Diabetes Management In Older Adults Research Articles

Diabetes management in older adults who fall: a study amongst older adults presenting to the emergency department.

Type 2 diabetes mellitus (T2D) is associated with poor health outcomes whilst tight glycaemic targets are questionable in those aged over 70years with increased frailty. Our aim was to examine whether people with T2D admitted to hospital with a fall, were more likely to have greater frailty, increased mortality and co-morbidity burden, or risk factors for falls than people without T2D, and whether these differences were associated with medications used for the treatment of T2D. The Older Persons Assessment Service (OPAS) is a local emergency department (ED) service, which accepts patients on frailty criteria. The OPAS accepts patients primarily aged over 70years who present with frailty and geriatric syndromes such as falls, with retrieval from the ED department directly to the service from triage. The OPAS databank was analysed for people with T2D admitted with a fall between June 2020-September 2022. We examined clinical outcomes relating to medication, age, Charlson co-morbidity index (CCI) and clinical frailty score (CFS). 1081 patients were included: 294 (27.2%) with T2D and a mean HbA1c of 53.9 (± 15.8) mmol/mol [7.1%]. People with T2D had a similar mean CFS and age compared to those without T2D, but higher mean CCI (7.0 ± 2.2 vs 5.9 ± 2.1, p < 0.001). Of those people with T2D, 175 (59.5%) and 240 (81.6%) had a HbA1c ≤ 53mmol/mol [7.0%] and ≤ 64mmol/mol [8.0%], respectively. In total, 48 (16.3%) people with T2D were identified to have a capillary blood glucose below 4.0mmol/L on admission to the ED. At 12months' follow-up, 831 (76.9%) patients were alive and 250 (23.1%) had died. People with T2D treated with insulin and/or gliclazide had a greater 1-year mortality (36.6% vs 23.6%, p < 0.05), greater frequency of hypoglycaemia (35.4% vs 11.8%, p < 0.001), and greater HbA1c (65.5 ± 17.2mmol/mol [8.2] vs 48.9 ± 12.1mmol/mol [6.6%]) compared to those who used other agents. Logistic regression confirmed a diagnosis of T2D was associated with 1-year mortality, but mortality was not significantly associated with hypoglycaemic-inducing agents. People with T2D were not more likely to live in deprived areas. A diagnosis of T2D is associated with greater 1-year mortality, and may be influenced by use of hypoglycaemia-inducing diabetes medications. Clinician awareness can support de-prescribing for patients with frailty and HbA1c < 64mmol/mol.

Continuous glucose monitoring with data sharing in older adults: A qualitative study.

This study examined the perceptions of the SHARE plus intervention and its effects on communication, collaboration, and involvement in day-to-day diabetes management in older adults with Type 1 diabetes (T1D) and their care partners. The SHARE plus intervention includes continuous glucose monitoring with a data sharing app that allows care partners to view glucose data on a smartphone and receive alerts. People with T1D and their care partners are educated about communication strategies, problem-solving strategies, and action planning when using glucose data sharing. Qualitative descriptive design. Older adults with T1D wore a continuous glucose monitor for 3 months (n = 10). Care partners (n = 10) used a data-sharing app. The SHARE plus intervention consisted of one 90-min education session. Semi-structured interviews were conducted across 10 dyads (person with diabetes and care partner) following the 12-week study. A qualitative description and a constant comparison approach were used to examine similarities and differences in experiences. Interviews were transcribed, coded, and analysed for common themes. The manuscript adheres to COREQ EQUATOR checklist. The SHARE plus intervention increased diabetes knowledge across the dyads, improving confidence and helping partners understand how to navigate symptoms and behaviours and when to intervene. Dyads worked together to optimise diabetes management through improved communication, collaboration, and management of disagreements. Although the majority of persons with diabetes and their care partners reported no conflictual communication, disagreements about diabetes management remained in some dyads. The SHARE plus intervention impacted care partners in various ways from a psychological perspective. While live-in-care partners felt peace of mind, care partners living away from persons with diabetes had some increased worry and concern. The SHARE plus intervention results can help guide future development of diabetes dyadic care and education interventions using diabetes technology. The SHARE plus intervention is a brief, practical intervention that can help diabetes clinicians improve communication and collaboration among spouses living with older adults with T1D who use continuous glucose monitoring with data sharing. A person with diabetes was part of the research team and assisted with design of the intervention and subsequent interviews and analysis.

