Grades are shown as the source states them. Neither source grades its recommendations: one is an expert position paper and the other a systematic review comparing guidelines. Where guidelines disagree, the summary says so.
Key recommendations
Set the HbA1c target by function and frailty, not age: 7.0–7.5% (53–58.5 mmol/mol) if functionally independent; 7.5–8.0% (58.5–63.9 mmol/mol) if partially dependent or pre-frail; 8.0–8.5% (63.9–69.4 mmol/mol) if frail or dependent. A target as low as 6–6.5% is acceptable for independent people taking only drugs that do not cause hypoglycaemia (metformin, SGLT2 or DPP-4 inhibitors).
Individualization: individualized targets for glucose controlEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Screen older people with diabetes for frailty (for example the Clinical Frailty Scale, where 5 or more indicates frailty) and offer a comprehensive geriatric assessment to those who are frail or pre-frail.
Identification of frailty; Table 2European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Make avoiding hypoglycaemia central to drug choice. Most guidelines advise avoiding sulfonylureas or using them with caution in older people, and avoiding long-acting ones such as glibenclamide (glyburide).
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
Assess nutrition before starting drugs that cause weight loss (metformin, SGLT2 inhibitors, GLP-1 receptor agonists, tirzepatide), and avoid them in people who are malnourished or at risk until nutrition improves. Weight loss is not a primary goal in older adults, even if overweight.
Innovation in pharmacological treatments; Key considerationsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
De-intensify and deprescribe in moderate to severe frailty, dementia, care-home residence or limited life expectancy. From age 80, HbA1c below 6.5% (or below 7% in some situations) is generally not recommended, especially with frailty, frequent hypoglycaemia, complex regimens, kidney impairment or dementia.
Individualization: de-intensification of glucose-lowering medicationsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Simplify regimens — once-daily drugs, long-acting basal insulin, devices that reduce complexity — and involve carers when cognition or physical function is impaired.
Table 1; Individualization: de-intensification of glucose-lowering medicationsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Diagnosis
Frailty affects about a third to a half (32–48%) of older people with diabetes, and diabetes predicts progression to worse frailty.
IntroductionEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Two contrasting metabolic phenotypes need different approaches: “anorexic malnourished” (weight loss, lower insulin resistance, a slower diabetes course — de-intensify) and “sarcopenic obese” (muscle loss with visceral fat, higher insulin resistance and cardiovascular risk — may need more intensive treatment with cardiovascular risk reduction).
Introduction; ConclusionsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
A quick frailty workflow: screen people aged 65 or over with multimorbidity, weight loss, functional decline or falls (ask about unintended weight loss in 6 months, persistent fatigue, and difficulty walking 400 m), then grade: pre-frail with 1–2 markers; frail with 3 or more markers or a Clinical Frailty Scale score of 5 or more.
Table 2European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Investigations
In the geriatric assessment include gait speed and grip strength, nutrition (for example the Mini Nutritional Assessment), cognition, a medication review, and carer support and living conditions.
Table 2, step 4European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Screen at least yearly for geriatric syndromes: cognitive impairment, depression, urinary incontinence, falls, chronic pain and frailty.
Individualization of non-glycaemic managementEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Eye and foot screening matter for people with good functional reserve, but may add burden with little benefit for the frailest people with very limited life expectancy.
Individualization of non-glycaemic managementEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Look at glucose variability as well as HbA1c. Continuous glucose monitoring, with alarms for falling glucose, is particularly useful for people at risk of hypoglycaemia, living alone or with cognitive impairment.
Individualized targets; Integration of digital health technologiesEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Treatment
Among guidelines that address older adults, six name metformin as the first-line drug, and seven suggest DPP-4 inhibitors as an alternative or second-line choice.
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
DPP-4 inhibitors suit the whole frailty spectrum: weight-neutral, low hypoglycaemia risk and well tolerated, useful for mild hyperglycaemia, high hypoglycaemia risk or when metformin is contraindicated, although they do not improve major cardiovascular outcomes.
Individualization: de-intensification of glucose-lowering medicationsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
SGLT2 inhibitors protect the heart and kidneys and reduce heart failure admissions, including in heart failure with preserved ejection fraction. Use them with care in malnutrition, orthostatic hypotension, high falls risk, osteoporotic fractures, recurrent urinary infection or urinary incontinence.
