Many older adults with diabetes can credit their old age to the work they put in to keep their blood sugar within what they believe to be a healthy range. But what if those efforts are actually making things worse?
New research suggests the guidelines for high blood glucose levels in older people with diabetes may not need to be so stringent. In fact, treatment that is too aggressive may backfire, leading to dangerous falls, hospitalizations, and even death.
Overtreatment in Older Adults Can Be Fatal
Many diabetes patients are prescribed drugs to keep their hemoglobin A1c – a measure of average blood glucose levels over several months – from getting too high.
This is because high blood sugar, also called hyperglycemia, can cause serious long-term damage, including mental decline, organ damage, and heart disease.
Patients may not notice hyperglycemia symptoms for days or weeks, and long-term complications often take 10 years or more to develop – possibly longer than some older patients’ remaining life expectancy, especially if they have other health conditions.
But the effects of hypoglycemia – or low blood sugar – can be felt much sooner, and the risk of serious hypoglycemia rises with age. Given that more than 1 in 4 people in the U.S. over 65 have diabetes, and just under half have prediabetes, millions of Americans could be at risk.
A 2017 study found that one-third of older adults with type 2 diabetes who had a severe hypoglycemic episode died within three years of that episode. Another study, published in 2020, found that severe hypoglycemia was linked to a much higher risk of falls.
Elizabeth Selvin, PhD, director of the Welch Center for Epidemiology and Clinical Research, and a professor at Johns Hopkins Bloomberg School of Public Health, was involved in both studies. Sometimes, treatment for high blood sugar goes too far, and hypoglycemia is potentially a "more serious condition than we have truly understood," she says in a news release.
"If the benefit is 10 or 20 years down the line and your patients are in their 70s, maybe we shouldn’t be putting them on anti-diabetes medications," Selvin adds.
But why does the risk of hypoglycemia increase as we get older?
Jacqueline Lonier, MD, an endocrinologist and assistant professor of medicine at Columbia University’s Irving Medical Center, says it has to do with metabolism and body composition.
"Type 2 diabetes is a disease of aging," she says. "As people age, their metabolisms change, and insulin resistance may increase. As body composition changes, the insulin-producing cells in the pancreas may not respond as well to changing glucose levels."
A Focus on Preventing Lows
Most patients who have diabetes or prediabetes are told to keep their A1c levels below 7%. Often, this goal stays the same across their lifetimes, despite changes in age, lifestyle, and overall health.
This is the case for Paula Griffin. At 71, her goals in managing her diabetes have stayed largely the same since her diagnosis in her 40s, she says. What has changed is how she meets them, she adds.
She says she used insulin to control blood sugar for most of the time since her diagnosis. In the past year, she stopped using insulin in favor of a combination of metformin, empagliflozin (Jardiance), and semaglutide (Ozempic). She also monitors her glucose levels regularly.
Since starting the new drug plan, Griffin hasn’t had a single hypoglycemic episode. When she did have them, they would typically happen in the middle of the night or early in the morning, and by the time she realized what was happening, her levels were already too low.
"It was terrible," she says. "It was heart palpitations; it was sweating. It was lightheadedness and dizziness."
It’s common to miss the signs of a low glucose level, especially for older people. Symptoms vary, but they often include fatigue, confusion, color draining from the skin, and headaches, which can easily be overlooked or mistaken for another illness.
Managing Glucose Without Increasing Medications
Griffin has found a medication plan that works for her, but she says she started to see improvements in her glucose levels even before switching medications. The trick? Diet and exercise.
Griffin lost 40 pounds in 2021 through regular exercise and a personalized meal plan from a dietitian. This was possible because she tailored her approach to her lifestyle and needs, as no one plan will work for everyone.
Tristin Geschwender, a registered dietitian and former diabetes educator based in Atlanta, says that older patients may have more power over their bodies than they think.
"Even as we age, we can still keep our metabolism in check with a healthy lifestyle," she says.
Patients can build muscle through exercise, and the more muscle a patient has, she says, the more their metabolism will increase.
Geschwender says a dietitian will take into account all parts of a patient’s lifestyle, including lab results, routines, and preferences, to make a customized treatment plan. "I would want every single person who has diabetes to see a dietitian."
Rejecting a One-Size-Fits-All Approach
Several medical organizations have updated their guidelines in recent years to reflect these nuances in treatment. As of 2025, the American Diabetes Association recommends the following targets:
- Healthy older adults: A1c target of less than 7.5%
- Older adults with complex/intermediate health:A1c target of less than 8%
- Older adults with very complex or poor health or limited life expectancy: Avoid reliance on A1c target goals entirely
Moti Gamburd, a biochemist and CEO of CARE Homecare, which offers nonmedical home care for older people in Los Angeles, says he’s seen the benefits of less aggressive treatment firsthand.
He says one of his clients, an 86-year-old male patient, had an A1c level of just over 7. His doctor wanted to prescribe him a drug to lower his levels, but instead, his treatment team decided to change his diet and add a daily walk. The patient’s levels were soon back to normal without a lot of big changes.
"Comfort, not control, is the compass once you're mapping care with aging," Gamburd says. "Tight glucose targets seldom give more than they take away."
Ultimately, patients benefit most when their treatment is tailored to them, and often, this can only happen when a patient or caregiver learns to advocate for themselves.
Griffin says being her own advocate is one reason she has been able to keep her health issues in check over the years.
"Find a doctor who is going to understand that you know what's going on with your body," she says.
And if you feel like your doctor isn’t listening to you, Griffin says, don’t be afraid to find a new one.
Several years ago, she asked her doctor about the Libre – a continuous glucose monitor that allows her to take her blood sugar in real time without pricking her finger. The doctor discouraged it, saying that insurance likely would not cover it before a claim had ever been filed.
"So I just changed doctors," Griffin says. Now that she has a continuous glucose monitor, she can make adjustments more quickly, and her glucose levels are more stable.
Ultimately, "everyone has to make these decisions on an individual basis in consultation with their doctor," Lonier says. "What's right for one person isn't always right for the next person … everyone is going to age differently and have different goals."
