Hypoglycemia in elderly individuals -
Cost concerns — If cost is a concern, adding a short- or intermediate-acting sulfonylurea with a relatively lower rate of hypoglycemia, such as glipizide , glimepiride , or gliclazide gliclazide not available in the United States , remains a reasonable alternative.
Choosing a sulfonylurea balances glucose-lowering efficacy, universal local availability, and low cost with risk of hypoglycemia and weight gain.
Short- or intermediate-acting sulfonylureas can also be used cautiously in patients with impaired kidney function when other classes are contraindicated. Generic pioglitazone is also inexpensive. However, we tend not to use pioglitazone in older adults due to risks of fluid retention, weight gain, heart failure, macular edema, and osteoporotic fracture.
See "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia' and "Thiazolidinediones in the treatment of type 2 diabetes mellitus", section on 'Safety'. A typical starting dose of a sulfonylurea is as follows see "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Dosing and monitoring' :.
In patients who are using sulfonylureas, the presence and frequency of hypoglycemia should be evaluated at each visit. All blood glucose monitoring BGM or continuous glucose monitoring CGM data that are available should be reviewed and the frequency and details of any recognized episodes of hypoglycemia determined.
See 'Monitoring of glycemia' below and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus", section on 'Hypoglycemia'. The reported frequency of sulfonylurea-related hypoglycemia in older adults is variable. In an analysis of adverse event data from a drug surveillance project, oral hypoglycemic agents accounted for 10 percent of hospitalizations for adverse drug events [ 49 ].
Long-acting sulfonylureas eg, glyburide should be avoided in older adults due to higher risk of hypoglycemia, especially in individuals with inconsistent timing or content of their meals or those with cognitive decline that prevents prompt recognition or treatment of hypoglycemic episodes [ 50 ].
Drug-induced hypoglycemia may be a limiting factor for sulfonylurea use in older adults and is most likely to occur in the following circumstances:. These issues may arise when there is a change in overall health status in older adults with diabetes.
Dual agent failure — For patients who do not achieve A1C goals with two agents eg, metformin plus sulfonylurea or another agent , we suggest starting or intensifying insulin therapy see "Insulin therapy in type 2 diabetes mellitus", section on 'Designing an insulin regimen'.
In patients on sulfonylureas and metformin who are starting insulin therapy, sulfonylureas are generally tapered and discontinued, while metformin is continued. Another option is two oral agents and a GLP-1 receptor agonist. It is reasonable to try a GLP-1 agonist before starting insulin in patients who are near glycemic goals, those who prefer to avoid insulin, and those in whom weight loss or avoidance of hypoglycemia is a primary consideration.
A once-weekly GLP-1 agonist formulation is particularly attractive for patients and caregivers. However, this option often increases costs and contributes to the problem of polypharmacy in older adults see 'Polypharmacy and deintensification' below.
The management of persistent hyperglycemia is reviewed in more detail separately. See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Dual agent failure'. Polypharmacy and deintensification — Use of multiple drugs is common in older adults. Management of hyperglycemia and its associated risk factors often increases the number of medications even more in the older adult with diabetes.
Side effects may exacerbate comorbidities and impede patients' ability to manage their diabetes. Therefore, the medication list should be kept current and reviewed at each visit [ 1,6 ].
Overtreatment and complicated regimens should be avoided. Complex regimens that may have been required in the past can often be simplified to be consistent with the modified glycemic targets of an older patient [ 53,54 ].
See 'Controlling hyperglycemia' above. It is important to look for any conditions that interfere with A1C measurement eg, anemia, recent infections, kidney failure, erythropoietin therapy, etc. In these settings or when unexpected or discordant A1C values are encountered, medication adjustments should be based on glucose readings from a glucose meter or continuous glucose monitoring CGM rather than A1C.
See "Measurements of chronic glycemia in diabetes mellitus", section on 'Glycated hemoglobin A1C '. However, infrequent or no BGM may be adequate for older patients with type 2 diabetes who are diet treated or who are treated with oral agents not associated with hypoglycemia.
