Hypoglycemia In Elderly Patients Research Articles

FRI662 Quetiapine Induced Severe Hypoglycemia In Elderly Patients Without Diabetes

Abstract Disclosure: T. gusov: None. A. Akofu: None. F. marium: None. S. Dejhansathit: None. M.J. Gardner: None. N. Sheung: None. A. Uddin: None. N. Akabogu: None. Introduction: Quetiapine is a second-generation antipsychotic (SGA) commonly used for a wide range of psychotic and mood disorders, sleep aid and others. Older individuals are often treated with quetiapine to relieve psychotic symptoms associated with conditions including dementia and delirium. Common metabolic side effects include weight gain, hyperglycemia, dyslipidemia, and diabetes mellitus. There are few reports of mild asymptomatic hypoglycemia in individuals without diabetes. Hypoglycemia is a serious medical condition with high morbidity and mortality. We report an older individual without diabetes who developed severe hypoglycemia from treatment with quetiapine. Clinical case: 84 years old female was admitted to the hospital for altered mentation, right sided weakness. Cerebral vascular accident was ruled out with imaging studies. The patient was found to be hypoglycemic at 64 mg/dl. Treated with IV D5 with effect, hypoglycemia recurred and was persistent, IV treatment with glucose was initiated. Laboratory results: glucose 46 mg/dL, C- peptide 0.361nmol/L, insulin 1.21 mcunit/ml, proinsulin 6.1 pmol/L, sulfonylurea negative, beta hydroxybutyrate 0.97mmol/L, insulin Ab negative, Administration of 1 mg of glucagon increased blood glucose by 20 mg/dl. Cosyntropin test was normal, TSH and thyroxine levels are normal. Abdominal US ruled out obvious liver and pancreatic pathology. Medication list reviewed. Quetiapine was suspected as the cause and was stopped. Within the next 24 hours blood glucose normalized, IV glucose treatment stopped. She was observed for 2 more days, had no recurrent episodes and was discharged. Conclusion: Quetiapine is widely used to relieve psychotic symptoms and sleep aid. MEdication is usually associated with hyperglycemia. In the present case we report quetiapine-induced hypoglycemia in the patient without diabetes, which was more severe than that described in previous reports, and required dextrose fluid infusion. Quetiapine may increase the amount of basal insulin secreted by pancreatic β-cells and thereby cause hypoglycemia. Since quetiapine is used for the relief of psychotic symptoms, it is crucial to understand the potential adverse effects related to the use of this medication, and to observe any symptoms that may appear. We suggest that clinicians should carefully observe older patients receiving quetiapine to identify any hypoglycemic symptoms that may appear. Reference: Quetiapine-Induced Severe Hypoglycemia in the patient without Diabetes Mellitus: A Case Report Suk Ju Cho, Sang Ah Lee. Annals of Geriatric Medicine and Research 2019;23(1):35-37 Presentation: Friday, June 16, 2023

Effectiveness of the SUGAR intervention on hypoglycaemia in elderly patients with type 2 diabetes: A pragmatic randomised controlled trial.

A pharmacist-led, individualised, educational intervention (SUGAR) was formulated to prevent hypoglycaemia among elderly patients with type 2 diabetes mellitus (T2DM) in Jordan. To evaluate the effectiveness of the SUGAR intervention added to usual care compared with usual care only in preventing hypoglycaemic attacks in elderly patients with T2DM in Jordan. A single-centre, pragmatic, open-label, randomised controlled trial with embedded process evaluation was conducted at the outpatient clinics of a hospital in Jordan. Elderly patients (≥65 years) with T2DM and on sulfonylurea, insulin, or at least three anti-diabetic medications were recruited and parallelly randomised to the SUGAR intervention with usual care or the control (usual care) groups. The primary outcome was the rate of total hypoglycaemic attacks per patient after 3 months from randomisation. Secondary outcomes included rate of hypoglycaemia subtypes, the incidence of any and subtypes of hypoglycaemia, hypoglycaemia-free survival probability, and incidence of fasting hyperglycaemia necessitating therapy modification. Outcomes were measured through glucose meters and diaries, assessed at 3 months, and analysed by intention to treat. A total of 212 participants (mean age 68.98 years, 58.96% men) were randomly allocated (106 in each group), with 190 (89.62%) participants completing the study. The mean of total hypoglycaemic attacks was less in the intervention group compared with the control group (3.91 [SD 7.65] vs. 6.87 [SD 11.99]; p<0.0001) at three months. The intervention significantly reduced the rate of hypoglycaemia subtypes; the odds to experience any, severe, and symptomatic hypoglycaemia; and increased hypoglycaemia-free survival probability compared with the control group at three months. Incidence of fasting hyperglycaemia necessitating therapy modification was similar between groups. The SUGAR intervention can prevent hypoglycaemia without increasing the risk of fasting hyperglycaemia warranting therapy adjustment in elderly Jordanians with T2DM.

