**Background:** The elderly population with diabetes in Asia is rapidly increasing, with an estimated 78 million older adults (≥65 years) with diabetes by 2045 in Southeast Asia alone. This population is diverse, ranging from functionally independent to frail and terminally ill. Managing diabetes in this group is complicated by unique regional factors such as a carbohydrate-dominant diet, the thin-fat phenotype, lower per capita income, and a high prevalence of geriatric syndromes. Existing guidelines from Western societies may not fully address these specific challenges. To address this gap, an Asian hybrid steering committee meeting was conducted in Rishikesh, India, involving experts from 12 Asian countries. The goal was to develop a consensus on best practices for the care of diabetes in the elderly (ABCDE), focusing on patient-centric, tailored interventions based on functional status and comorbidities.
**Methods:** The expert panel, comprising key opinion leaders and representatives from government and private institutions across Afghanistan, Bangladesh, Bhutan, India, Iran, Malaysia, Maldives, Mauritius, Myanmar, Nepal, Pakistan, and Sri Lanka, deliberated on various aspects of diabetes management. They reviewed clinical evidence from landmark trials, position papers, and expert opinions, as well as recommendations from major international organizations (ADA, AACE, EASD, IDF, etc.). The panel discussed their own experiences and insights to develop tailored care for elderly diabetics. A consensus was drafted, circulated among panel members for critical appraisal, and subsequently amended. The document covers a wide range of topics including screening, diagnosis, clinical features, geriatric syndromes, glycemic goals, non-pharmacological and pharmacological management, and the use of technological aids.
**Key Results:** The consensus categorizes older adults into four functional groups (I: functionally independent; II: frail without cognitive impairment; III: frail with cognitive impairment; IV: terminally ill) to guide management. Key recommendations include:
- **Screening and Diagnosis:** The ABCDE recommends using the 2-hour OGTT over FPG or A1c alone for diagnosis in the elderly, as the Baltimore Longitudinal Study of Aging (BLSA) found that more than one-third of diabetes cases would be missed using only FPG and A1c, particularly in Asians with low A1c. Annual screening is recommended for those with risk factors.
- **Glycemic Targets:** The experts agree on a personalized approach, with a realistic and modest glycemic goal of A1c between 7% and 8% for most older patients, rather than tight control. For frail older adults with multiple comorbidities, a less stringent target of <8-8.5% is recommended, focusing on avoiding hypoglycemia and hyperglycemia.
- **Geriatric Syndromes:** The document addresses menopause, late-onset hypogonadism, sarcopenia, osteoporosis, and impaired cognition. For sarcopenia, the prevalence in Asian adults with type 2 diabetes is 15% using the AWGS definition. For osteoporosis, the ABCDE recommends using the trabecular bone score instead of BMD alone and suggests an intervention threshold of T-score ≤ -2.0 at the femoral neck or total hip or lumbar spine.
- **Hypoglycemia:** The risk is significantly higher in older adults (12.8% in >70 years vs. 9.0% in <60 years, p<0.01). The consensus emphasizes selecting anti-diabetic regimens with a lower risk of hypoglycemia and adjusting glycemic targets to avoid it.
- **Pharmacotherapy:** The document provides detailed tables on drug classes, including metformin, sulfonylureas, DPP-4 inhibitors, GLP-1 RAs, and SGLT-2 inhibitors, with specific caveats for the elderly. For example, glibenclamide is contraindicated in those over 65 years due to high hypoglycemia risk. Metformin is recommended but requires renal function monitoring and vitamin B12 level checks. SGLT-2 inhibitors should be used with caution in patients ≥75 years due to volume depletion risk.
- **Non-Pharmacological Interventions:** Lifestyle management includes a protein intake of 1.0-1.2 g/kg/day (1.2-1.5 g/kg/day for those at risk of malnutrition), structured exercise (aerobic and resistance training), stress management, sleep hygiene, and environmental modulation to prevent falls.
- **Technological Aids:** The use of continuous glucose monitoring (CGM), insulin pumps, and activity trackers is recommended based on functional status. For example, CGM is useful in patients with hypoglycemia unawareness, and hybrid closed-loop systems can reduce hypoglycemia.
**Clinical Implications:** This consensus provides a comprehensive, region-specific framework for managing diabetes in the Asian elderly. By emphasizing functional status over chronological age, it allows for more individualized care. The recommendations aim to reduce the risk of hypoglycemia, falls, and fractures, while improving quality of life. The document highlights the importance of addressing geriatric syndromes and using therapeutic parsimony to simplify regimens. It also underscores the need for caregiver involvement and the use of technology to enhance adherence and safety. The ABCDE best practices are intended to guide clinicians in Asia to optimize diabetes management in this growing and vulnerable population.