The effectiveness of BGM in terms of improving glycemic management in patients with type 2 diabetes is less clear than for type 1 diabetes.
See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'. CGM use also should be considered for older patients with impaired awareness of hypoglycemia, those taking other medications that confer higher risk of hypoglycemia eg, sulfonylureas , and those who have difficulty performing BGM through fingerstick checks due to cognitive or physical limitations.
Advances in CGM have made it possible to use the technology in older and even frail patients. Professional CGM devices, applied like a patch on a patient's arm or abdomen depending on the CGM model , measure interstitial glucose levels every 5 to 15 minutes for 10 to 14 days.
These devices provide patterns of glucose excursions that can be the foundation for choosing or adjusting insulin doses in patients on multiple daily insulin regimens. These CGM devices are covered by Medicare in qualifying patients.
See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'CGM systems'. Retinopathy, nephropathy, and foot problems are all important complications of diabetes mellitus in older patients. Monitoring recommendations for older patients with diabetes are similar to those in younger patients table 3.
In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly [ 12 ].
Retinopathy — The prevalence of retinopathy increases progressively with increasing duration of diabetes figure 2. See "Diabetic retinopathy: Classification and clinical features". Regular eye examinations are extremely important for older patients with diabetes because poor vision can lead to social isolation, an increased risk of accidents, and impaired ability to measure blood glucose and draw up insulin doses.
A complete ophthalmologic examination should be performed by a qualified ophthalmologist or optometrist at the time of diagnosis and at least yearly thereafter. The purpose is to screen not only for diabetic retinopathy, but also for cataracts and glaucoma, which are approximately twice as common in older individuals with diabetes compared with those without diabetes [ 55,56 ].
See "Diabetic retinopathy: Screening". Nephropathy — The availability of effective therapy for diabetic nephropathy with angiotensin-converting enzyme ACE inhibitors, angiotensin receptor blockade agents ARBs , mineralocorticoid receptor antagonists, and sodium-glucose co-transport 2 SGLT2 inhibitors has led to the recommendation that all patients with diabetes be screened for increased urinary albumin excretion annually.
See "Moderately increased albuminuria microalbuminuria in type 1 diabetes mellitus" and "Moderately increased albuminuria microalbuminuria in type 2 diabetes mellitus". However, the prevalence of increased urinary albumin excretion increases in the older population for reasons unrelated to diabetic nephropathy.
For older patients who are already taking an ACE inhibitor or ARB and have progressive decline in glomerular filtration rate GFR or increase in albuminuria, referral to a nephrologist for further evaluation and treatment is warranted. Foot problems — Foot problems are an important cause of morbidity in patients with diabetes, and risk is much higher in older patients.
Both vascular and neurologic disease contribute to foot lesions. See "Management of diabetic neuropathy". In addition to the increasing prevalence of neuropathy with age, more than 30 percent of older patients with diabetes cannot see or reach their feet, and they may therefore be unable to perform routine foot inspections.
We recommend that older patients with diabetes have their feet examined at every visit; this examination should include an assessment of the patient's ability to see and reach his or her feet and inquiry about other family members or friends who could be trained to do routine foot inspections.
Visits to a podiatrist on a regular basis should also be considered if feasible. A detailed neurologic examination and assessment for peripheral artery disease should be performed at least yearly.
It is also important that prophylactic advice on foot care be given to any patient whose feet are at high risk. See "Evaluation of the diabetic foot". In addition, they are at high risk for polypharmacy, functional disabilities, and other common geriatric syndromes that include cognitive impairment, depression, urinary incontinence, mobility impairment, falls, and persistent pain [ 1 ].
See "Comprehensive geriatric assessment". All older adults should undergo screening for mild cognitive impairment or dementia at initial evaluation and, thereafter, annually or as appropriate for the individual patient [ 12 ].
