Frailty and Type 2 Diabetes (T2DM)

Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
National

This section concentrates on prescribing in older people living with frailty who have T2DM, with a particular focus on:

  • whether intensive blood glucose control (aimed at a target HbA1c less than 48mmol/mol / <6.5%) reduces the risk of mortality, cardiovascular events, and diabetes related end points
  • the risks of intensive blood glucose control and potential increase in adverse events

The mixed quality and limited evidence indicates:98,99

  • In those with frailty, higher HbA1c (>69mmol/mol, >8.5%) is associated with poor muscle quality and sarcopenia.
  • In older adults with T2DM and CKD, tight glycaemic control (<42mmol/mol, <6%) increases the risk of hypoglycaemia, further deterioration in function and cessation of disability-free living. Therefore, acceptable glycaemic targets are:
    • 53-64 mmol/mol (7-8%) generally
    • 59-69 mmol/mol (7.5-8.5%) for frail older adults with CKD
    • Avoid tight glycaemic control (<42mmol/mol, <6%)
  • Higher levels are acceptable in those with limited life expectancy (whilst minimising symptomatic hyperglycaemia or hypoglycaemia).
  • Assess HbA1c readings from the previous 6-12 months to set goals for discharge regarding glycaemic control. Previous targets could be revisited and goals individualised to take account of comorbid medical conditions or functional and cognitive status. In people with moderate to severe frailty, a higher glucose range was acceptable.
  • If a person is admitted to hospital, it is necessary to immediately review the therapy regimen on admission, and then every 24 hours, to ensure a satisfactory level of glycaemia, avoiding overtreatment and minimising adjustments.
  • It is important to be aware that insulin doses at hospital discharge can be very different to those needed in the community. Any medication changes need to be communicated clearly in the discharge summary to the primary and community care team and family members/carers. There should be a rapid review post discharge.

The list below sets out the recommendations based on the evidence, and a considered judgment process.

 

Recommendations to manage frailty and T2D

1 - Good practice point

Healthcare professionals (HCP) and older people with frailty may want to discuss the following regarding diabetes medication:

Strict avoidance of both hypoglycaemia (defined as <4.0 mmol/L) and osmotic symptoms (usually seen when glucose levels are greater than 15 mmol/L) should be a major goal of care for the frail older inpatient.

2 - Good practice point

A higher glucose range should be considered by the care team in people with moderate to severe frailty or those with limited life expectancy.

3 - Good practice point

The need for glycaemic control to be less rigid for frail older adults with chronic kidney disease: an HbA1c range of 59-69mmol/mol (7.5-8.5%), due to an increased risk of hypoglycaemia. Avoid tight glycaemic control (Hba1c <42mmol/mol (6%)).

4 - Good practice point

Higher HbA1c of >69 mmol/mol (>8.5%) has been shown to be independently associated with poor muscle quality, which may lead to sarcopenia.

5- Good practice point

To review medication regimen post discharge, at home, or in a care facility.