Management of hypoglycemia in older adults with type 2 diabetes

Abstract

Treatment of older adults with type 2 diabetes (T2D) is complex because they represent a heterogeneous group with a broad range of comorbidities, functional abilities, socioeconomic status, and life expectancy. Older adults with T2D are at high risk of recurring hypoglycemia, a condition associated with marked morbidity and mortality, because their counter-regulatory mechanism to hypoglycemia is attenuated, and recurring hypoglycemic episodes can lead to hypoglycemia unawareness. In addition, polypharmacy, a result of multiple chronic comorbidities (including heart disease, stroke, and chronic kidney disease), can increase the risk of severe hypoglycemia, especially when patients are taking sulfonylureas or insulin. Often the signs of hypoglycemia are nonspecific (sweating, dizziness, confusion, visual disturbances) and are mistaken for neurological symptoms or dementia. Consequences of hypoglycemia include acute and long-term cognitive changes, cardiac arrhythmia and myocardial infarction, serious falls, frailty, and death, often resulting in hospitalization, which come at a high economic cost. The American Diabetes Association has recently added three new recommendations regarding hypoglycemia in the elderly, highlighting individualized pharmacotherapy with glucose-lowering agents with a low risk of hypoglycemia and proven cardiovascular safety, avoidance of overtreatment, and simplifying treatment regimens while maintaining HbA1c targets. Thus, glycemic goals can be relaxed in the older population as part of individualized care, and physicians must make treatment decisions that best serve their patients' circumstances. This article highlights the issues faced by older people with T2D, the risk factors for hypoglycemia in this population, and the challenges faced by health care providers regarding glycemic management in this patient group.

Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty

“…Activation of the polyol pathway, increased formation of advanced glycation end-products, diacylglycerol activation of protein kinase C, and increased glucose shunting to the hexosamine pathway, all of which are altered in response to hyperglycemia, can impair neuronal function [63]. Conversely, older adults with diabetes are at greater risk of hypoglycemia due to multiple comorbidities such as malnutrition, polypharmacy, and renal dysfunction [64,65]. Similar to hyperglycemia, hypoglycemia can also cause neuronal death and cognitive impairment via excitotoxicity and DNA damage [66].…”

The Safety and Efficacy of Second-Generation Basal Insulin Analogues in Adults with Type 2 Diabetes at Risk of Hypoglycemia and Use in Other Special Populations: A Narrative Review

“…Older adults with diabetes often have an increased duration of diabetes and other comorbidities, such as CV events, retinopathy and renal impairment [8]. Impaired cognitive function, dementia and falls are also increased in older persons compared to younger people with T2DM [54,55]. All of these factors increase the complexity of managing older people with T2DM [55] and may substantially increase the risk of hospitalization for hypoglycemia and associated death [8,56].…”

A Multicenter, Prospective, Observational, Open-Label Study of the Safety and Comfort of Gensulin® Delivery Device Use in a Large Cohort of Adult and Elderly Patients with Type 2 Diabetes

“…It is difficult to estimate the exact incidence of hypoglycemia in the elderly due to the low number of studies that enroll older patients and group heterogeneity [ 18 ]. There is no doubt that older adults with diabetes possess a greater risk of hypoglycemia and are at risk of worse consequences than younger patients [ 19 ]. In this context, in the large group of adult and elderly patients, there were only 0.2% of severe hypoglycemia incidents.…”