Review
Review of Hypoglycemia in the Older Adult: Clinical Implications and Management

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Abstract

The aging of the population is a worldwide phenomenon. The prevalence of diabetes rises with increasing age, so the personal and financial costs of diabetes in the aging population have become significant burdens. In 2012, 104 billion (59%) of the estimated $176 billion in United States healthcare expenditures attributable to diabetes were utilized by patients older than 65 years of age [American Diabetes Association (1)]. With improvement in diabetes management and better glycemic control in the general population, there is an increase in the prevalence of hypoglycemia, which is the complication of the treatment of diabetes. Older adults with diabetes have a higher risk for hypoglycemia due to altered adaptive physiologic responses to low glucose levels. These patients also have comorbidities, such as cognitive and functional loss, that interfere with prompt identification and/or appropriate treatment of hypoglycemia. Older adults who suffer from hypoglycemia also have increased risk for falls, fall-related fractures, seizures and comas and exacerbation of chronic conditions, such as cognitive dysfunction and cardiac events. Thus, hypoglycemia in the older adult must be proactively avoided to decrease significant morbidity and mortality. Education of the patients and caregivers is important in prevention and treatment of hypoglycemia. In this article, we discuss the important aspects and unique challenges pertaining to hypoglycemia in older population. We also highlight the risks, consequences and prevention and management strategies for hypoglycemia that can be used by healthcare providers caring for older populations.

Résumé

Le vieillissement de la population constitue un phénomène mondial. La prévalence du diabète augmente en fonction de l'âge, de sorte que les coûts personnels et financiers du diabète liés à la population vieillissante sont devenus d'importants fardeaux. En 2012, les 104 milliards de dollars (G$) (59%) en soins de santé attribuables au diabète que les É.–U. ont dépensés par rapport à l'estimation prévue de 176 G$ ont servi aux patients de plus de 65 ans [American Diabetes Association (1)]. En raison de l'amélioration de la prise en charge du diabète et de la meilleure régulation de la glycémie de la population générale, on observe une augmentation de la prévalence de l'hypoglycémie, qui est la complication liée au traitement du diabète. Les personnes âgées souffrant de diabète sont exposées à un risque plus élevé d'hypoglycémie en raison de l'altération des réponses physiologiques adaptatives aux faibles taux de glycémie. Ces patients ont également des comorbidités comme des pertes cognitives et fonctionnelles qui interfèrent avec l'identification prompte et/ou le traitement approprié de l'hypoglycémie. Les personnes âgées qui souffrent d'hypoglycémie sont également exposées à l'augmentation du risque de chutes, de fractures liées aux chutes, de crises épileptiques et de comas et à l'exacerbation de maladies chroniques comme le dysfonctionnement cognitif et les événements cardiaques. Par conséquent, l'hypoglycémie chez la personne âgée doit être évitée de manière proactive pour diminuer significativement la morbidité et la mortalité. L'éducation des patients et la formation des soignants sont importantes pour la prévention et le traitement de l'hypoglycémie. Dans le présent article, nous traitons des aspects importants et des défis particuliers de l'hypoglycémie dans la population âgée. Nous mettons également l'accent sur les risques, les conséquences et les stratégies de prévention et de prise en charge de l'hypoglycémie que les prestataires de soins de santé peuvent utiliser pour intervenir auprès des populations âgées.

Section snippets

Definition and Classification of Hypoglycemia

It is difficult to know the exact prevalence of hypoglycemia (usually defined as blood glucose levels less than 70 mg/dL or 3.9 mmol/L) because many different classifications have been used in studies over the years. In addition, developments in new technologic methods over the past decades have made changes in how hypoglycemia is determined. Traditionally, hypoglycemia was defined as the presence of the Whipple triad, which included 1) low blood glucose; 2) symptoms and signs associated with

Physiologic Responses to Hypoglycemia

In healthy adults, when blood glucose levels fall (usually below 70 mg/dL or 3.9 mmol/L), multiple responses are triggered, and euglycemia is quickly restored. In response to hypoglycemia, insulin secretion from the pancreas will first decrease as the initial response. Next, the pancreas will increase glucagon production as counter-regulation. The liver then detects the decrease in insulin and the increase in glucagon and responds by increasing both glycogenolysis and gluconeogenesis. The

Age-Related Compromise of the Adaptive Responsive to Hypoglycemia

The responses of a healthy adult to hypoglycemia are lost to varying degrees in the adult patient with diabetes and are critically lost in the older population 3, 4. Increased duration of diabetes, as well as the effect of aging on the endocrine, neurologic and cardiovascular systems is additive to the consequences of hypoglycemia in older patients.

Aging has an impact on counter-regulation 5, 6. In healthy older adults without diabetes, glucose counter-regulation by glucagon as well as growth

Consequences of Hypoglycemia in Older Adults

Consequences of hypoglycemia in older adults can be catastrophic. Hypoglycemia can increase the risk for cardiovascular events (4). Acute hypoglycemia in patients can promote QT prolongation, which can predispose patients to life threatening ventricular arrhythmias. There is also a potentially maladaptive vagal response, which only increases the chances for ventricular ectopy (4). It is likely that hypoglycemia is a marker of frailty as well as multiple comorbidities 7, 8.

There is a

Establish appropriate glycemic goals

From clinicians' perspectives, studies from the 1990s pushed the physician community toward tighter glycemic control by demonstrating reduction in long-term complications 12, 13. This practice has led to increased use of insulin earlier in the course of the disease and to increased risk for hypoglycemia. A recent national survey of the older adult population in the United States showed that between 1999 and 2011, the hospital admission rates for hyperglycemia decreased by 55%, while those for

Conclusions

It is challenging to manage diabetes in the elderly population because they may have many associated comorbidities and utilize multiple medications. All elderly patients should be managed with individualized care and treatment plans that include early recognition and management of hypoglycemia. The goals of diabetes management vary based on patients' cognitive and functional capacities, comorbidities and life expectancies. It is imperative to avoid hypoglycemia in the elderly because it may

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