Despite limited treatment options, identification of underlying cognitive impairment is critical for assessing a patient's capacity to self-manage diabetes treatment and care.
In particular, cognitive function and the possibility of depression should be assessed in older patients with diabetes when any of the following are present see "Evaluation of cognitive impairment and dementia" and "Screening for depression in adults" :.
Nursing home patients — Few studies have focused on management of older adults with diabetes residing in nursing homes [ 4 ]. Life expectancy, quality of life, severe functional disabilities, and other coexisting conditions affect goal setting and management plans.
See 'Controlling hyperglycemia' above and 'Avoiding hypoglycemia' above. Treatment regimens should be chosen with a focus on avoidance of hypoglycemia and control of hyperglycemic symptoms [ 17 ]. For patients requiring insulin, metformin combined with once-daily basal insulin is an effective, relatively simple regimen.
If prandial insulin is necessary, it can be administered immediately after a meal to better match the meal size and minimize hypoglycemia. Sliding scale insulin should not be used as a sole means of providing insulin.
If a patient is temporarily managed with sliding scale insulin to determine the requisite dose s of insulin therapy, a more physiologic glucose control strategy should be implemented within a few days table 4.
End-of-life care — Management of patients with diabetes at the end of life must be tailored to individual needs and the severity of the illness. In general, the risks and consequences of hypoglycemia are greater than those of hyperglycemia in patients at the end of life.
The goal is to avoid extreme hyperglycemia and dehydration as well as excessive treatment burdens such as multiple insulin injections or intensive monitoring.
For patients with type 2 diabetes who are no longer taking anything by mouth, discontinuation of diabetes medications is reasonable [ 59 ].
This is in contrast to patients with type 1 diabetes, in whom continuing a small amount of basal insulin is required to prevent iatrogenic acute hyperglycemia and ketoacidosis.
See "Palliative care: The last hours and days of life", section on 'Eliminating non-essential medications' and "Deprescribing", section on 'Glucose-lowering medications'. SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.
See "Society guideline links: Diabetes mellitus in adults". Older adults with diabetes are a heterogeneous population that includes persons residing independently in communities, in assisted care facilities, or in nursing homes.
They can be fit and healthy, or frail with many comorbidities and functional disabilities. Therefore, older adults in particular require individualized goals for diabetes management, keeping in mind their limited life expectancy and comorbidities.
See 'Goals' above. Thus, avoidance of hypoglycemia is an important consideration in establishing goals and choosing therapeutic agents in older adults. See 'Avoiding hypoglycemia' above and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'.
See 'Cardiovascular risk reduction' above. The nutrition prescription is tailored for older people with diabetes based upon medical, lifestyle, and personal factors. Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve body composition and insulin sensitivity in older patients with diabetes.
See 'Lifestyle modification' above. Because of concern for hypoglycemia, some clinicians use insulin only for a short time to ameliorate glucose toxicity. Once insulin secretion and sensitivity are improved, it may be possible to lower the dose or replace insulin with metformin or another oral hypoglycemic agent with lower risk of hypoglycemia.
See 'Choice of initial drug' above. Metformin will likely reduce glycemia safely at any level of hyperglycemia and further may reduce progression of hyperglycemia or the risk of developing diabetes-related complications.
See 'Metformin' above. An alternative option for patients who present with A1C near their medication-treated target and who prefer to avoid medication is a three- to six-month trial of lifestyle modification before initiating metformin. The approach to choosing alternative therapy in metformin-intolerant patients is similar in older and younger adults.
See 'Contraindications to metformin' above and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin'.
The therapeutic options for patients who do not reach glycemic goals with lifestyle intervention and metformin are similar in older and younger patients. All of the medications have advantages and disadvantages table 2.
The choice of a second agent should be individualized based upon efficacy, risk of hypoglycemia, the patient's underlying comorbidities, the impact on weight, side effects, and cost figure 1. See 'Persistent hyperglycemia' above and "Management of persistent hyperglycemia in type 2 diabetes mellitus".
