Top cases
When it comes to treating diabetes in older adults, one size does not fit all.
What works for a younger patient doesn’t always translate to someone in their 80s or 90s. And when a patient chooses not to pursue additional medications, it requires clinicians to carefully balance risk, benefit, and quality of life. In elderly diabetes management, the focus often shifts from hitting strict numbers to simply supporting quality of life in favor of patient preferences.
In this case shared on Healthcasts, a practitioner is seeking perspectives on how others would have managed an elderly patient with type 2 diabetes who declined all additional medications.
How would you approach building a care plan for the patient case below? Log in or sign up to share your perspective and view the consensus summary.
Post:
About 25 years ago, I inherited a lovely elderly woman from a physician who retired.
She was a long-standing type 2 diabetic. She was in her late eighties when she first became my patient.
Her only diabetic medication was glipizide; her hemoglobin A1c was always in the mid-nines, and her glucose readings were mostly in the 200s. She had CRI stage 3. Her only other medication was an ACE for hypertension. Her BPs were a tad high but not terrible, and she had some modest micro-albumin in her urine. She refused any other medications, eg, statins, insulin. She agreed to see me only every 6 months and have labs only once a year. She came in faithfully with her daughter, with whom she lived.
Year after year, her sugars remained in the 200s, and her A1C hit 10. When the DPP-4 inhibitors came out, I tried to convince her to let me add that, and she politely declined.
She was mentally sharp and had a good quality of life. Despite her poorly controlled DM2, she died peacefully at home several years ago at 102. I was dinged in my DM 2 quality numbers, I am sure, but when it comes to the very old, less is more.
Questions for consult
Would you have treated her differently?
Comments
Key takeaways about elderly diabetes management:
- Patient autonomy is paramount
Clinicians agreed that respecting the patient’s informed decisions, especially in advanced age, takes priority over strictly following treatment guidelines. - Tailor treatment goals to the individual
For very elderly patients, prioritizing quality of life over aggressive targets is key. Relaxed glucose targets, careful risk-benefit considerations, and quality of life should guide management rather than strict numeric goals. - Shared decision-making and ongoing support matter
Engaging patients and their families in discussions, documenting preferences, and remaining available for care fosters trust and ensures clinicians can support them within their chosen approach.
Family Practice
"No. At her age, she had every right to informed consent. Now, if she were 40-70, it would be different. But she wasn’t, and the risk of other complications, including falls from hypoglycemia, was a bigger risk—in my opinion—at her age. At some point, we have to agree that less is more, and if the patients are content in their 80s, 90s, have informed consent, and have what they consider to be a good quality of life- we have done our job."
Endocrinology/Diabetes
"Well done. I think most people have similar patients—medicine is not about just treating numbers, but aligning and adapting the therapeutic strategy to the patient in front of you. She clearly valued your input but decided to adapt it to her own beliefs and preferences. It is very difficult to argue that any different therapeutic strategy would have improved her outcomes or quality of life."
Family Practice
"At each office visit with this patient and her daughter. I would engage in shared decision-making. I would review current treatment guidelines for her conditions, discuss the pros/cons of adding additional medications, as well as the risks of non-treatment vs potential benefits of additional treatment. If the patient still declined further medication, I would document this in her record and respect her decision."
Internal Medicine
"Firstly, the patient’s autonomy needs to be respected. Assuming that she was mentally competent, she had the right to refuse treatment after informed consent. However, I would have tried to convince her to change from glipizide to an SGLT-2 agent. This would act to limit hypoglycemia as well as being renal protective. Of course, at her age, my goal for glucose control would be more relaxed (HgbA1C in the 8 range)."
Endocrinology/Diabetes
"I would not have done much differently. You can not force anyone to take medications. If you try, they likely will never return and therefore get no care. 25 years ago, the choices for medication were very limited. I also would have offered metformin, and subsequently other meds like SGLT2 when they became available. I would explain the benefits, ease of taking, reason to take, etc. If she declined, then I would agree that it is her choice and I am still there for her."
What is your strategy for balancing patient autonomy with appropriate care in senior patients? Head to the full post to leave a comment and read other perspectives from the community.
