Endocrine and Metabolic Disorders
Diabetes in Older Adults
Glycemic goals should be individualized: a reasonable A1C target for healthy older adults is below 7.0–7.5%, while frail patients with comorbidity or limited life expectancy may target below 8.0–8.5% to avoid hypoglycemia. Hypoglycemia is the dominant harm - it causes falls, fractures, arrhythmia, and cognitive decline. Agents with low hypoglycemia risk (metformin, DPP-4 inhibitors, SGLT2 inhibitors, GLP-1 receptor agonists) are favored; sulfonylureas and insulin require caution. Metformin should be reviewed when eGFR falls below 30 and is not started below 45; hold during acute illness or contrast exposure. SGLT2 inhibitors carry genital mycotic infection, volume depletion, and euglycemic ketoacidosis risk; GLP-1 agonists cause weight loss and GI effects that may be undesirable in frail or sarcopenic patients.
Thyroid Disease
Hypothyroidism is common and often subtle; treat with levothyroxine, titrating by TSH, and be alert to over-replacement causing atrial fibrillation and bone loss. Start low in patients with coronary disease. Hyperthyroidism may present as atrial fibrillation or weight loss rather than tremor.
Bone and Mineral Metabolism
Vitamin D and calcium intake support bone health; hypercalcemia should prompt evaluation for malignancy and hyperparathyroidism.
Traps
A stem showing tight control with recurrent hypoglycemia is a signal to deintensify, not intensify. Another trap is continuing metformin in advanced kidney disease or during acute illness. Remember that A1C may be falsely low in anemia or recent transfusion.
Rule of Thumb
When an older adult on insulin or a sulfonylurea reports a fall or confusion, check glucose first and consider relaxing the target; deprescribing is often the correct answer.