The appropriate target for glycated hemoglobin A1C needs to be individualized based on overall health and life expectancy, as well as patient-specific risks for hypoglycemia and the patient's ability to adopt and adhere to specific treatment regimens table 1.

The results of the Action to Control Cardiovascular Risk in Diabetes ACCORD trial suggest that intensive glycemic therapy in persons at high risk for cardiovascular disease CVD , especially when achieved through polypharmacy, may increase the risk for both total and CVD mortality [ ].

An A1C of 8. These include anemia and other conditions that impact red blood cell life span, chronic kidney disease, recent transfusions and erythropoietin treatment, recent acute illness or hospitalizations, and chronic liver disease. Residents of long-term care facilities tend to have higher prevalence of these medical conditions [ 17 ].

To assess glycemia for management decisions in this setting, glucose monitoring with fingersticks and a glucose meter, or continuous glucose monitoring CGM in selected patients, may be used see 'Monitoring of glycemia' below. Biologic and patient-specific factors that may cause misleading A1C results are reviewed separately.

See "Measurements of chronic glycemia in diabetes mellitus", section on 'Unexpected or discordant values' and "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus", section on 'Type 2 diabetes'.

Avoiding hypoglycemia — Hypoglycemia should be avoided in older adults. Avoidance of hypoglycemia is an important consideration in choosing therapeutic agents and establishing glycemic goals. Insulin secretagogues such as sulfonylurea and meglitinides, as well as all types of insulin, should be used with caution in frail older adults [ 18 ].

See 'Choice of second drug' below and "Hypoglycemia in adults with diabetes mellitus", section on 'Strategies to manage hypoglycemia'. The vulnerability to hypoglycemia is substantially increased in older adults [ 1,19 ].

Older adults may have more neuroglycopenic manifestations of hypoglycemia dizziness, weakness, delirium, confusion compared with adrenergic manifestations tremors, sweating , resulting in delayed recognition of hypoglycemia [ 18 ]. These neuroglycopenic symptoms may be missed or misconstrued as primary neurologic disease such as a transient ischemic attack , leading to underreporting of hypoglycemic episodes by the patients.

Hypoglycemia can result in poor outcomes, such as traumatic falls, adverse cardiovascular events, and cardiac autonomic dysfunction [ 20,21 ]. In addition, severe hypoglycemia requiring hospitalization has been associated with an increased risk of developing dementia that is higher in patients with repeated hypoglycemic episodes, although the direction of causality, if any, is unknown [ 22,23 ].

Even a mild episode of hypoglycemia may lead to acute, adverse outcomes in frail older patients, including falls and fractures. Cardiovascular risk reduction — Older adults with diabetes are at risk of developing a similar spectrum of macrovascular complications as their younger counterparts with diabetes.

However, their absolute risk for CVD is much higher than that in younger adults [ 24 ]. As in younger patients with type 2 diabetes, risk reduction should be focused on established risk factors. See "Prevalence of and risk factors for coronary heart disease in patients with diabetes mellitus".

Older patients are likely to derive greater reduction in morbidity and mortality from cardiovascular risk reduction, with treatment of hypertension and lipid lowering with statin therapy, than from tight glycemic control [ 1,13,25 ].

Both diabetes and older age are major risk factors for coronary heart disease CHD. Unsurprisingly, therefore, CHD is by far the leading cause of death in older patients with diabetes.

Few data specifically address optimal cardiovascular risk reduction in older patients. Benefits from lipid lowering and blood pressure control have been extracted from trials in older adults not restricted to individuals with diabetes and from trials in patients with diabetes, which included some older adults [ 1,25 ].

As with glycemic control, the benefit of cardiovascular risk reduction depends upon the patient's degree of frailty, overall health, and projected period of survival. See 'Polypharmacy and deintensification' below.

Smoking cessation — Smoking in patients with diabetes mellitus is an independent risk factor for all-cause mortality, which is due largely to CVD. Despite the absence of any high-quality trial data, smoking cessation should be vigorously promoted. See "Overview of smoking cessation management in adults".

Treatment of hypertension — Treatment of hypertension in older patients is clearly beneficial, including in patients over age 80 years. Recommended therapeutic goals and drug options for patients with diabetes and older adults are reviewed in detail elsewhere.

See "Treatment of hypertension in patients with diabetes mellitus" and "Treatment of hypertension in older adults, particularly isolated systolic hypertension". Treatment of dyslipidemia — For most older patients with diabetes, we use a statin drug unless contraindicated to lower cholesterol.