Another option is two oral agents and a glucagon-like peptide 1 GLP-1 receptor agonist. See 'Dual agent failure' above. In particular, complications that impair functional capacity eg, retinopathy, foot problems should be identified and treated promptly. See 'Screening for microvascular complications' above.
Cognitive function should be assessed routinely in older adults with diabetes. Unexplained deterioration in glycemia or nonadherence to diabetes care may reflect underlying depression.
See 'Common geriatric syndromes associated with diabetes' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you.
Select the option that best describes you. View Topic. Font Size Small Normal Large. Treatment of type 2 diabetes mellitus in the older patient.
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Language Chinese English. Author: Medha Munshi, MD Section Editors: David M Nathan, MD Kenneth E Schmader, MD Deputy Editors: Katya Rubinow, MD Jane Givens, MD, MSCE Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jan This topic last updated: Jan 04, Diabetes in older adults: a consensus report. J Am Geriatr Soc ; Thorpe CT, Gellad WF, Good CB, et al. Tight glycemic control and use of hypoglycemic medications in older veterans with type 2 diabetes and comorbid dementia.
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European Diabetes Working Party for Older People clinical guidelines for type 2 diabetes mellitus. Executive summary. Diabetes Metab ; 37 Suppl 3:S Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. International Diabetes Federation.
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Heath JM, Stuart MR. To determine risk factors for developing hypoglycemia, a multivariate logistic regression analysis was performed Table 3. As shown, sepsis was associated with an odds ratio OR of 6. Malignancy was associated with an OR of 2. Other risk factors found to contribute significantly to developing hypoglycemia were ISIT, alkaline phosphatase level, creatinine level, and female sex.
We compared patients with and without DM. The mean age of patients with DM was significantly lower However, there were no statistically significant differences in sex, sepsis, malignancy, hypoalbuminemia, or elevated alkaline phosphatase level.
More patients in the DM group received treatment with angiotensin-converting enzyme inhibitors Mortality rates are presented in Figure 1.
During the next 3 months, the number of deaths was relatively small: 12 patients in the hypoglycemic group and 9 in the nonhypoglycemic group died. We did not find a correlation between the degree of hypoglycemia and mortality. There were no statistically significant differences in in-hospital mortality or 6-month mortality between patients with DM and those without.
Interestingly, ISIT was associated with lower mortality in the hypoglycemic group. Thus, hypoglycemia in patients who underwent ISIT was associated with lower mortality than in patients who had no ISIT.
Since our data showed that hypoglycemia was associated with a high in-hospital mortality rate, we wanted to determine whether risk factors for developing hypoglycemia were also predictors of mortality.
A multivariate logistic regression analysis of the whole study population hypoglycemic and nonhypoglycemic patients was performed, including the occurrence of hypoglycemia as well as all the clinical variables associated with hypoglycemia Table 4.
Sepsis, malignancy, and low albumin levels, which were predictors of developing hypoglycemia, were also found to be strong predictors of in-hospital mortality.
Interestingly, ISIT was associated with lower mortality. It is also noteworthy that hypoglycemia was not found to be an independent risk factor for in-hospital mortality in the multivariate analysis. The present study dealing exclusively with hospitalized subjects 70 years or older shows that hypoglycemia is a common complication in this age group associated with 2-fold increased mortality during hospitalization and during 3 months of follow-up.
The incidence of 5. Older age can increase the risk of developing hypoglycemia because of the higher rate of comorbidities such as renal failure, malnutrition, malignant diseases, and dementia, which were found to be risk factors for hypoglycemia in the present study and in previous studies.
In the present study, multivariate regression analysis found sepsis to be a strong predictor for developing hypoglycemia OR, 6. The association found in the present study between sepsis, hypoglycemia, and increased mortality is in accordance with 2 previous studies.
A low albumin level in our study was also a strong predictor for hypoglycemia OR, 4. Low serum albumin has been shown by several studies to indicate higher rates of mortality and complications.