Innovation in pharmacological treatmentsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
GLP-1 receptor agonists and tirzepatide give cardiovascular benefit and weight loss, but 20–50% of the weight lost can be lean mass. If used for weight, limit loss to 1 kg a week, with at least 1 g/kg/day of protein (allowing for kidney function) and resistance exercise.
Innovation in pharmacological treatmentsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
If insulin is needed, six guidelines recommend starting with basal insulin; once-daily long-acting analogues are preferred to limit hypoglycaemia, and several advise lower starting doses. Insulin needs adequate vision, dexterity and cognition, or a carer to give it.
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
Seven guidelines advise against thiazolidinediones in older adults because of fluid retention and worsening heart failure.
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
Manage cardiovascular risk (blood pressure, lipids, healthy behaviours) and prefer drugs with dual benefits, such as SGLT2 inhibitors in heart failure or kidney disease.
Individualization of non-glycaemic management; Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Vaccination remains essential even in the frailest: influenza, pneumococcal, zoster, RSV and COVID-19.
Individualization of non-glycaemic managementEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Important geriatric considerations
Hypoglycaemia is linked with death, falls and injuries, dementia, and macro- and microvascular events, and age and frailty increase both its risk and its consequences.
DiscussionBolt J, et al. (systematic review) 2024
India's RSSDI guideline (as summarised in the review): metformin first line; DPP-4 inhibitors safe; sulfonylureas not preferred — if used, a short-acting one (gliclazide, glipizide), avoiding long-acting glibenclamide; avoid meglitinides and thiazolidinediones; SGLT2 inhibitors for people under 70 of average weight or above. In frailty: metformin first, a low-dose sulfonylurea as the alternative, and oral GLP-1 agonists and SGLT2 inhibitors not suitable.
Table 2: RSSDI (India)Bolt J, et al. (systematic review) 2024
Protect muscle: ensure adequate protein, avoid rapid weight loss, and prescribe resistance exercise and nutritional support for frail people.
Individualization of non-glycaemic management; Table 2, step 5European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
For people with very complex or poor health, or at the end of life, aim to prevent hypoglycaemia and symptomatic hyperglycaemia rather than chase an HbA1c number, and align care with the person's goals.
Individualization: individualized targets for glucose controlEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Technology such as continuous glucose monitoring and telehealth needs simple interfaces and carer support to work for frail older people.
Integration of digital health technologiesEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Drug doses
Starting insulin in older people: guidelines advise lower doses — AACE 0.2–0.3 units/kg/day, and RSSDI (India) below the usual 0.2 units/kg/day, preferring long-acting insulins.
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
If a sulfonylurea is used, Diabetes Canada advises starting at half the usual dose and increasing slowly, preferring gliclazide or glimepiride to glibenclamide.
Results: pharmacological therapy; Table 2Bolt J, et al. (systematic review) 2024
When to refer
Older people with diabetes and frailty benefit from access to a multidisciplinary team — geriatrician, diabetes specialist, dietitian and social worker — for coordinated care.
Table 1European Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
Red flags
Severe or recurrent hypoglycaemia, wide glucose swings, or admissions caused by treatment side effects are triggers to deprescribe (criteria given by the ADA).
Results: deprescribingBolt J, et al. (systematic review) 2024
Unintended weight loss or malnutrition on a weight-lowering diabetes drug: stop or avoid the drug until nutrition is restored.
Innovation in pharmacological treatments; Key considerationsEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
GLP-1 agonists and SGLT2 inhibitors can cause dehydration, falls and acute kidney injury; SGLT2 inhibitors can also cause orthostatic hypotension (watch for it with loop diuretics) and urinary infections.
Discussion; Table 2Bolt J, et al. (systematic review) 2024
Recent updates
The 2025 EuGMS position paper extends the EuGMS–EDWPOP primary care guideline with frailty-based targets, newer drugs (tirzepatide, weekly and ultra-long-acting insulins), continuous glucose monitoring and AI tools, noting that frail people are under-represented in the trials behind these drugs.
Objectives; Five I'sEuropean Geriatric Medicine Society (EuGMS) Special Interest Group in Diabetes 2025
A 2024 review of 23 guidelines found most recommend HbA1c below 7.0–7.5% for healthier older adults and below 8.0–8.5% for frail or complex patients, but few give drug advice specific to frailty and none offers a deprescribing algorithm.
Abstract; Results: deprescribingBolt J, et al. (systematic review) 2024