The ACCORD trial found no benefit of adding fenofibrate to statin therapy in patients with diabetes who were at high risk for CVD [ 26 ].

The relative beneficial effects of lipid lowering with statins are similar in older and younger patients with diabetes, and the absolute benefit is typically greater in older than in younger patients [ 27,28 ].

As with goal setting for glycemic management, goals for lipid management should be adjusted based upon older patients' comorbidities, cognitive status, and personal preferences. Reductions in events with statin therapy can occur quickly within weeks to months , and so even in older patients, such therapy can be expected to reduce events during a patient's expected lifespan.

See "Management of low density lipoprotein cholesterol LDL-C in the secondary prevention of cardiovascular disease".

The presence or absence of CVD risk factors other than diabetes should guide the intensity of statin therapy. Dosing based upon risk of CVD is reviewed in detail separately. See "Management of low density lipoprotein cholesterol LDL-C in the secondary prevention of cardiovascular disease", section on 'Our approach' and "Low-density lipoprotein cholesterol-lowering therapy in the primary prevention of cardiovascular disease".

Some patients may require medical therapy to reduce the risk of pancreatitis. The treatment of hypertriglyceridemia is reviewed elsewhere. See "Hypertriglyceridemia in adults: Management", section on 'Treatment goals'.

Aspirin — The value of daily aspirin therapy in patients with known macrovascular disease secondary prevention is widely accepted see "Aspirin for the secondary prevention of atherosclerotic cardiovascular disease". A meta-analysis of a large number of secondary prevention trials found that the absolute benefit of aspirin was greatest in those over age 65 years with diabetes or diastolic hypertension [ 29 ].

The role of aspirin for the primary prevention of cardiovascular events in patients with diabetes is less certain. These trials and recommendations for aspirin therapy are reviewed elsewhere. See "Overview of general medical care in nonpregnant adults with diabetes mellitus", section on 'Aspirin'.

Exercise — The benefits of exercise are reviewed below. See 'Lifestyle modification' below. Weight reduction if needed through diet, exercise, and behavioral modification can be used to improve glycemic control, although the majority of older patients with type 2 diabetes will require medication over the course of their diabetes.

See "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Diabetes education'. These data suggest that older persons can respond well to lifestyle programs. See "Prevention of type 2 diabetes mellitus", section on 'Lifestyle modification'. Lifestyle modification is also beneficial for improving glycemia in older adults with established type 2 diabetes.

In one trial, older adults mean age approximately 72 years on stable oral or injectable medications for the previous six months were randomly assigned to an intensive lifestyle intervention diet and exercise to achieve a 10 percent body weight loss for six months followed by a maintenance phase or a control intervention monthly educational group sessions [ 32 ].

After one year, reductions in A1C mean difference 0. See 'Avoiding hypoglycemia' above. In sedentary individuals, we stress the importance of gradually increasing activity from current baseline and provide practical guidance on how to do so.

For example, patients can initially walk inside their home for five minutes, one to three times a day, and build progressively to the daily exercise goal. Routine testing by electrocardiogram or cardiac exercise testing is not indicated for most asymptomatic adults prior to initiating moderate physical activity, unless they are at high risk for coronary disease on the basis of multiple risk factors.

Exercise is beneficial to help maintain physical function, reduce cardiac risk, and improve insulin sensitivity in patients with diabetes. In older adults, exercise also improves body composition and arthritic pain, reduces falls and depression, increases strength and balance, enhances the quality of life, and improves survival [ ].

Studies of older people with frailty have shown that weight training should be included in addition to aerobic exercises [ 37 ]. See "Exercise guidance in adults with diabetes mellitus" and "Physical activity and exercise in older adults". Most older adults with diabetes should be considered for a medical nutrition evaluation.

Unique challenges with aging, such as altered taste perception, coexisting illnesses and dietary restrictions, compromised dentition, altered gastrointestinal function, impaired food shopping and preparation capabilities, and memory decline leading to skipped meals, should be considered before developing meal plans.

In general, it is best to avoid a complex dietary treatment regimen in older adults. See "Medical nutrition therapy for type 2 diabetes mellitus", section on 'Medical nutrition therapy'.

A regular diet with preferred food items may improve quality of life and prevent weight loss. Weight loss is associated with risk of morbidity and mortality in older adults, although separating the effects of intentional from unintentional weight loss has been problematic [ 41 ].

