The goal when treating patients with diabetes mellitus is to achieve the maximum longevity consistent with an optimal quality of life. To achieve this goal, treatment is typically focused on management of hyperglycaemic symptoms and prevention of microvascular and macrovascular complications. While appropriate for most individuals, including many older adults with robust health, this focus is often too limited for older adults facing diminished life expectancy and co-existing medical illness, frailty and disability. Creating a treatment plan that optimises health and function, and reduces the risk for morbidity and mortality, requires individualised therapy that judiciously manages symptoms and multiple competing health risks while remaining consistent with the patient's or his/her caregiver's healthcare preferences. Physicians caring for older adults with diabetes must be adept at recognising conditions commonly associated with diabetes, including the interplay with co-morbid illness, and be able to assess the patient's health status and use this information to recommend a treatment plan that is consistent with the patient's personal goals for care. The majority of older adults with diabetes will benefit from management of cardiovascular risk, including intensive management of hypertension, lipids, use of aspirin (acetylsalicylic acid) and smoking cessation, and screening for common geriatric syndromes. For a significant minority of older adults with life expectancy of >or=10 years, it is reasonable to consider intensive management of hyperglycaemia (glycosylated haemoglobin [HbA1c] target<or=7%). For frail older adults with life expectancy of <or=5 years, strategies for reducing medical burden, improving function and moderate glucose control (HbA1c approximately 8%) is reasonable and sufficient to control hyperglycaemic symptoms.