Hypoglycemic episodes are common in older adults with poor glycemic control. Raising HbA1C goals may not be adequate to prevent hypoglycemia in this population.1
Symptoms of hypoglycemia in the elderly are poor concentration, confusion, sweating, trembling, weakness, inco-ordination, unsteadiness and light headedness. These symptoms may change over the years yet they are often still not recognised in emergency rooms and dismissed as confusion or even a fit. Staff just don’t seem to appreciate the significance of them and a lot of patients also deny having them.
One study found that of a total of 102 hypoglycemic episodes, 93% were unrecognised by finger-stick glucose measurements performed four times a day or by symptoms.1
Risk factors for hypoglycemia include a recent change in diabetes agent, hospitalisation, comorbidities, elderly single male, alcohol, cognitive impairment and increasing age.
But why do they matter so much? A longitudinal cohort study from 1980–2007 of 16,667 patients with a mean age of 65 years and type 2 diabetes in northern California looked at whether hypoglycemic episodes severe enough to require hospitalisation are associated with an increased risk of dementia. This was in a population of older patients with type 2 diabetes followed up for 27 years. It found that older patients with type 2 diabetes and a history of severe hypoglycemic episodes were associated with a greater risk of dementia. Whether minor hypoglycemic episodes increase risk of dementia is unknown.1
A further study looked at whether hypoglycemia commonly occurs in patients with diabetes and negatively influences cognitive performance. Also whether cognitive impairment in turn can compromise diabetes management and lead to hypoglycemia. During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycemic event had a two-fold increased risk for developing dementia compared with those who did not have a hypoglycemic event.2
Similarly, older adults with diabetes who developed dementia had a greater risk for having a subsequent hypoglycemic event compared with participants who did not develop dementia.
Another study found an association between tight glycemic control (when HbA1c <7%) and greater risk of hip fracture in individuals being treated for type 2 diabetes. Greater caution therefore needs to be exercised in treating older patients
with diabetes.3
The European Diabetes Working Party for Older People 2011 suggest a HbA1c of between 7.0–7.5% for non frail older patients and a HbA1c of 7.6 –8.5% for the frail.
Hypoglycemia may also be associated with greater risk of death. A retrospective study looked to determine whether patient self-report of severe hypoglycemia is associated with increased mortality. It found that severe hypoglycemia was associated with 3.4-fold increased risk of death. Patient-reported outcomes, including patient-reported hypoglycemia, may therefore augment risk stratification and disease management of patients with diabetes.4
Management options in the older patient include SGLT-2 inhibitors, gliptins, DPP-4 inhibitors or insulin degludec.

1. Munshi MN, et al. Arch Intern Med 2011; 171(4): 362-4
2. Yaffe K, et al. JAMA Intern Med. 2013; 173(14): 1300–1306
3. Paur T. Journal of the American Geriatrics Society 2012; 60: 1493–97
4. McCoy R, et al. Diabetes Care September 2012; 35: 1897–1901