Clinical Effect of Comprehensive Nursing on Nocturnal Hypoglycemia in Elderly Patients with Diabetes

Clinical Effect of Comprehensive Nursing on Nocturnal Hypoglycemia in Elderly Patients with Diabetes

396-P: Investigating the Risk of Severe Hypoglycemia in Elderly Patients with Type 2 Diabetes Mellitus

In Japan, The prevalence of type 2 diabetes mellitus (T2DM) is increasing, especially in the elderly population. Many of these patients have co-morbidities like renal insufficiency and personalized blood sugar goals, increasing the risk of hypoglycemia. This study was conducted to examine the associations of patients characteristics such as HbA1c level, BMI and use of glucose level-lowering medication with hypoglycemia-related hospitalizations. This study was cross sectional study conducted over 6 years January 2014 and March 2019. We recruited 9,798 patients with elderly patients over 65 years with T2DM. To assess the odds ratio (OR) of hypoglycemia-related hospitalizations, we constructed a logistic regression analysis, having adjusting for age, gender, BMI, eGFR, baseline HbA1c levels, use of hypoglycemic agents. Hypoglycemia was documented in 124 (1.27%) patients. In multivariate logistic regression analysis, age≧75years and gender were not significantly. DPP-4I (OR: 0.52, 95%CI: 0.28-0.96) showed lower odds ratio. BMI≦25kg/m2 (OR: 2.94, 95%CI: 1.26-6.86), baseline HbA1c&amp;lt;6.0% (OR: 4.43, 95%CI: 2.25-8.73), eGFR 15-≦30 mL/min(OR: 2.54, 95%CI: 1.05-6.10), &amp;lt;15mL/min(OR: 3.01, 95%CI: 1.26-7.16), Insulin (OR: 2.05, 95%CI: 1.22-3.43) showed higher odds ratio. In this study of elderly patients with T2DM, the risk of hospitalization for hypoglycemia appeared to be highest among patients with too low Hba1c and BMI, decreased renal function, and sulfonylurea and/or insulin use. On the other hand, DPP-4I have been shown to reduce the risk of hospitalization for hypoglycemia. By leveraging the results of this study, at-risk elderly patients can benefit from individualized treatment plans to reduce the risk of hypoglycemia. Disclosure T. Horii: None. K. Atsuda: None.

Type 2 diabetes mellitus in elderly patients treated with endocrinologists in clinical practice

A large-scale epidemic of type 2 diabetes mellitus (T2DM) is observed with advanced ageing worldwide. The prevalence of T2DM significantly increases with age. Therefore, this review aimed to summarise the data on T2DM in advanced and older aged patients. The primary geriatric syndromes, which should be considered for the management of older patients (cognitive impairment, sarcopenia, orthostatic hypotension, falls, urinary incontinence, senile asthenia, etc.), are presented. The causes of the high risk for hypoglycaemia in elderly patients are analysed. Improving the treatment for T2DM is a priority of modern medicine. Using antihyperglycaemic therapy is especially difficult in this population due to the high risk of hypoglycaemia and the multi-organ pathology leading to polypharmacy. Therefore, special attention is paid to treatment recommendations. Hypoglycaemic drugs used in elderly patients should be low risk of hypoglycaemia, without nephro- and hepatic toxicity, safe for cardiovascular organs, easy to administer. Furthermore, advantages and limitations of using various groups of hypoglycaemic drugs in elderly patients are discussed. DPP-4 inhibitors are also considered in detail. Modern data on mechanisms of hypoglycaemic action of DPP-4 inhibitors are presented. Possibilities of using sitagliptin in elderly patients were also considered. Finally, evidence-based studies demonstrating the obvious advantages of sitagliptin for the treatment of T2DM in the elderly and advanced aged population are discussed.