Therefore, the association between hypoalbuminemia and mortality can be explained by either malnutrition or by long-standing comorbidities. Hypoalbuminemia can therefore be regarded as an indicator of poor health. Renal insufficiency was found to be a risk factor for hypoglycemia in our study as well as by Fisher et al, 5 but not for mortality.
The association between hypoglycemia and renal insufficiency in patients without diabetes has already been reported with several proposed mechanisms. In a large study of admissions of patients with end-stage renal failure, 3. The finding in the present study that malignancy was a strong predictor not only for mortality but also for hypoglycemia is intriguing.
In the past, malignancy-associated hypoglycemia was mainly attributed to secretion of insulinlike growth factor by non—β-cell tumors such as large mesenchymal tumors.
Use of sulfonylureas that are insulin secretagogues or insulin was associated with a 2-fold increase in hypoglycemia in the present study.
This finding is not surprising, considering that previous studies have shown a high incidence of hypoglycemia associated with these treatment modalities, which further increases with advancing age and polypharmacy.
This unexpected finding may be explained by possible better surveillance of patients receiving antidiabetic treatment and earlier recognition of clinical deterioration. Recent data also suggest that insulin exerts an anti-inflammatory effect compared with glucocorticoids. Further studies are needed to confirm this finding.
The present study evaluated not only in-hospital mortality but also 3- and 6-month mortality, and it is the first study to show that hypoglycemia is a marker for short- and long-term poor outcome. However, a multivariate analysis for in-hospital mortality revealed that hypoglycemia did not remain an independent predictor.
The risk factors that predicted increased mortality in this model were sepsis, low albumin level, and malignancy. These findings point out that hypoglycemia is only a marker for poor health and general deterioration associated with higher mortality rates. One previous study found hypoglycemia to be a risk factor for mortality in the elderly in a multivariate analysis, 7 although in this study as well as in others, hypoglycemia was not a direct cause of mortality.
In conclusion, hypoglycemia was a common finding in elderly hospitalized patients, predicting in-hospital as well as 3-month and 6-month higher mortality rates.
Female sex, sepsis, malignancy, renal failure, serum albumin level, alkaline phosphatase level, and ISIT for DM were predictors for developing hypoglycemia. Multivariate analysis revealed that sepsis, hypoalbuminemia, and malignancy were predictors for in-hospital mortality.
However, hypoglycemia was not a predictor in this analysis, implying that hypoglycemia is a marker of poor health without a direct effect on survival. Frequent blood sampling in elderly patients and detecting asymptomatic hypoglycemia can therefore serve as a useful indicator for prognosis.
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View Large Download. Table 1. The Diabetes Control and Complication Trial Research Group, Hypoglycemia in the Diabetes Control and Complication Trial.
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Lisa Chow Herbal remedies for prostate health, Elizabeth Hypoglycemia in elderly individuals. Seaquist; How Indifiduals Is Severe Hypoglycemia in Older Inn With Top fat burners. Diabetes Care 1 March individals 43 3 : — Severe hypoglycemia is defined as an episode in which the person with diabetes requires the assistance of another to increase blood glucose, usually by administration of glucagon or contacting a medical professional. These occurrences are not rare. These events elicit profound fear in patients with diabetes.Video
Older Adults and Diabetes - HYPOGLYCEMIA Cumulative mortality at Hyopglycemia and at 3-month and Hypoglycemia in elderly individuals follow-up. Kagansky IndivudualsLevy SRimon E, et al. Sweet potato casserole as a Predictor of Mortality in Hospitalized Elderly Patients. Arch Intern Med. From the Department of Geriatric Medicine Drs Kagansky, Levy, Rimon, Fridman, and OzerMetabolic Unit Dr KnoblerKaplan-Harzfeld Medical Center, Rehovot, affiliated with Hebrew University and Hadassah School of Medicine, Jerusalem; and Ashkelon Academic College, Ashkelon Ms CojocaruIsrael.
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