss, rest pain or absent pulses requires urgent multidisciplinary diabetic-foot assessment.
Repeated nocturnal hypoglycaemia, falls or lost awareness requires prompt regimen and monitoring reduction before another severe event.
Vomiting, reduced intake or AKI during insulin, sulfonylurea, metformin or SGLT2 treatment requires a documented sick-day plan.
Inspect skin and deformity, test sensation and pulses and use urgent multidisciplinary pathways for active or limb-threatening disease.
06Retinal and cardiovascular surveillance
Why
Prevent treatable visual and vascular disability.
Interpretation and limitations
Arrange retinal screening and assess pressure, lipids, smoking and vascular symptoms according to current risk and goals.
07Self-management and capacity assessment
Why
Determine whether the regimen can be delivered.
Interpretation and limitations
Observe testing, pen use, dose selection, hypoglycaemia treatment and supply with cognition, vision, dexterity and carers.
Provide longer-acting carbohydrate after recovery and observe for recurrence from sulfonylurea or long-acting insulin.
3Identify meal, dose, renal, weight, cognition and administration causes and reduce the responsible regimen before discharge.
03Sick-day routePrevent ketosis, accumulation and dehydrationVomiting, infection, reduced intake or fluid loss disrupts usual diabetes care.+
1Increase glucose monitoring and check ketones according to type, SGLT2 exposure and symptoms and maintain safe fluids and carbohydrate.
2Continue basal insulin and obtain diabetes advice for dose adjustment while applying medicine-specific temporary holds for dehydration.
3EscalationEscalate persistent vomiting, ketones, low glucose, dehydration or inability to self-manage and document restart instructions.
04Functional and community routeMake the regimen reliableCognition, sensory loss, dexterity or care timing causes missed or duplicate treatment.+
1Observe the complete test, dose and injection task and identify the precise barrier rather than assuming non-adherence.
2Simplify devices and timing, align with meals and carers and provide accessible written target and rescue instructions.
3Review supply, sharps, foot care, retinal access and community diabetes ownership after every care transition.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Emergency community or clinical rescue from severe insulin-related hypoglycaemia when a trained responder is present.
Glucagon rescue
Give 1 mg intramuscularly or subcutaneously for severe hypoglycaemia in an adult unable to take oral carbohydrate when IV glucose is not immediately available, then give carbohydrate once swallowing is safe.
Effect may be limited after prolonged fasting, alcohol excess or severe liver depletion; call emergency help, place safely, monitor response and treat recurrent hypoglycaemia because glucagon is temporary.
Simplify timing and devices, involve diabetes nursing and pharmacy, and document who tests, injects, treats lows and orders supplies.