399-P: Deintensification of Diabetes Treatment in Elderly Patients with Type 2 Diabetes Mellitus

The prevalence of type 2 diabetes mellitus (T2DM) is increasing, especially in the elderly population. Many of these patients have co-morbidities like renal insufficiency, cognitive impairment and lack of social support, increasing the risk of hypoglycemia. Moreover, the benefits of tight glycemic control have not been established in the elderly. Therefore, the American Diabetes Association recommends relaxed glycemic goals (HbA1c ∼8%) in the elderly population. De-intensification of diabetes treatment is recommended to prevent potential harm. We conducted a retrospective study to evaluate the rate of de-intensification of antidiabetic treatment in patients aged ≥75 years with HbA1c ≤7% at the time of their clinic visits. All patients with ≥2 clinic visits over 1-year period at a major academic diabetes center were included. Out of 1,417 unique patients treated during 2017, 174 were ≥75 years old on the day of their last clinic visit. Out of these, 80 patients had an HbA1c ≤7%. Medical records of these 80 patients were manually reviewed for comorbidities, hypoglycemic episodes and drug therapy. A mention of de-intensification of antidiabetic treatment was found in physicians’ notes in only 12 cases. After excluding those with type 1 diabetes, inadequate documentation or controlled on medications without hypoglycemia potential, we found 36 patients treated with a sulfonylurea drug or insulin. Only 10 (27%) patients were advised to reduce the dose of sulfonylurea drug or insulin after an HbA1c &amp;lt;7% was noted. Out of patients receiving a sulfonylurea drug or insulin, 17 had at least one episode of hypoglycemia before the visit. Even among patients with documented hypoglycemia, only 7 (41%) were advised to de-intensify therapy. Our study suggests that de-intensification of antidiabetic medications is infrequent despite the potential harm of hypoglycemia in elderly patients with T2DM. Strategies need to be developed to prevent overtreatment of diabetes in the elderly patients. Disclosure D.V. Pirela: None. R. Garg: None.

The status of glycemic control and hypoglycemia in elderly patients visiting the outpatient department specializing in diabetes

The Japan Diabetes Society (JDS)/Japan Geriatrics Society (JGS) Joint Committee reported 'Glycemic Targets for Elderly Patients with Diabetes' in 2016. Based on this recommendation, we aimed to clarify 1) the achievement status of glycemic targets in the elderly and 2) the presence of hypoglycemia in real life among elderly individuals with an HbA1c below the lower limit. [Analysis I] In 326 elderly with diabetes ≥65 years of age visiting the outpatient department specializing in diabetes, the proportions of patients with HbA1c values below the lower limit and the use of drugs potentially associated with severe hypoglycemia (e.g. insulin formulations, sulfonylureas, glinides) were investigated. [Analysis II] Of the patients with HbA1c values below the lower limit, seven were tested for hypoglycemia in real life using a continuous glucose monitoring system (CGM). [Analysis I] Among the 326 subjects, 235 (72.1%) were using drugs potentially associated with severe hypoglycemia, and 63 (19.3%) had an HbA1c value below the lower limit. [Analysis II] In the seven patients examined using CGM, hypoglycemia was detected in five, all of whom were unaware. A considerable number of elderly patients were taking drugs associated with hypoglycemic risks and had an HbA1c value below the lower limit, some of whom actually had hypoglycemia as detected by CGM. Using tools such as CGM, preventive measures against hypoglycemia should be taken.

Evaluation of Insulin Use and Hypoglycemia in Hospitalized Elderly Patients.

Background: Routine administration of correctional insulin is no longer recommended as a primary strategy to treat hyperglycemia in hospitalized patients. Studies have demonstrated significant improvement in glycemic control in patients treated with basal and correctional insulin (B+C) versus correctional insulin alone (C). However, the effect of C or B+C on hypoglycemic events is not well understood. Objective: The objective of this study was to investigate the effect of B+C versus C on hypoglycemic events in hospitalized elderly patients. Methods: A single-center retrospective review of patients at least 65 years old that were admitted between April and July 2016, who were prescribed any type of insulin. Exclusion criteria included admission to the intensive care unit (ICU) on hospital admission, history of hypersensitivity to insulin, or insulin use for the management of hyperkalemia. Patients were divided based on the insulin regimen prescribed, B+C or C. The primary outcome of the study was the incidence of hypoglycemic episodes between groups. Secondary outcomes included severity of hypoglycemia, hospital length of stay (LOS), hospital mortality, and ICU transfer. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Results: A total of 709 patients were included, with 144 (20.3%) prescribed B+C and 565 (79.7%) prescribed C. Incidence of hypoglycemia was greater in the B+C group than C (29.1% vs 12.6%, p=0.012). The average blood glucose readings during hypoglycemic episodes between B+C and C were 50 mg/dL and 52.5 mg/dL, respectively (p<0.01). There was no difference observed in hospital LOS. No patients required ICU admission within 24 hours of a hypoglycemic event or died during the index hospitalization. Conclusion: There is a higher incidence of hypoglycemia in elderly patients prescribed basal plus correctional insulin than correctional insulin alone.