A Behavioral Economics-Electronic Health Record Module to Promote Appropriate Diabetes Management in Older Adults: Protocol for a Pragmatic Cluster Randomized Controlled Trial.

BackgroundThe integration of behavioral economics (BE) principles and electronic health records (EHRs) using clinical decision support (CDS) tools is a novel approach to improving health outcomes. Meanwhile, the American Geriatrics Society has created the Choosing Wisely (CW) initiative to promote less aggressive glycemic targets and reduction in pharmacologic therapy in older adults with type 2 diabetes mellitus. To date, few studies have shown the effectiveness of combined BE and EHR approaches for managing chronic conditions, and none have addressed guideline-driven deprescribing specifically in type 2 diabetes. We previously conducted a pilot study aimed at promoting appropriate CW guideline adherence using BE nudges and EHRs embedded within CDS tools at 5 clinics within the New York University Langone Health (NYULH) system. The BE-EHR module intervention was tested for usability, adoption, and early effectiveness. Preliminary results suggested a modest improvement of 5.1% in CW compliance.ObjectiveThis paper presents the protocol for a study that will investigate the effectiveness of a BE-EHR module intervention that leverages BE nudges with EHR technology and CDS tools to reduce overtreatment of type 2 diabetes in adults aged 76 years and older, per the CW guideline.MethodsA pragmatic, investigator-blind, cluster randomized controlled trial was designed to evaluate the BE-EHR module. A total of 66 NYULH clinics will be randomized 1:1 to receive for 18 months either (1) a 6-component BE-EHR module intervention + standard care within the NYULH EHR, or (2) standard care only. The intervention will be administered to clinicians during any patient encounter (eg, in person, telemedicine, medication refill, etc). The primary outcome will be patient-level CW compliance. Secondary outcomes will measure the frequency of intervention component firings within the NYULH EHR, and provider utilization and interaction with the BE-EHR module components.ResultsStudy recruitment commenced on December 7, 2020, with the activation of all 6 BE-EHR components in the NYULH EHR.ConclusionsThis study will test the effectiveness of a previously developed, iteratively refined, user-tested, and pilot-tested BE-EHR module aimed at providing appropriate diabetes care to elderly adults, compared to usual care via a cluster randomized controlled trial. This innovative research will be the first pragmatic randomized controlled trial to use BE principles embedded within the EHR and delivered using CDS tools to specifically promote CW guideline adherence in type 2 diabetes. The study will also collect valuable information on clinician workflow and interaction with the BE-EHR module, guiding future research in optimizing the timely delivery of BE nudges within CDS tools. This work will address the effectiveness of BE-inspired interventions in diabetes and chronic disease management.Trial RegistrationClinicalTrials.gov NCT04181307; https://clinicaltrials.gov/ct2/show/NCT04181307International Registered Report Identifier (IRRID)DERR1-10.2196/28723

Effects of Social Distancing on Diabetes Management in Older Adults during COVID-19 Pandemic.

BackgroundOn March 22, 2020, intense social distancing (SD) was implemented in Korea to prevent the spread of coronavirus disease 19 (COVID-19). This study examined the impact of SD on diabetes control in older adults with diabetes.MethodsAdults aged 60 to 90 years with type 2 diabetes mellitus who were physically and mentally independent were recruited. Participants who had complete blood chemistry data from April to July 2019 (pre-SD era) and April to July 2020 (SD era) were enrolled. Data were obtained about physical activity, nutrition, sarcopenia, and psychological and mental health from questionnaires in April to July 2020. Calf circumference was measured.ResultsIn total, 246 people (100 men, 146 women; mean age, 73.8±5.7 years) participated in this study. The levels of glycated hemoglobin (HbA1c, 7.4%±1.0% vs. 7.1%±0.8%, P<0.001), fasting glucose (142.2±16.7 mg/dL vs. 132.0±27.7 mg/dL, P<0.001), and body weight (62.6±9.4 kg vs. 61.8±10.1 kg, P<0.01) were higher in the SD era than in the pre-SD era. Total physical activity was lower in the SD era (2,584.6±2,624.1 MET-min/week–1 vs. 1,987.3±2,295.0 MET-min/week–1, P<0.001). A larger increase in HbA1c level was associated with increased body weight and decreased physical activity.ConclusionSD had negative effects on diabetes management in older adults with diabetes. Fasting glucose and HbA1c levels and body weight increased during the SD era. Participants with reduced physical activity gained more weight and had higher blood glucose levels. Given that the COVID-19 pandemic is ongoing, health professionals and diabetes educators should monitor changes in lifestyle factors in older adults with diabetes.

