Skip to content
Umbrella Aged Care
← Medicines and deprescribing

Diabetes in frail residents

GPs & clinicians Aged care staff Residents & families 6 min read

By Dr Josh Hatch, FRACGP

In a fit older adult, good glucose control helps prevent complications that develop over many years. In a frail resident, the more immediate risk is often the reverse: glucose that falls too low. Australian general practice guidance recommends less strict targets for frail older people and says treatment should aim to avoid hypoglycaemia 32.

Numbers in the text link to the 4 sources listed at the foot of this page.

What the guidance says

The RACGP guidance for older people and residential aged care says glucose targets may be higher than for younger adults, giving the example of an HbA1c target of 8% (64 mmol/mol) rather than 7% (53 mmol/mol). It also notes that HbA1c above 8 to 8.5% (64 to 69 mmol/mol) is associated with more illness and death in older patients, so a relaxed target is not the same as no target 32.

The same guidance recommends simplifying complex regimens where this can be done within the individual target, avoiding long-acting sulfonylureas in frail people or when eating patterns are irregular, avoiding complex insulin regimens, and using insulin pens in residential aged care to reduce dosing errors. These recommendations are dated November 2024 and are updated from time to time 32.

How common is overtreatment?

A systematic review led by Australian researchers found 15 studies of potential overtreatment in long-term care. Depending on the definition, between 5% and 86% of residents with type 2 diabetes were potentially overtreated. Where overtreatment meant an HbA1c below 7% in a resident on a glucose-lowering medicine with at least one risk factor for hypoglycaemia or a serious illness, the range was 16% to 74%. None of the studies followed residents forward to measure harm 30.

In US veterans’ nursing homes, 17% of 7,422 residents with type 2 diabetes were overtreated and a further 23% potentially overtreated. Within two weeks of the HbA1c result, treatment was reduced in only 27% and 19% of these groups, and a history of hypoglycaemia did not make reduction more likely 31. In a US national survey of older people living in the community, 56% of those in very complex or poor health had an HbA1c below 7%, and 60% of them were taking insulin or a sulfonylurea 29.

All of these studies are observational. They show how often treatment is tighter than guidance suggests, not how much harm resulted in each case.

Where the trial evidence runs out

No randomised trial was found that compared a less intensive glucose strategy with usual care in frail residents of aged care and measured outcomes such as hypoglycaemia, falls or quality of life. Recommendations for this group rest on guidelines and observational data 3032.

Things worth checking on the chart

  • Low readings. Any blood glucose readings low enough to need treatment, and whether they cluster at a particular time of day.

  • Medicines that cause hypoglycaemia. Insulin and sulfonylureas such as gliclazide carry the main risk, and complex regimens add to it 32.

  • Eating. A resident who eats less, misses meals or is unwell is at greater risk on a sulfonylurea 32.

  • The most recent HbA1c. A result well below the resident’s individual target may mean the regimen can be simplified 32.

  • Goals of care. Near the end of life, the aim may shift to avoiding symptoms of high or low glucose rather than reaching a number.

Sources cited on this page

  1. 29 Lipska KJ, Ross JS, Miao Y, Shah ND, Lee SJ, Steinman MA. Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Intern Med. 2015;175(3):356–62. (US national survey of community-dwelling adults, 2001–2010; cross-sectional.) View source
  2. 30 Stasinopoulos J, Wood SJ, Bell JS, Manski-Nankervis JA, Hogan M, Sluggett JK. Potential overtreatment and undertreatment of type 2 diabetes mellitus in long-term care facilities: a systematic review. J Am Med Dir Assoc. 2021;22(9):1889–97.e5. (15 observational studies.) View source
  3. 31 Lederle LI, Steinman MA, Jing B, Nguyen B, Lee SJ. Glycemic treatment deintensification practices in nursing home residents with type 2 diabetes. J Am Geriatr Soc. 2022;70(7):2019–28. (7,422 US Veterans Affairs nursing home residents; observational.) View source
  4. 32 Royal Australian College of General Practitioners. Management of type 2 diabetes: a handbook for general practice — Type 2 diabetes management for older people and residential aged care facilities. Recommendations dated 14 November 2024. View source

See every source cited across the medicines and deprescribing section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. Evidence and Australian regulatory, PBS and program arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

Enquire about care