Unintentional weight loss in an older adult requires further evaluation. See "Geriatric nutrition: Nutritional issues in older adults". We avoid strict dietary restrictions for such individuals. Thus, the approach to choosing initial, alternative, and combination therapy is similar in older and younger adults.

All types of oral hypoglycemic drugs and insulin are effective in older patients, although each has limitations table 2. In general, oral and injectable agents with low risk of hypoglycemia are preferred in older adults.

See 'Metformin' below and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Choice of initial therapy'. Because of concern for hypoglycemia, some clinicians use insulin only for a short time to ameliorate glucose toxicity transient suppression of beta cell function and increased insulin resistance from chronic exposure to very high concentrations of glucose.

Once insulin secretion and sensitivity are improved, the dose can be lowered or replaced with metformin or another glucose-lowering agent with lower risk of hypoglycemia.

See "Insulin therapy in type 2 diabetes mellitus". Our suggestions are based upon clinical trial evidence and clinical experience in achieving glycemic targets and minimizing adverse effects, with the recognition that there is a paucity of high-quality, head-to-head drug comparison trials and trials with important clinical endpoints, such as effects on diabetes-related complications [ 42 ].

The long-term benefits and risks of using one approach over another are unknown. Pharmacologic therapy must be individualized based upon patient abilities and comorbidities. Metformin is an attractive agent to use in older adults due to a low risk of hypoglycemia.

Healthy older adults may be treated similarly as younger adults with initiation of metformin at the time of diabetes diagnosis, even if the presenting A1C is below the individualized medication-treated target.

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 [ 43 ]. However, for patients who present with A1C near their medication-treated target and prefer to avoid medication, or in those with multiple comorbidities and concerns about polypharmacy, a three- to six-month trial of lifestyle modification before initiating metformin is reasonable.

We typically begin with mg daily and increase the dose slowly over several weeks to minimize gastrointestinal side effects. Extended-release formulations of metformin may be tolerated better in patients who are unable to tolerate immediate-release metformin due to gastrointestinal side effects.

While these recommendations are reasonable, few studies have established the therapeutic efficacy or safety of these reduced doses. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Dosing'. Therefore, metformin should be used with caution in older patients. Older patients treated with metformin should be cautioned to stop taking the drug immediately if they become seriously ill for any reason or if they are to undergo a procedure requiring the use of iodinated contrast material.

In addition, kidney function measurement of serum creatinine and eGFR should be monitored every three to six months rather than annually. See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Contraindications'.

This approach is reviewed in detail separately. See "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Contraindications to or intolerance of metformin' and "Initial management of hyperglycemia in adults with type 2 diabetes mellitus", section on 'Established cardiovascular or kidney disease' and "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease".

Evaluation — If glycemic goals are not met with a single agent, older patients should be evaluated for contributing causes similar to younger adults, such as difficulty adhering to the medication, side effects, or adherence to the nutrition plan [ 1,6 ].

If hyperglycemia above the individualized target persists, an additional agent is needed. In older patients who require more than one agent, pill-dosing dispensers may help improve adherence. As an alternative, family members or caregivers may be required to help administer medication.

Additional nutritional counseling and diabetes self-management education and support programs, when available, should be offered to patients. Choice of second drug — For older patients who have persistent hyperglycemia above their individualized glycemic target despite treatment with lifestyle intervention and metformin , a second agent should be selected.

The choice of a second agent should be individualized based upon efficacy, the patient's underlying comorbidities, risk of hypoglycemia, impact on body weight, side effects, and cost figure 1.

See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Indications for a second agent' and "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'Our approach'. The individual agents are discussed in more detail in the individual topic reviews.

See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus" and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus" and "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus" and "Sulfonylureas and meglitinides in the treatment of type 2 diabetes mellitus" and "Thiazolidinediones in the treatment of type 2 diabetes mellitus" and "Alpha-glucosidase inhibitors for treatment of diabetes mellitus".

Insulin is sometimes underutilized in older adults because of fear by the clinician, patient, or family that it is too complicated or dangerous. Addition of once-daily basal insulin to a non-insulin agent usually metformin is a low-complexity regimen with a relatively lower risk of hypoglycemia compared with regimens using multiple daily insulin doses [ 44 ].

Before beginning insulin therapy, it is important to evaluate whether the patient is physically and cognitively capable of using an insulin pen or drawing up and injecting the appropriate dose of insulin using syringes and vials , monitoring blood glucose, and recognizing and treating hypoglycemia.

