Older Adults Still Struggle With Hypoglycemia

NEW ORLEANS — Many older adults with type 1 diabetes were unaware when they experienced hypoglycemia, researchers reported here from a small study.

Using blinded continuous glucose monitoring (CGM) data, older adults — ages ≥60 years — spend a median of 5% of their day in hypoglycemia (blood glucose <70 mg/dL), equivalent to about 72 minutes, found Anders Carlson, MD, of the International Diabetes Center in Minneapolis, and colleagues.

These older adults also spent around 1.6% of their day in “dangerously low” severe hypoglycemia (blood glucose <54 mg/dL), equivalent to about 24 minutes per day, said Carlson at ENDO 2019, The Endocrine Society's annual meeting.

Most notably, though, is that a longer time spent in a hypoglycemic or severe hypoglycemic range was tied to these patients being unaware of their hypoglycemia. Compared with patients who were aware or just uncertain they were in hypoglycemia, patients with reduced awareness spent significantly more time each day with low blood sugar:

• Hypoglycemia (<70 mg/dL): 7% (101 min/day) [aware] vs 5% (72 min/day) [unaware]

• Severe hypoglycemia (<54 mg/dL): 3% (43 min/day) vs 1% (14 min/day)

Overall, these older patients with type 1 diabetes only spent around 56% of their day in postprandial target glucose range — of 70 to 180 mg/dL — equivalent to around 13.4 hours per day. These patients typically spent over a third of their day in hyperglycemia (>180 mg/dL) as well, making up for around 8.4 hours of their day. As for severe hyperglycemia, patients spent a median of 12% of their day — 2.8 hours — with a blood glucose level over 250 mg/dL.

The analysis included 203 older adults with an HbA1c <10%. They were provided a Dexcom G4 CGM, and instructed to wear the sensor for up to 21 days and for a minimum of 240 hours.

Other factors that were tied with a significantly greater proportion of time spent in target glucose range included being retired versus those who were either employed or unemployed. Retired older adults also spent significantly less time in hyperglycemia or severe hyperglycemia. Also, those who had a lower total daily insulin per kilogram of body weight were associated with a significantly greater time spent in target range.

Comparing this group’s time spent in range to 2019 consensus target goals for older adults, the researchers found that these patients were seeing less time in target range, and more time in both hypoglycemia and hyperglycemia:

• Time spent >250 mg/dL: 12% (study) vs <5% (consensus targets)

• >180 mg/dL: 35% vs <25

• 70-180 mg/dL: 57% vs ≥70%

• <70 mg/dL: 5% vs <4%

• <54 mg/dL: 1.6% vs <1%

But because this was an older population, hypoglycemia arguably plays a bigger threat than hyperglycemia due to fall risk, Carlson explained during a press conference, calling unawareness of hypoglycemia still a “major issue” for this patient population.

New Guidelines

At this same press conference, The Endocrine Society unveiled their new clinical practice guidelines for treating older adults ages 65 and older with diabetes, published in The Journal of Clinical Endocrinology & Metabolism.

Part of the new recommendations made in this guideline included a pivot toward simplifying medication regimens for these older patients with type 1 or type 2 diabetes, explained lead author Derek LeRoith, MD, PhD, of the Icahn School of Medicine at Mount Sinai in New York City. Along with this, the recommendation is to tailor the treatment plan and blood glucose targets for the patient, taking into account the level of cognitive functioning to avoid complications.

The guideline also revised glucose targets for these patients in the hospital or in nursing homes, with a fasting target of 100-140 mg/dL or postprandial target of 140-180 mg/dL. The guideline also recommends tailoring outpatient treatment regimens specifically with the intent to reduce time spent in hypoglycemia.

Blood pressure targets should rest around 140/90 mmHg, the guideline also states, in order to reduce macrovascular complications such as cardiovascular disease, stroke, and chronic kidney disease. As for microvascular complications, an annual eye exam is recommended to prevent diabetic retinopathy.

“We also believe that all the decisions in terms of management of these patients should be a team approach,” LeRoith underscored.