Type 2 Diabetes Management in Older Adults: A Personalized Approach

Aging is considered a significant risk factor for diabetes, and over the next decade, the largest increase in diabetes prevalence is expected to be in older adults. Our study aimed to investigate the challenges in managing type 2 diabetes in older adults and its multifactorial components that affect diabetes goal setting. “My Diabetes GOAL” hypothesized that a nursing intervention, along with a collaborative approach to management, education, and care, can engage older patients in personalized goal setting and address barriers to quality of life. A total of 88 patients with type 2 diabetes mellitus were included in this 6-month randomized controlled trial, with 42 patients enrolled in the intervention arm and 46 patients in the delayed-start control arm. Patients were required to complete a survey delivered through the patient portal to initiate personalized goal setting and care management support. Patients in the intervention arm received their first telephonic care management call by a study team nurse within five business days of the initial survey completion. The nurse discussed survey responses, barriers, and concerns the patient may have involving their care. Barriers included hypoglycemia, medication, co-morbidity, and physical activity. For this abstract, we report the frequency of care management topics for all 88 patients. The majority of our patient population identified as African American (68%) and female (68%). The average A1c at baseline was 7 %. For every monthly call, A1c goal setting and education was a required discussion topic and did not vary significantly throughout the intervention (73% month one, 74% month six). During the first call, hypoglycemia was addressed among 56% of participants, and education on medication was provided to 64%. Co-morbidities (heart failure, incontinence, depression, chronic pain, falls, lung conditions, malignancies) were highly prevalent, with 68% having one or more. Physical activity was discussed in 42% of conversations with participants, and a referral (diabetes education, physical therapy) was needed by 25%. After six months, discussions regarding hypoglycemia (14%), medication (19%), co-morbidities (56%), physical activity (22%), and referrals (6%) were reduced. These results suggest that personalized telephonic care management for older adults can positively impact patient outcomes. Diabetes care management is not a one size fits all. Personalized goal setting was successfully discussed based on an individual’s risk factor, which took into consideration co-morbidities and physical mobility barriers. Future studies should evaluate long-term clinical outcomes with a randomized control design.

Implementation of a Behavioral Economics Electronic Health Record (BE-EHR) Module to Reduce Overtreatment of Diabetes in Older Adults.

Intensive glycemic control is of unclear benefit and carries increased risk for older adults with diabetes. The American Geriatrics Society's (AGS) Choosing Wisely (CW) guideline promotes less aggressive glycemic targets and reduction in pharmacologic therapy for older adults with type II diabetes. Meanwhile, behavioral economic (BE) approaches offer promise in influencing hard-to-change behavior, and previous studies have shown the benefits of using electronic health record (EHR) technology to encourage guideline adherence. This study aimed to develop and pilot test an intervention that leverages BE with EHR technology to promote appropriate diabetes management in older adults. A pilot study within the New York University Langone Health (NYULH) EHR and Epic system to deliver BE-inspired nudges at five NYULH clinics at varying time points from July 12, 2018, through October 31, 2019. Clinicians across five practices in the NYULH system whose patients were older adults (age 76 and older) with type II diabetes. A BE-EHR module comprising six nudges was developed through a series of design workshops, interviews, user-testing sessions, and clinic visits. BE principles utilized in the nudges include framing, social norming, accountable justification, defaults, affirmation, and gamification. Patient-level CW compliance. CW compliance increased 5.1% from a 16-week interval at baseline to a 16-week interval post intervention. From February 14 to June 5, 2018 (prior to the first nudge launch in Vanguard clinics), CW compliance for 1278 patients was mean (95% CI)-16.1% (14.1%, 18.1%). From July 3 to October 22, 2019 (after BE-EHR module launch at all five clinics), CW compliance for 680 patients was 21.2% (18.1%, 24.3%). The BE-EHR module shows promise for promoting the AGS CW guideline and improving diabetes management in older adults. A randomized controlled trial will commence to test the effectiveness of the intervention across 66 NYULH clinics. NCT03409523.

The Relationship Between CGM-Derived Metrics, A1C, and Risk of Hypoglycemia in Older Adults With Type 1 Diabetes.