For older patients taking a fixed daily dose of insulin who are capable of injecting insulin but not of drawing it into the syringe, a pharmacist or family member may prepare a week's supply of insulin in syringes and leave them in the refrigerator.

Such a plan may allow an older patient to remain living independently at home. Insulin pens, when available and affordable, are an alternative for patients who have difficulty administering insulin using vials and syringes due to vision or motor limitations.

Morning administration reduces the risk of nocturnal hypoglycemia, and fasting hyperglycemia is less of a concern in older patients [ 45 ]. See "Management of hyperglycemia in patients with type 2 diabetes and advanced chronic kidney disease or end-stage kidney disease", section on 'Treatment'.

Insulin therapy is discussed in detail elsewhere. See "General principles of insulin therapy in diabetes mellitus" and "Insulin therapy in type 2 diabetes mellitus". History of cardiovascular or kidney disease — Sodium-glucose co-transporter 2 SGLT2 inhibitors empagliflozin or canagliflozin or glucagon-like peptide 1 GLP-1 receptor agonists liraglutide or semaglutide are reasonable second agents for patients with established cardiovascular or kidney disease [ 46,47 ].

All of these drugs confer low risk of hypoglycemia on their own or in combination with other drugs that do not usually cause hypoglycemia. GLP-1 receptor agonists should be titrated slowly, with monitoring for gastrointestinal GI side effects, which could precipitate dehydration and acute kidney injury AKI.

We avoid use of SGLT2 inhibitors in patients with frequent bacterial urinary tract infections or genitourinary yeast infections, low bone density and high risk for falls and fractures, foot ulceration, and factors predisposing to diabetic ketoacidosis eg, pancreatic insufficiency, drug or alcohol abuse disorder because of increased risk while using these agents.

See "Glucagon-like peptide 1-based therapies for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects' and "Sodium-glucose cotransporter 2 inhibitors for the treatment of hyperglycemia in type 2 diabetes mellitus", section on 'Cardiovascular effects'.

Avoidance of hypoglycemia — In older adults at increased risk of hypoglycemia, GLP-1 receptor agonists, SGLT2 inhibitors, and dipeptidyl peptidase 4 DPP-4 inhibitors are options as they are associated with a low hypoglycemia risk.

DPP-4 inhibitors are useful only to improve mild hyperglycemia since they are relatively weak agents and usually lower A1C levels by only 0.

However, in frail older adults with late-onset diabetes, particularly patients at high risk of hypoglycemia and impaired awareness of hypoglycemia, a DPP-4 inhibitor can be a useful agent to lower glycemia to the individualized target.

See "Dipeptidyl peptidase 4 DPP-4 inhibitors for the treatment of type 2 diabetes mellitus", section on 'Glycemic efficacy'. Avoidance of weight gain — GLP-1 receptor agonists may be appropriate to use when avoidance of weight gain is a primary consideration and cost is not a major barrier.

SGLT2 inhibitors are also associated with weight loss. However, in the absence of cardiovascular or kidney disease, the risks of SGLT2 inhibitors in older individuals eg, dehydration, falls, fractures may outweigh the benefits.

DPP-4 inhibitors, which are weight neutral, also may be a reasonable option. 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 ].

ϑ P value adjusted for use of assistive devices during the test, in addition to age and site. ΦEnglish Continuous Text Near Vision Card; P value obtained from treating reading vision as an ordinal variable and adjusting for visual aids used during the test such as a magnifying glass , in addition to age and site.

Case and control subjects had similar depression scores, but there was a trend for slightly lower scores on the Duke Social Support Scale in case versus control subjects mean score Case subjects scored higher on the Hypoglycemia Fear Survey than control subjects mean score Case subjects were substantially more likely than control subjects to have significant hypoglycemia unawareness Fig.

A : How low does your blood glucose need to go before you feel symptoms? B : To what extent can you tell by your symptoms that your blood glucose is low?

Hypoglycemia Unawareness Questionnaire response missing for two case subjects and one control subject. This case-control study of older adults with long-standing T1D found that the occurrence of recent severe hypoglycemia was associated with greater hypoglycemia unawareness and higher glucose variability but not with lower HbA 1c or mean glucose levels.

The latter finding indicates that the risk of severe hypoglycemia in this age group was not due to tighter glycemic control. The greater risk also was not due to less fear of hypoglycemia, and in fact, those with recent severe hypoglycemia, not surprisingly, had greater fear of hypoglycemia.

