Diabetes in Seniors: The 4S Pathway to Simplify and Step-Down

Background

Diabetes exists in 1 in 5 people aged 65 years and older, representing one of the largest proportions of diabetes. Among them, individual needs vary drastically, and this includes not only daily living aspects (functional status, comorbidities, frailty etc.), but also their diabetes care. Preventing hypoglycemic episodes is a key consideration in older adults to avoid overtreatment and its complications. Guidelines in the past have highlighted higher glucose targets and individualised approaches, but recommendations often lack direction on modification of treatments.

Introducing the 4S Pathway

This 4-Step approach was created by a group of experts (geriatricians, endocrinologists, primary care physicians, pharmacists, educators, nurses, and researchers) to “realign” and focus treatment strategies for the needs of older adults with diabetes. 

• Step 1: Seeking triggers- Identify changes in a person’s health status and investigate causes for those changes

  • For example, a fall or hospitalization should prompt a review of medication side effects, interactions, and adherence

• Step 2: Shared decision making- care providers should aim to align the treatment goals with the patient’s priorities

• Step 3: Setting and resetting goals- individualize treatment targets to realistic and safe levels, minimizing hypoglycemic episodes 

• Step 4: Simpler and safer medications- aim to reduce harm by avoiding insulin and sulfonylureas with increasing age and frailty if possible. The specifics of choosing medications are further broken down into Type of diabetes, and whether patients live in community or long-term care facilities. 

Bottom Line

Care of older adults with diabetes should be adaptable to the changes that occur in a patient’s lifetime, including changes to frailty, cognition, comorbidities, and living situation. Using the 4S pathway, a series of four algorithms can help enable care providers to optimize diabetes treatment while minimizing harm.

Source:

Munshi M, Kahkoska AR, Neumiller JJ, Alexopoulos A. Realigning diabetes regimens in older adults: A 4S pathway to guide simplification and deprescribing strategies. The lancet. Diabetes & endocrinology. 02/2025. doi: 10.1016/s2213-8587(24)00372-3.