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Normal A1c Target Range for Seniors – Are You Over treated?

Introduction

Seniors years of the life comes with its own challenges of wear and tear of your body parts impacting the body functions. Seniors of ≥ 65 years of age, the incidence and prevalence of diabetes is increasing as per Center of Disease
Control (You can be a longterm sufferer of diabetes starting around -40-45 years of age or have developed diabetes in your senior years, which is considered short term. It might have happened you have never tested for diabetes and suddenly found to be diabetic at your senior years.
It does not matter, when you got diabetes, keeping control of your body sugar has been vital. A1c test is a reliable and repeatable diagnostic test used by medical practitioners. American Dibetes Association (ADA) has A1c target of <7 for seniors in its 2008 guidelines. The medications prescribed by the physicians are based on this target.
Cuurrent guidelines are the updated and this blog is about the A1c level of seniors where various heath authorities have recommended higher target than <7 which was recommended earlier.
The unrealized, unseen and uncontrolled sugar level becomes detrimental breeding multiple complex symptoms. It adds burden to a senior’s health. 1 in 3-4 Americans suffer from diabetes type 2 and it has taken a toll in the entire world.

A1c Naturally Increases With Age- How About the Target?

A1c increases with age for both diabetics as well as for non-diabetics. This finding is reported by multiple health authorities and research sites which are based on real population based studies and statistics. However the current clinical practice does not incorporate these variations to prescribe medication and treatment of diabetes patients.
The target for everyone inclusive of seniors is <7% as 2008 ADR guidelines. The clinicians use this number for treatment and management of diabetes,
Currently, a new global cut off for diabetes for seniors is being introduced as guidelines based on of couple of population studies

What  is the Most Recent ADA Guidelines?

There is a new guideline comprising an elevated A1c which can go up to 8.5 or even 9 for adult seniors ≥65 years of age.
What’s the Big Deal with Higher Normal A1c Target?- Incorrect Diagnosis Can Lead to Complex Symptoms
For Diabetes, higher A1c target is a relaxing guideline. Because accomplishing 8 or 8.5-9ish is easier than achieving <7%. <7% needs more stringent glycemic control, and higher medication requirement. Using more than adequate medicines when not necessary may cause dangerous low sugar situation. In essence senior patients can be easily misdiagnosed and over treatment harm the body rather than improving. Realizing your normal A1c target range as a senior can help you mitigating the risks.

A1c Number Represents a Reliable and Offers Accurate Diagnosis of Diabetes:

1. They are repeatable
2. It is convenient as it doesn’t need fasting before the blood sample is withdrawn

American Diabetes Association (ADR) offers <7% A1c as the normal target for adults without diabetes.

Aging Related A1c Increase With Non-Diabetes (2008)

Age in Years.      A1c          Mmol.      Mg/ dL
20-39.                  6.0%.       42.1           126
40-59.                  6.1%.        43.2          140
≥60 years.           6.5%.       47.5.          160

Underlying Factors for Enhanced A1c for Seniors (≥ 65 years)
Causes-Behind-the-Higher-A1c -Normal-for-Seniors

Disease Duration: Obviously if the onset is during the middle age, (mid 40’s) you have suffered longer compared to the onset during your seniors years (~65 years).
Life Expectancy: You are expected to live more or less than 10 years
Relevant Diabetes and Other Unrelated Medical Symptoms: The diseases and symptoms determine your overall wellbeing, how you function on day-to-day basis.
Pancreas Overwhelmed Addressing the Insulin Requirement for Years Up to Senior Life: In many cases it can’t support converting your body glucose entirely or partially to energy. The glucose stays on the blood stream resulting in higher A1c.

This accompanied table can help you quickly looking at the conversion if you are more familiar with Mmol/dL. The implications of these numbers In context to health are described following this table.

A1c.      Mmol/ dL

7%        154
7.5%.    169
8%.       183
8.5%.    197
9%         212


A1c Targets- What Does the number Mean?

A1c >7
1. You are functioning well
2. Just have a few other symptom related or unrelated to diabetes
3. It’s easy for you to achieve

A1c 7.5

1, It is a reasonable goal for healthier adult
2. <3 chronic syndromes
3. No significant cognitive or visual impairment
4. Life expectancy of <10 years
0-1 living dependency

A1c <8.5

1. It is a great goal for senior type 2 diabetes patients living with complex medical issues.
2. They are suffering from multiple diseases related to diabetes and otherwise.
3. Poor overall health conditions
Not functioning well
4. ≥2 living dependency

This relaxed guideline is recommended by American Diabetes Association (ADR)

Is A1c Age Dependent?