The slightly higher daily frequency of blood glucose monitoring in case subjects compared with control subjects might be related to their higher fear of hypoglycemia. Hypoglycemia unawareness, which is associated with altered counterregulation, is more common in older adults with long-duration T1D than in younger individuals or those with type 2 diabetes Individuals with reduced hypoglycemia awareness are more prone to severe hypoglycemia and high morbidity and mortality, particularly in the elderly 5 — 7 , Current insulin therapies are unable to eliminate this risk.

Routine screening for hypoglycemia unawareness in this population is recommended and can be accomplished using a brief questionnaire Whether the glucose counterregulatory failure that characterizes hypoglycemia unawareness may explain the greater glucose variability reported here requires further study, and future work should explore strategies to correct defective glucose counterregulation in T1D.

The finding of greater glucose variability in case subjects than in control subjects is a concern, particularly when combined with a lack of awareness of hypoglycemia. Earlier studies examining limited glucose data from self-monitoring of blood glucose in younger patients suggested that blood glucose variance was related to hypoglycemia 29 , A more recent study in long-standing T1D complicated by reduced awareness of hypoglycemia showed that glucose variability as determined by h CGM was related to the severity of clinically problematic hypoglycemia Although the percentages of participants with measurable C-peptide levels were not different between the two groups, single C-peptide measurements are not as sensitive as provocative testing.

Further research is required to determine if endogenous insulin secretion can assist in explaining our findings. β-Blockers, which are commonly used in older patients with diabetes for a variety of indications, were more commonly used by case subjects than by control subjects.

In younger age groups with shorter durations of diabetes than in our report, the adverse effect of selective and nonselective β-blockers on hypoglycemia unawareness has been studied 32 , 33 , although we did not find an association between hypoglycemia unawareness and β-blocker use.

We also note that there are no data about hypoglycemia risks in elderly patients with T1D, although one report of 13, subjects with type 2 diabetes did not find that β-blockers significantly increased the risk of severe hypoglycemia Use of β-blockers in that report included oral and eye drop preparations, and the indications for use were not recorded.

Further research is needed to better understand the possible influence of nonselective β-blocker use on hypoglycemia in this population. The study found some differences in executive function and psychomotor processing speed between case and control subjects.

These could be contributory factors for severe hypoglycemia, could result from recurrent hypoglycemia, or could be part of a vicious cycle involving both. Those with cognitive impairment may be less able to determine and self-administer the correct insulin doses for meals and correction of hyperglycemia and amounts of carbohydrate for falling glucose levels.

They may fail to anticipate the consequences of exercise or missed meals. This may be particularly problematic in those who lack physiological symptoms to alert them of hypoglycemia.

Conversely, hypoglycemia could be related to the development of these cognitive impairments. No differences between case and control subjects were seen in functional activities score, numeracy, vision testing, depression, or social support. A potential limitation of the study is that participants were from specialized diabetes centers; however, because case and control subjects were matched within centers, this was not likely a source of bias.

Nevertheless, it is possible that results could differ in patients meeting study eligibility criteria receiving care in other settings.

There is also the possibility of survivor bias. Individuals with a history of more severe hypoglycemia could have had earlier mortality.

The study excluded users of CGM at home because frequency of use in this age group is low and it would be inappropriate to pool data from CGM and non-CGM users. Because hypoglycemia is a major problem in older adults with longstanding T1D, current guidelines suggest higher HbA 1c goals for this population based on the assumption that this will lead to less hypoglycemia 9.

Our results suggest that raising HbA 1c goals in many patients will be insufficient to reduce severe hypoglycemia in this population due to the presence of hypoglycemia unawareness and increased glucose variability.

Therefore, until an artificial pancreas or β-cell replacement therapy becomes available, frequent home glucose measurements may be an important strategy for these patients.

Other methods to reduce hypoglycemic exposure 35 and minimize β-blocker use should be considered. The use of current technologies, such as CGM and threshold suspend pumps, in this population requires further study.

Funding was provided by the Leona M. and Harry B. Helmsley Charitable Trust. The nonprofit employer of R. has received grant funding from the National Institutes of Health and the Leona M. The nonprofit employer of N. has received grant funding from the National Institutes of Health.