Continuous glucose monitoring (CGM) is now commonly used in the management of type 1 diabetes (T1D). The CGM-derived coefficient of variation (CV) measures glucose variability, and the glucose management indicator (GMI) measures mean glycemia (previously called estimated A1C). However, their relationship with laboratory-measured A1C and the risk of hypoglycemia in older adults with T1D is not well studied. In a single-center study, older adults (age ≥65 years) with T1D wore a CGM device for 14 days. The CV (%) and GMI were calculated, and A1C and clinical and demographic information were collected. We evaluated 130 older adults (age 71 ± 5 years), of whom 55% were women, 97% were White, diabetes duration was 39 ± 17 years, and A1C was 7.3 ± 0.6% (56 ± 15 mmol/mol). Participants were stratified by high CV (>36%; n = 77) and low CV (≤36%; n = 53). Although there was no difference in A1C levels between the groups with high and low CV (7.3% [56 mmol/mol] vs. 7.3% [53 mmol/mol], P = 0.4), the high CV group spent more time in hypoglycemia (<70 mg/dL and ≤54 mg/dL) compared with the group with low CV (median 31 vs. 84 min/day, P < 0.0001; 8 vs. 46 min/day, P < 0.001, respectively). An absolute difference between A1C and GMI of ≥0.5% was observed in 46% of the cohort. When the A1C was higher than the GMI by ≥0.5%, a higher duration of hypoglycemia was observed (P = 0.02). In older adults with T1D, the use of CGM-derived CV and GMI can better identify individuals at higher risk for hypoglycemia compared with A1C alone. These measures should be combined with A1C for better diabetes management in older adults with T1D.

Performance of High-Sensitivity Cardiac Troponin Assays to Reflect Comorbidity Burden and Improve Mortality Risk Stratification in Older Adults With Diabetes.

OBJECTIVEIncorporation of comorbidity burden to inform diabetes management in older adults remains challenging. High-sensitivity cardiac troponins are objective, quantifiable biomarkers that may improve risk monitoring in older adults. We assessed the associations of elevations in high-sensitivity cardiac troponin I (hs-cTnI) and T (hs-cTnT) with comorbidities and improvements in mortality risk stratification.RESEARCH DESIGN AND METHODSWe used logistic regression to examine associations of comorbidities with elevations in either troponin (≥85th percentile) among 1,835 participants in the Atherosclerosis Risk in Communities (ARIC) Study with diabetes (ages 67–89 years, 43% male, 31% black) at visit 5 (2011–2013). We used Cox models to compare associations of high cardiac troponins with mortality across comorbidity levels.RESULTSElevations in either troponin (≥9.4 ng/L for hs-cTnI, ≥25 ng/L for hs-cTnT) were associated with prevalent coronary heart disease, heart failure, chronic kidney disease, pulmonary disease, hypoglycemia, hypertension, dementia, and frailty. Over a median follow-up of 6.2 years (418 deaths), both high hs-cTnI and high hs-cTnT further stratified mortality risk beyond comorbidity levels; those with a high hs-cTnI or hs-cTnT and high comorbidity were at highest mortality risk. Even among those with low comorbidity, a high hs-cTnI (hazard ratio 3.0 [95% CI 1.7, 5.4]) or hs-cTnT (hazard ratio 3.3 [95% CI 1.8, 6.2]) was associated with elevated mortality. CONCLUSIONS Many comorbidities were reflected by both hs-cTnI and hs-cTnT; elevations in either of the troponins were associated with higher mortality risk beyond comorbidity burden. High-sensitivity cardiac troponins may identify older adults at high mortality risk and be useful in guiding clinical care of older adults with diabetes.

Finding the Sweet Spot: An Interactive Workshop on Diabetes Management in Older Adults.

Intensive glucose lowering in older adults with diabetes leads to increased risks with minimal benefits. Surveys indicate that clinician confidence for individualizing glycemic goals and regimens remains low. We created an interactive workshop and clinical tool kit to improve clinician knowledge of safe diabetes management in older adults. Finding the Sweet Spot was a 1-hour workshop taught by pharmacists to medical and pharmacy learners that introduced a five-step framework for diabetes management in older adults. The interactive presentation included cases and a clinical tool kit based on current recommendations from the American Diabetes Association and American Geriatrics Society. Pilot workshops were held for 6 months, allowing for real-time revisions based on feedback; final implementation occurred for 6 months thereafter. We evaluated learner self-efficacy (via a 5-point Likert scale) and knowledge (via multiple-choice questions) of diabetes management in older adults before and after the workshop. Thirty learners participated in Finding the Sweet Spot (70% medicine, 30% pharmacy). The percentage of confident learners increased from 55% to 97% (p < .05) after the workshop. All learners demonstrated improvements in knowledge, with the mean score on the knowledge assessment increasing from 61% to 80% (p < .05). Via open-ended feedback, learners expressed satisfaction and found the clinical tool kit especially helpful. Our Finding the Sweet Spot workshop demonstrated statistically significant changes in self-efficacy and knowledge among learners, indicating that this interactive workshop improves medical and pharmacy provider confidence and skills in caring for older adults with diabetes.

