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The “4S Pathway” offers strategies for realigning treatment goals and approaches for older adults with type 1 diabetes (T1D) or type 2 diabetes (T2D) who are struggling with self-management.

Worldwide, more than 20% of people aged 65 years or older have diabetes. This population is very diverse; while some individuals successfully manage their diabetes as they age, others face cognitive and physical challenges that impede self-management. In a session held during the Advanced Technologies & Treatments for Diabetes (ATTD) 2025 speakers summarized concepts from the February 2025 publication of the Geriatric Diabetes Society’s consensus statement Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies, with particular emphasis on the potential role of diabetes technology.

This is the “4S Pathway”:

• Step 1: Seek triggers: Investigate signs, symptoms, or factors that may affect treatment goals or strategies.
• Step 2: Shared decision-making: Consult with older adults and care partners on next steps.
• Step 3: Set or reset goals: Revise goals based on changes in clinical, psychosocial, and environmental milieu.
• Step 4: Simpler and safer treatment: Modify the treatment strategy based on individual- and disease-specific considerations, putting safety first.

“This is not meant for every adult with diabetes who is over the age of 65. We are particularly talking about people who are having difficulty,” said Medha Munshi, MD, professor of medicine at Harvard Medical School and director of the Joslin Geriatric Diabetes Program at Beth Israel Deaconess Medical Center, both in Boston.

The authors introduced the term “realignment” to encompass facets beyond just “deprescribing” or “deintensification,” and to avoid the perception that treatment is being abandoned.

American Diabetes Association (ADA) Co-President Joshua J. Neumiller, PharmD, CDCES, told Medscape Medical News that the term “realignment” is seen as “a more dynamic and individualized approach to adjusting therapy in older adults with diabetes that may include a variety of strategies to meet individualized management needs.”

Neumiller pointed out that the heterogeneity among older people with diabetes extends not only to clinical characteristics but also to self-care abilities and/or support, goals and priorities, and living situations. “So as we talk about realignment in older adults, it’s really not based on chronological age.” 

Such approaches can include modification/adjustment of glycemic goals, deintensification of therapy to increase safety and/or decrease therapeutic burden, and/or simplification of the medication regimen. For example, people with T2D who had been using sulfonylureas for years in their 40s and 50s with no problems might begin to experience hypoglycemia as they age, which could require a medication switch rather than simply stopping the drug.

Hypoglycemia is a major concern in older adults due to several factors including irregular meal intake, insulin deficiency (absolute or relative) requiring insulin therapy, and impaired kidney function. The risk increases with greater intensity and complexity of the glucose-lowering regimen.

In fact, increased glycemic variability, not necessarily low A1c, is what increases hypoglycemia risk. “Just because someone has an A1c of 8% or above doesn’t mean they’re not at risk or experiencing hypoglycemic events. That really highlights the role of diabetes technology to investigate appropriate changes to the therapeutic strategy,” Neumiller said.

He also noted that the relationship between hypoglycemia and cognitive impairment is bidirectional as each can drive the other.

Munshi, who is both an endocrinologist and a geriatrician, said that continuous glucose monitoring (CGM) is essential for detecting asymptomatic hypoglycemia, particularly during the night, as well as in identifying glucose patterns that may require targeted intervention. “Without CGM, I don’t know how to realign their therapy,” she said.

When Should Re-Alignment Be Considered

For Step 1 of the 4S pathway, “triggers” signaling the need for therapeutic realignment include: 

• Medical events: A fall or accidental injury, emergency department visit, or hospitalization
• Life-altering events: Change in living situation, death of spouse, loss of a care partner, or change in financial situation
• Change in physical, cognitive, or mental health status: New or worsening frailty, a new diagnosis or disability (eg, kidney disease), new or worsening cognitive impairment, or new-onset depression, anxiety, stress, or substance abuse

Medication “red flags” may also signal the need for re-alignment, such as: 

• Possibly inappropriate prescriptions: Complex regimens, missed refills, confusion over insulin type (basal vs rapid-acting) or administration times
• Medication adverse effects: Hypoglycemia, unintended weight loss, urinary incontinence, hypotension, volume depletion, etc.
• Signs of unrecognized hypoglycemia: Increased confusion, falls, new or worsening cognitive impairment, lethargy
• Signs/symptoms of excessive hyperglycemia: Increase in diabetes symptoms, repeated infections

Potential contributing factors to those red flags should be identified and investigative action be taken. This might include review of medications and of adherence, and use of CGM to evaluate glycemic patterns.

Neumiller also highlighted key recommendations for older adults in chapter 13 of the 2025 ADA Standards of Care that align with the 4S approaches. Section 13.1 advises assessment of medical, psychological, functional, (self-management abilities) and social domains, while 13.2 recommends annual screening for geriatric syndromes including cognitive impairment, depression, urinary incontinence, frailty, falls, pain, hypoglycemia, and polypharmacy.