Duality of Interest. receives royalties from the Betty Crocker Diabetes Cookbook and holds stock in Merck. has received lecture fees from BRIOmed. has received consultancy payments and stock from PhaseBio. has received payments as a board member for Eli Lilly, Merck, Novartis, and Sanofi and consultancy payments from Roche Diagnostics.

No other potential conflicts of interest relevant to this article were reported. Author Contributions. researched data and wrote and edited the manuscript. researched data, wrote and edited the manuscript, and performed statistical analyses.

researched data and reviewed and edited the manuscript. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis.

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Risk Factors Associated With Severe Hypoglycemia in Older Adults With Type 1 Diabetes Ruth S. Weinstock ; Ruth S. This Site. Google Scholar. Stephanie N. DuBose ; Stephanie N. Richard M. Bergenstal ; Richard M. Naomi S. Chaytor ; Naomi S.

Christina Peterson ; Christina Peterson. Beth A. Olson ; Beth A. Medha N. Munshi ; Medha N. Alysa J. Hypoglycemia in the elderly is not only due to tight blood sugar control, but also due to a multitude of other factors.

Hypoglycemia often occurs with insulin, sulfonylureas, or meglitinide therapy. However, other causes may also contribute to hypoglycemia, such as decreased cognition, renal impairment, or 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. full text icon Full Text. Download PDF Top of Article Abstract Methods Results Comment Article Information References.

View Large Download. Table 1. The Diabetes Control and Complication Trial Research Group, Hypoglycemia in the Diabetes Control and Complication Trial. Abraira CColwell JANuttall FQ et al. Veterans Affairs cooperative study on glycemic control and complications in type II diabetes VS CSDM : results of the feasibility trial.

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If you have any of these diabetes warning signs, talk to your doctor. Detecting diabetes early can help prevent serious complications down the road. When your body has trouble with insulin, you end up with too much glucose in your bloodstream hyperglycemia , which can eventually wreak havoc with your health.

The most common form of diabetes in older adults is type 2 diabetes. In fact, nearly half of all people with type 2 diabetes are people aged 65 or older. This group is at greater risk for developing complications related to diabetes, including hypoglycemia, heart disease, and kidney failure.

Diabetes signs and symptoms vary from person to person. Some people have such mild symptoms that they don't notice them, while others have clear signs something is not quite right.

Here are 10 diabetes warning signs to look out for. They will likely use one or more of the following tests to screen you for diabetes:. If your test results show you have diabetes, your doctor will work with you to create a comprehensive diabetes management plan. With the right treatment, it is possible to lead a healthy, active, and enjoyable life with diabetes.

By getting screened regularly and watching out for diabetes symptoms, you can increase your chances of early detection, prevent serious complications, and stay healthy for longer. Want to know more? Visit our Diabetes for Older Adults resource library.

Special Considerations for Older Adults With Diabetes, Endocrine Society. Type 2 diabetes mellitus in older adults: clinical considerations and management, Nature Reviews Endocrinology. Understanding neuropathy and your diabetes, American Diabetes Association.

Get information on prevention and how to manage ongoing health conditions focused on physical and mental health. From exercise tips to diet and nutrition, this is your one-stop shop for caring for yourself and loved ones.

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How Significant Is Severe Hypoglycemia in Older Adults With Diabetes? Lisa Chow Lisa Chow. Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN.

This Site. Google Scholar. Elizabeth R. Seaquist Corresponding author: Elizabeth R. Seaquist, seaqu umn. Diabetes Care ;43 3 — Connected Content. A commentary has been published: Severe Hypoglycemia and Cognitive Function in Older Adults With Type 1 Diabetes: The Study of Longevity in Diabetes SOLID.

A commentary has been published: Confirming the Bidirectional Nature of the Association Between Severe Hypoglycemic and Cardiovascular Events in Type 2 Diabetes: Insights From EXSCEL. Get Permissions. toolbar search Search Dropdown Menu.

toolbar search search input Search input auto suggest. Figure 1. View large Download slide. Severe hypoglycemia and diabetic ketoacidosis in adults with type 1 diabetes: results from the T1D Exchange clinic registry.

Search ADS. Severe hypoglycemia and cognitive funtion in older adults with type 1 diabetes: the Study of Longevity in Diabetes SOLID. Confirming the bidirectional nature of the association between severe hypoglycemic and cardiovascular events in type 2 diabetes: insights from EXSCEL. Poor cognitive function and risk of severe hypoglycemia in type 2 diabetes post hoc epidemiologic analysis of the ACCORD trial.

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