Designing for implementation: user-centered development and pilot testing of a behavioral economic-inspired electronic health record clinical decision support module

BackgroundCurrent guidelines recommend less aggressive target hemoglobin A1c (HbA1c) levels based on older age and lower life expectancy for older adults with diabetes. The effectiveness of electronic health record (EHR) clinical decision support (CDS) in promoting guideline adherence is undermined by alert fatigue and poor workflow integration. Integrating behavioral economics (BE) and CDS tools is a novel approach to improving adherence to guidelines while minimizing clinician burden.MethodsWe will apply a systematic, user-centered design approach to incorporate BE “nudges” into a CDS module and will perform user testing in two “vanguard” sites. To accomplish this, we will conduct (1) semi-structured interviews with key informants (n = 8), (2) a 2-h, design-thinking workshop to derive and refine initial module ideas, and (3) semi-structured group interviews at each site with clinic leaders and clinicians to elicit feedback on three proposed nudge module components (navigator section, inbasket refill protocol, medication preference list). Detailed field notes will be summarized by module idea and usability theme for rapid iteration. Frequency of firing and user action taken will be assessed in the first month of implementation via EHR reporting to confirm that module components and related reporting are working as expected as well as assess utilization. To assess the utilization and feasibility of the new tools and generate estimates of clinician compliance with the Choosing Wisely guideline for diabetes management in older adults, a 6-month, single-arm pilot study of the BE-EHR module will be conducted in six outpatient primary care clinics.DiscussionWe hypothesize that a low burden, user-centered approach to design will yield a BE-driven, CDS module with relatively high utilization by clinicians. The resulting module will establish a platform for exploring the ability of BE concepts embedded within the EHR to affect guideline adherence for other use cases.

Diabetes Management in Older Adults With Chronic Kidney Disease.

Older adults often live with chronic disease including diabetes and its complications. In this review, we examine the complexity and heterogeneity of older adults with diabetes and chronic kidney disease, explore the nuances in their diabetes-related monitoring, and discuss their best diabetes management. Although there remains an overall lack of studies in older adults with diabetes and chronic kidney disease, recent reports have highlighted their vulnerabilities. These individuals face an increased risk of cognitive impairment and dementia, frailty, dysglycemia, polypharmacy, declining kidney function, and acute kidney injury. Their diabetes management should focus upon safer antihyperglycemic medications, close monitoring, and care individualization. Older adults with diabetes and chronic kidney disease are a complex population who requires careful diabetes management and monitoring. Research efforts might focus on improving the care and outcomes of these patients.

Diabetes Management in Older Adults: Seeing the Forest for the Trees.

Diabetes is a burdensome chronic disease that affects older adults disproportionately. The Public Health Agency of Canada estimates that approximately 18% of adults aged 65 years of age and older have diabetes, and 21% of adults aged 70 years and older have diabetes (1). The unique and heterogeneous group comprising older adults presents challenges in the management of diabetes and its complications. The clinical management of diabetes has become increasingly difficult, straining even the most advanced and highquality healthcare systems (2). Thus, clinical guidelines to address diabetes management and education for diabetes in older adults are necessary. Over the past several years, 3 leading diabetes organizations, the American Diabetes Association (ADA), the Canadian Diabetes Association (CDA) and the International Diabetes Federation (IDF), published their respective guidelines for the management of diabetes in older adults; all 3 were met with some degree of applause, debate, confusion and appreciation. All 3 reported their respective recommendations for various aspects of diabetes management in older adults, including clinical management and glucose, blood pressure and cholesterol targets, as well as recommendations for education and psychosocial well-being (3–5).