Deprescribing and Avoiding Overtreatment

Anna Kahkoska, MD, PhD, of the Department of Nutrition and Division of Endocrinology and Metabolism at the University of North Carolina at Chapel Hill, emphasized that older adults with diabetes frequently have other coexisting health conditions. More than two thirds of older adults have two or more chronic conditions, which often necessitates polypharmacy. That, in turn, can increase treatment burden and confer medication-associated risks such as falls, hospitalization, and mortality.

Patients who may be considered high priority for deprescribing include those with a high comorbidity burden, excessive polypharmacy, nursing home residents, those with life expectancy < 2 years, or with advanced stage dementia.

Medications considered high priority for deprescribing include strong anticholinergics, benzodiazepines, chronic proton pump inhibitors, chronic nonsteroidal anti-inflammatory drugs, aspirin for primary cardiovascular disease prevention, and insulin/insulin secretagogues.

Deprescribing is generally considered in the context of “overtreatment,” but “in diabetes there isn’t a universal threshold for ‘overtreatment,’ due to the need for individualization. The definitions that we use on the population level often don’t apply to the individual,” Kahkoska observed.

Moreover, the balance between the short-term risk for hypoglycemia and long-term risk for micro- and macro-vascular complications differs between individuals and even within a single person “and can change fairly quickly,” she added.

Aside from the glucose pattern data that A1c misses, reliance on that metric to define “overtreatment” is also problematic because it may be inaccurate in people with conditions such as chronic kidney disease and anemia, which disproportionately affect older adults.

And of course, stopping high-risk medications may not always be possible, such as with insulin in people with T1D or those with T2D who have medical contraindications or financial barriers to using less risky medications.

Older adults may also have strong emotions regarding treatment changes, particularly with regimens they’ve been using for a long time. People may fear losing control of their diabetes, or not understand why their regimen or treatment goals are suddenly being changed, Kahkoska noted.

From the provider perspective, “we don’t have particularly robust scientific evidence to guide deprescribing. Most of our evidence is in the prescribing space,” she said.

Thus, Kahkoska said, “realignment is more dynamic, more individualized, and comprises a broader set of strategies than deprescribing…it is best accomplished with shared decision-making, care partner integration, and multidisciplinary care.”

‘Without CGM, I Don’t Know How to Realign Their Therapy’ 

Munshi closed out the session by describing the use of CGM to realign treatment in people with either T1D or T2D who are struggling with self-management. For patients who don’t qualify for insurance reimbursement for real-time CGM, she uses the blinded professional version.

Unlike A1c and fingersticks, CGM can demonstrate when hypoglycemic episodes are happening and inform realignment of therapy to minimize them. In her 2016 study, simplification from multiple daily injections to once-daily glargine plus non-insulin agents in 65 adults aged 65 years or older with T2D led to a reduction in hypoglycemia without worsening glycemic control.

One case involved a 69-year-old man with T2D who was taking degludec at bedtime, metformin twice daily, and semaglutide once weekly, achieving an A1c of 6.8%. Following an episode of chest pain during exertion, a blinded CGM revealed that he spent approximately 4% of the time in hypoglycemia, primarily during the night.

Munshi changed the timing of his degludec from nighttime to morning, reduced the metformin to once daily in the morning only, and increased his weekly semaglutide dose. “There are various ways of realignment, even in type 2, that can actually be achieved successfully with CGM technology.” 

As for people with T1D who can’t come off insulin, her group conducted another study using CGM in 131 adults with T1D aged 65 years or older with frequent hypoglycemia. The use of individualized goal-setting and regimen simplification when indicated led to reduced hypoglycemia without worsening control.

The simplification intervention removed many of the routine aspects of T1D management, including carb counting and correction dosing, while also changing the low glucose alarm to avoid even mild hypoglycemia. Technology can also be used to adapt to caregiver preferences, Munshi added.

The “4S” paper includes algorithms for using CGM data to guide therapeutic changes. It also addresses the management of patients in settings outside the home, including nursing homes, skilled rehabilitation, and end-of-life care. Each has different goals of management, depending on the patient’s condition and expectation for recovery, she noted.

In response to a question about the use of automated insulin delivery (AID) systems in older adults, Munshi said that the picture has shifted compared to just a few years ago. “Now, people who are aging are more technology savvy…and the technology is becoming more user-friendly. The data show that older adults can use the AID technology successfully, but they do need a lot more time and it is still not without patient input. We need more data on whether people with cognitive dysfunction can use AID…but I’m much more hopeful than I was,” she concluded.

Munshi had received grant support from the National Institutes of Health, the American Diabetes Association, and Dexcom, and is a consultant for Sanofi, Medtronic, and Abbot. Neumiller serves on an advisory board for Proteomics International, and is on the Board of Directors of the American Diabetes Association. Kahkoska had received grant support from the National Institute on Aging, ADA, American Heart Association, and the North Carolina Diabetes Research Center.

Munshi has co-authored a lay audience book with exercise physiologist Sheri Colberg, PhD, Aging Well With Diabetes: A 10-Point Action Plan for Older Adults. It will be published on April 29, 2025.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X (formerly Twitter) @MiriamETucker and BlueSky @miriametucker.bsky.social.