According to the CDC, nearly 1 in 3 Americans over age 65 live with diabetes. However, our health care system treats diabetes as if all adults are metabolically and functionally the same. In their attempt to maximize glycemic control, it’s not uncommon for elderly patients to experience hypoglycemic episodes, resulting in falls and confusion among other issues, exacerbating other health conditions while taking a mental and emotional toll on patients and caregivers alike.
Prior to medical school, I spent two years working at a geriatric primary care clinic in Philadelphia, watching elderly patients take steps to worsen their health, like taking excessive doses of their medications or skipping meals to get their A1c to 7.0. I also remember how those actions often caused them to end up in the emergency department and complicate their care for their physicians upon discharge. Consequently, this attempt at preventive care ends up harming our elderly patient population in the long run.
Presently, quality metrics used by the Centers for Medicare & Medicaid Services (CMS) and many other health systems reward physicians for maintaining an A1c below 7.0: a suitable metric for a healthy adult in their 40s, but hardly beneficial for a senior citizen in their 80s struggling with frailty and cognitive impairments nearing the end of their life. Of course, standardized guidelines for A1c in diabetes treatments are beneficial for various reasons, including continuity of care across clinics across the country as well as improving the quality of research studies. However, providing standardized, modified A1c ranges that account for a patient’s other conditions could improve diabetes care while opening new avenues for research for underrepresented patient populations.
While the American Diabetes Association (ADA) and American Geriatrics Society (AGS) now recommend individualized A1c targets between 7.5 and 8.5 based on a geriatric patient’s multiple comorbidities, the payment structures that guide daily clinical decisions do not align with these guidelines. Consequently, physicians are often forced to prioritize rigid quality standards instead of providing personalized care that reflects the patient’s physiologic and social changes that accompany their aging process. As a result, more medications are prescribed, only complicating care for the patient and more visits to the emergency room.
A 2023 JAMA Internal Medicine analysis found that up to 40 percent of older adults are “over-treated,” defined as receiving medications that provide no proven benefit but significantly raise the risk of devastating hypoglycemic episodes and other side effects that only further worsen the patient’s quality of life.
Managing diabetes in geriatric patients should prioritize function, comfort, and independence instead of trying to hit some lab number. This shift in perspective requires a change on the systemic level instead of blindly assuming that a patient has reached their optimal state once their A1c reaches 7.0. CMS can update its quality-reporting programs to financially reward clinicians for hitting individualized targets instead of standardized ones. A new system of patient-specific target A1c ranges adjusted for level of frailty and presence of various comorbidities would realign incentives with evidence-based care. Hospitals and electronic medical records could incorporate this new system into their internal dashboards for reinforcement.
Insurance policies must also do their part in optimizing geriatric diabetes management. Until recently, Medicare covered continuous glucose monitors only for those patients on multiple daily insulin injections. While this may have been an attempt to reserve resources for the most severe of patient cases, it ended up neglecting thousands of geriatric patients at risk of hypoglycemia, be it from excessive use of oral agents or food insecurity. Even from a cost perspective, the resources necessary to provide geriatric patients with continuous glucose monitors pale in comparison to the financial, mental, and administrative burden resulting from the consequential and preventable admissions for hypoglycemic episodes.
Ultimately, this is a responsibility of the medical industry as a whole. The CMS can revise quality metrics and expand coverage for continuous glucose monitoring to incentivize provider care that prioritizes the patient’s quality of life and reduces financial, emotional, and administrative burden caused by preventable admissions, respectively. Similarly, hospital quality boards can adjust internal performance goals away from standardized A1c goals and more towards individualized goals based on level of frailty and associated comorbidities.
The ADA and AGS can enhance advocacy for individualized A1c targets in reimbursement policies. They can also increase the prevalence of diabetes education programs for all aspects of daily diabetes care, be it medication administration, daily blood glucose checks, or even cooking diabetes-friendly meals. Implementing these changes will do wonders for improving patient care for our ever-growing elderly population and will lighten the unnecessary encumbrance placed on medical staff at all levels due to these outdated and downright harmful practices.
George James is a medical student.