Assessment of Barriers to Improve Diabetes Management in Older Adults

OBJECTIVETo evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control. The American Diabetes Association guidelines recommend the assessment of age-specific barriers. However, the effect of such strategy on outcomes is unknown.RESEARCH DESIGN AND METHODSWe randomized 100 subjects aged ≥69 years with poorly controlled diabetes (A1C >8%) in two groups. A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group. The control group received equal amounts of attention time. The active intervention was performed for the first 6 months, followed by a “no-contact” period. Outcome measures included A1C, Tinetti test, 6-min walk test (6MWT), self-care frequency, and diabetes-related distress.RESULTSWe assessed 100 patients (age 75 ± 5 years, duration 21 ± 13 years, 68% type 2 diabetes, 89% on insulin) over 12 months. After the active period, A1C decreased by −0.45% in the intervention group vs. −0.31% in the control group. At 12 months, A1C decreased further in the intervention group by −0.21% vs. 0% in control group (linear mixed-model, P < 0.03). The intervention group showed additional benefits in scores on measures of self-care (Self-Care Inventory-R), gait and balance (Tinetti), and endurance (6MWT) compared with the control group. Diabetes-related distress improved in both groups.CONCLUSIONSOnly attention between clinic visits lowers diabetes-related distress in older adults. However, communication with an educator cognizant of patients’ barriers improves glycemic control and self-care frequency, maintains functionality, and lowers distress in this population.

Use of Serum c-Peptide Level to Simplify Diabetes Treatment Regimens in Older Adults

Background Diabetes management in older adults is challenging. Poor glycemic control and high risk of hypoglycemia are common in older patients on a complicated insulin regimen. Newer oral hypoglycemic agents have provided an opportunity to simplify regimens in patients with type-2 diabetes on insulin. Serum c-peptide is a test to assess endogenous production of insulin. We analyze the use of serum c-peptide level in simplifying diabetes regimen by decreasing or stopping insulin injection and adding oral hypoglycemic agents in older adults. Methods One hundred patients aged over 65 years with either poor glycemic control or difficulty coping with insulin regimen seen at a geriatric diabetes clinic were analyzed for this study. The data on serum c-peptide levels and A1c, along with demographic information, were obtained from medical charts. Results Sixty-five of 100 patients (aged 79 ± 14 years, duration of diabetes 21 ± 13 years) had detectable serum c-peptide levels. Forty-six of 65 patients were available for simplification of regimen. Eleven of 46 patients had other co-morbidities preventing use of oral hypoglycemic agents. In 35/65 patients, simplification was completed successfully. Nineteen of 35 patients were converted to all-oral regimens (off insulin), while 16/35 had simplification of regimen by addition of oral hypoglycemic agents and lowering the number of insulin injections from an average of 2.7 to 1.5 injections/day ( P = .001). Glycemic control improved significantly in patients with a simplified regimen (8.0% ± 1.5% vs 7.4% ± 1.5%; P < .002), and patients reported fewer hypoglycemia episodes. Conclusions Serum c-peptide level can be used to simplify insulin regimen in older adults with diabetes.

Glycemia Treatment Strategies in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial

There is an independent progressive epidemiologic relation between glycemia and cardiovascular disease (CVD) events; however, whether lowering glucose levels with currently available therapies can reduce CVD events remains unknown. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is designed to answer this question in high-risk patients with type 2 diabetes mellitus. In ACCORD, 10,251 patients with type 2 diabetes and other CVD risk factors or CVD were randomly allocated to intensive glycemic control, targeting a glycosylated hemoglobin (HbA1c) level <6%, or standard glycemic control, targeting an HbA1c level of 7.0%-7.9%. All participants are provided with diabetes education, glucose-monitoring equipment, and antidiabetic medications. All participants in the intensive glycemic control group are started on > or = 2 classes of agents. Doses are intensified or a new medication class is added every month if HbA1c levels are > or = 6% or if >50% of premeal or postmeal capillary glucose readings are >5.6 mmol/L (100 mg/dL) or >7.8 mmol/L (140 mg/dL), respectively. All drug combinations are permitted, and drugs are reduced only because of side effects or contraindications. Annual training, menus of approaches for intensification, regular electronic messaging, audits of achieved glycemia, and central feedback to sites support glycemic intensification strategies in intensive participants. In participants in the standard glycemic control group, therapy is intensified whenever HbA1c is > or = 8%, and antihyperglycemic drugs that promote hypoglycemia (ie, insulin or insulin secretagogues) are reduced if HbA1c persistently decreases to <7% in the setting of hypoglycemia. ACCORD addresses the hypothesis that aggressive glucose lowering prevents CVD events in patients with type 2 diabetes. It is focused on the levels of glycemia achieved using a variety of strategies, not on the specific therapies used. It will also provide information on how to safely approach near-normal levels of glucose control in clinical practice and evidence to support future clinical guidelines for diabetes management in older adults.