The reasons A1c changes with aging because RBC numbers change with aging.
1. There might be a change in the way how RBCs are made from stem cells.
2. Compromise between RBC production and clearance.
3. All RBC contribute to the measured level of HbA1c. Although older RBCs are supposed to be exposed more to plasma glucose, younger ones are more in numbers. (ref: Review of hemoglobin A1c in the management of diabetes).
4. The changed RBC numbers contribute to changed A1c.
The clinicians have not yet accepted the natural enhanced change in A1c with older adults.

Implications of Higher A1c Numbers

Hypoglycemia: Hypoglycemia is lowering of blood sugar level than normal level. In severe cases this can take the patient to coma o rer even death. It is more common in patients ≥80 years vs. ≥60-69 years. Patients having diabetes for longer duration are 3x times more prone getting them. Older patients with insulin and sulfonyl urea as treatment regimen are at higher risk.
Stay in touch with your physician and glucose monitoring to avoid hypoglycemia.
Fall: it is more common with senior diabetes patient of ≥ 75% of age. Tighter glycemic control was associated 32% of higher risk of fall with patients having >7% Of hemoglobin A1c level.
Non Spine Fracture: >300,000/ year 65 year old patients are hospitalized for hip fracture. Mortality rate after 1 year of hip fracture have been reported at over 25% in observational studies.
Patients ≥ 65 years with HbA1c between 6.5-6.9 were at lowest risk after a 3.3 year follow up.
Patients ≥ 65 years with HbA1c between 6-7 and a 7 year follow up were seen to have ≥ 90% higher risk of hip fracture.
Randomized trials are currently looking at this.
Frailty: 7000 adults of ≥ 65 years age in a survey study (National Health and Nutrition Examination survey)over 1988-2011, having A1c ≥ 8% had higher risk of all cause mortality compared with HbA1c <6.5.
Cardiovascular Outcome: The risk of cardiovascular outcome increases with poor glycemic control with new onset of diabetes at older age, However this data is mixed with patients suffering from long term diabetes.
Microvascular Outcome: Renal failure and death from rentl failure showed a 25% reduction in an U.K. based trial after a 17 year follow up. Sulfonyl urea showed a persistent reduction of 24% while metformin did not.

Do Seniors Need Personalized Care?

There are ongoing discussions by the health authorities to treat patient population according to their unique need based on A1c, tion of diabetes, complexities of health conditions based on diabetes and otherwise. For example a senior with A1c of 8.5 and suffering from mue complex syndromes will be in a worse situation if he would medicated to target A1c of <7. Too much medicine lead to hyperglycemia, i.e. low sugar situation where there can be a possibility of going into diabetes coma.
Healthy diet recommendation from your dietician and exercise suggestions based on your health condition fro your diabetes care team can help you along with medication(s).
Bottom line
The higher A1c level might just be normal and reflection of of your aging and expected longevity based on your over all health. The senior diabetes patients would benefit more with prsonalized treatments.
Clinical studies have been conducted where seniors have been excluded from the trials. More studies needed to be done with senior patients to help the ever growing senior diabetes population.
Showlow are the official guidines from multiple health authorities.
Professional society Older age definition Recommendations
American Diabetes Association (ADA) [1] ≥65 years
Health status     HbA1c    FPG/PPG
Healthy           <7.5%  90–130 mg/dl
Intermediate  <8.0%  90–150 mg/dl
Poor                 <8.5%  100–180 mg/dl

American Geriatrics Society [2]
≥65 years
Category            HbA1c
Overall             7.5–8.0%
Healthy/few comorbidities  7.0–7.5%
Poor health     8.0–9.0%

American Association of Clinical Endocrinologists (AACE) [3]

No age indicated Category “Less healthy” Glycemic control “Less stringent”

International Diabetes Federation [4]
≥70 years

Category                                   HbA1c
Functionally independent  7.0–7.5%
Functionally dependent      7.0–8.0%
Frail/dementia                      Up to 8.5%
End of life  “Avoid symptomatic hyperglycemia”
European Association for the Study of Diabetes [5]
No age indicated Personalize HbA1c targets based on expected life duration, age, etc.

References:

https://healthhelmet.com/a1c-test-for-diagnosis-of-diabetes-type-2

https://bmcendocrdisord.biomedcentral.com/articles/10.1186/s12902-019-0338-7

https://healthhelmet.com/causes-of-diabetes-type-2-above-and-beyond-impaired-insulin

https://healthhelmet.com/17-ways-to-reduce-

https://healthhelmet.com/treat-severe-vitamin-d-deficiency-empower-your-body-to-fight-and-prevent-life-threatening-diseases

 

 

Anusuya Choudhury

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