Spotlight on hypoglycemia in older patients

One recent study highlighted the problem of physical food insecurity and another identified predictors of impaired hypoglycemia awareness, both in older diabetes patients. A review suggested varying continuous glucose monitoring targets for older patients by their health status.

Several recent articles looked at issues related to hypoglycemia in older patients with diabetes.

One study, published by the Journal of General Internal Medicine on May 20 and also covered in the May 28 I.M. Matters Weekly from ACP, focused on food insecurity and hypoglycemia. Researchers surveyed 1,164 U.S. patients who were ages 65 years or older and had type 2 diabetes treated with insulin or sulfonylureas in 2019. Food insecurity was reported by 12.3% of the respondents. Of those with food insecurity, 38.4% said it was due to economic factors, 21.1% said it was due to physical factors, and 40.5% said it was due to both. Both economic and physical food insecurity were strongly associated with risk of severe hypoglycemia, which was reported by 5.4% of participants in the previous 12 months. According to its authors, the study highlights the effects on diabetes care of food insecurity, including physical insecurity, which is not typically asked about. "Difficulty cooking or shopping for food represent underrecognized and potentially modifiable risk factors for severe hypoglycemia," they wrote, adding that the physical and economic causes of food insecurity likely require distinct solutions.

Another study, published by Diabetes Care on May 7, looked at impaired awareness of hypoglycemia in older patients. It was a post hoc analysis of a clinical trial of continuous glucose monitoring (CGM) that included 199 patients ages 60 years or older with type 1 diabetes. Overall, 30.6% of the patients had impaired awareness of hypoglycemia. Those with impaired awareness had longer diabetes duration, greater daytime hypoglycemia, and more glycemic variability, and they were more likely to have undetectable C-peptide levels. Less daytime hypoglycemia and shorter diabetes duration predicted the possibility of restoring hypoglycemia awareness. The study authors noted that the factors they identified in this older population are consistent with those previously found in younger populations with type 1 diabetes. It's significant that time in hypoglycemia is the only modifiable risk factor that has been identified, they said. "Therefore, it should be addressed earlier in the course of disease and managed aggressively, and its importance should be emphasized with patients with long-standing type 1 diabetes," the study authors said.

Finally, a review article, published by the Journal of Diabetes Science and Technology on May 7, discussed appropriate glucose targets for CGM in older diabetes patients. The review notes that an international consensus group has offered CGM targets, but they are based only on patients' age rather than other criteria. "However, older adults with diabetes are a heterogeneous group, ranging from healthy to very complex frail individuals based on chronological, biological, and functional aging," said the review authors. Their work reviews "the bidirectional associations between glucose and health status in older adults with diabetes" and current guidelines, and the authors propose a new set of CGM targets for older patients with insulin-treated diabetes. They suggest dividing them into three categories—healthy, in intermediate health, or in poor health—with differing CGM targets for each group.