It seems ironic, but often the best way to advocate for older adults in our health care system is to articulate how critically important it is to consider age, and in the next breath, explain its irrelevance.

While admittedly oversimplified, my point can be seen in a consensus report on diabetes in older adults released in late October. The report addresses the unique needs of older adults with diabetes as a population, and at the same time, strongly recommends against using age as the basis for treatment decisions. Why? Because screening and treatment decisions should be individualized based on health status and complexity.

For example, maintaining tightly controlled blood sugar levels might make sense for an otherwise healthy 70-year-old who has just been diagnosed with diabetes. It may not make sense for a person of the same age who has Alzheimer’s disease, lives in a nursing home, and has other chronic conditions that are more disabling.

The report, prepared by a consensus panel convened by the American Diabetes Association (ADA) with a grant from the Association of Specialty Professors (through an initiative funded by the John A. Hartford Foundation), makes a compelling case for focusing on older adults. More than a quarter of people aged 65 and older have diabetes and roughly half can be considered pre-diabetic. Diabetes diagnoses will increase 4.5-fold in older adults by 2050, compared to 3-fold in the total population. Older adults with diabetes have the highest rates of related lower limb amputations, heart attacks, vision problems, and kidney failure.

However, older adults—especially those with multiple chronic conditions or cognitive impairment—have been largely excluded from clinical treatment trials. We know little about what works best in this population, but we know they are very different from younger adults.

The ADA consensus panel gathered and synthesized the evidence that is available. They summarized research on the most important issues that distinguish older adults and that should affect screening and treatment decisions. These factors include comorbidities and geriatric syndromes (for example, functional impairment, polypharmacy, depression, vision and hearing impairment), unique nutritional issues, self-management capacity, and life expectancy. The report also discusses shared decision making with patients and families (critically important given the dearth of evidence), racial and ethnic health disparities, and settings of care as other critical considerations.

The report, published by both the ADA and the American Geriatrics Society, concludes with recommendations for diabetes prevention and treatment that, while focused on older adults, are not based on age. To help clinicians and patients think through treatment goals for blood sugar, blood pressure, and cholesterol control, the panel recommends a framework utilizing health status defined by comorbidities and functional impairments (based on the work of Drs. Carolyn Blaum, Cynthia Boyd, and others).

Other recommendations focus on screening, pharmacotherapy, and managing diabetes in settings outside the home. The panel rightly gives attention to the sensitivities that older adults have to certain drugs and the dangers they face in transitions between care settings, when their diabetes medications may be changed.

The bottom line is summed up nicely by one of the panel members and long-time Hartford grantee, Dr. Jeff Halter. As he states in the press release, “... older people are a very heterogeneous population, which means that recommendations cannot be simply based on age … It’s critical to consider overall physical and cognitive function, quality of life, and patient preferences when developing a treatment plan with an older patient.”

This is a classic case where age matters and doesn’t, all at the same time.