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American Diabetes Association Framework for Glycemic Control in Older Adults: Implications for Risk of Hospitalization and Mortality

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posted on 18.05.2021, 15:16 by Mary R. Rooney, Olive Tang, Justin B. Echouffo Tcheugui, Pamela L. Lutsey, Morgan E. Grams, B. Gwen Windham, Elizabeth Selvin
Objective: The 2021 American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults based on comorbid health status. We assessed risk of mortality and hospitalizations in older adults with diabetes across glycemic control (A1C <7%, 7-<8%, ≥8%) and ADA-defined health status (healthy, complex/intermediate, very complex/poor) categories.

Research Design and Methods: Prospective cohort analysis of older adults aged 66-90 years with diagnosed diabetes in the Atherosclerosis Risk in Communities (ARIC) Study.

Results: In the 1841 participants (56% were women, 29% Black), 32% were classified as healthy, 42% had complex/intermediate, and 27% had very complex/poor health. Over a median 6-year follow-up, there were 409 (22%) deaths and 4130 hospitalizations (median, 25th-75th: 1, 0-3 per person). In the very complex/poor category, individuals with A1C≥8% (versus A1C<7%) had higher mortality risk (HR 1.76, 95%CI:1.15-2.71), even after adjustment for glucose-lowering medication use. Within the very complex/poor health category, individuals with A1C≥8% had more hospitalizations (incidence rate ratio (IRR) 1.41, 95%CI:1.03-1.94) than those with A1C<7%. In the complex/intermediate group, individuals with A1C≥8% (versus A1C<7%) had more hospitalizations even with adjustment for glucose-lowering medication use [IRR 1.64 (1.21-2.24)]. Results were similar, but imprecise, when the analysis was restricted to insulin or sulfonylurea users (n=663).

Conclusions: There were substantial differences in mortality and hospitalizations across ADA health status categories, but older adults with A1C<7% were not at elevated risk, regardless of health status. Our results support the 2021 ADA guidelines and indicate that <7% is a reasonable treatment goal in some older adults with diabetes.


The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services, under Contract nos. (HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700005I, HHSN268201700004I). Research reported in this publication was supported by the NIH/NHLBI grant T32HL007024 (Rooney), NIH/NHLBI grant K24HL152440 (Selvin), and NIH/NIDDK grant R01DK089174 (Selvin).