Study of 100 Cases of Hypoglycaemia in Elderly Patients of Diabetes Mellitus

Study of 100 Cases of Hypoglycaemia in Elderly Patients of Diabetes Mellitus

Severe hypoglycaemia in elderly patients with type 2 diabetes and coexistence of cardiovascular history.

Hypoglycaemia is a condition that occurs when blood glucose levels fall below 3.9 mmol/L (70 mg/dL), while hypoglycaemic coma is usually associated with glycaemia around 1.1 mmol/L (20 mg/dL). Recurrent severe hypoglycaemia may result in permanent neurological disorders and also has a negative impact on the cardiovascular system. To evaluate the causes of severe hypoglycaemia in elderly patients with type 2 diabetes and coexistence of cardiovascular history. We analysed retrospectively the history of 33 elderly patients with type 2 diabetes and coexistence of cardiovascular history, who were admitted to our clinic due to severe hypoglycaemia with loss of consciousness. The mean age of the patients was 76.0 ± 11.1 years, and the mean duration of diabetes was 12.0 ± 9.8 years. Glycated haemoglobin (HbA1c) was measured and the prevalence of cardiovascular diseases and therapeutic procedures were evaluated. In the group of patients with severe hypoglycaemia, the mean value of HbA1c was 6.3 ± 1.2% (44 ± 13.1 mmol/mol), which indicates a mean glucose value below 7.8 mmol/L (140 mg/dL). Ischaemic heart disease was diagnosed in 18 patients (eight had a history of myocardial infarction), and 22 patients had arterial hypertension. Severe hypoglycaemia requiring hospitalisation in elderly patients with type 2 diabetes and coexistence of cardiovascular history was related to insulin or sulfonylurea therapy. A low HbA1c level indicates inappropriate intensification of therapy and was associated with high risk of severe hypoglycaemic episodes in older people. The majority of severe hypoglycaemic episodes were observed in sulphonylurea or insulin-treated type 2 diabetic patients.

Hypoglycaemia in elderly patients with type 2 diabetes mellitus: a review of risk factors, consequences and prevention

AbstractThe prevalence of diabetes in the elderly is high. Hypoglycaemia is a treatment‐related complication of diabetes. Owing to age‐related changes, decreased perception of hypoglycaemic symptoms, comorbidities and polypharmacy, elderly diabetic persons are at a greater risk of developing hypoglycaemia. Other risk factors include longer duration of diabetes, history of previous hypoglycaemic episodes, intensive glycaemic control, poor nutrition or missed meals and recent hospitalisation. Insulin and sulphonylureas are the medication classes most frequently associated with hypoglycaemia. Other antidiabetic medications typically cause hypoglycaemia only when used in combination with sulphonylureas or insulin. Hypoglycaemia in older people is associated with loss of independence, increased morbidity and mortality. Prevention of hypoglycaemia requires recognition of the risk, identification of precipitating factors, patient and caregiver education, appropriate prescribing and ongoing health professional support.

Hypoglycemia Common Even With High A1C

Miriam E. Tucker is a senior writer with Elsevier Global Medical News. ORLANDO – Hypoglycemic episodes were common despite high hemoglobin A1c levels among 40 elderly community-living adults with diabetes who underwent continuous glucose monitoring. “Raising A1c goals may not be adequate to prevent hypoglycemia in this vulnerable population,” Medha N. Munshi, MD, said at the annual scientific sessions of the American Diabetes Association. Guidelines from the American Diabetes Association and the American Geriatric Society advise that the usual recommended HbA1c target of less than 6.5%-7.0% might be relaxed for elderly adults who have a history of severe hypoglycemia, limited life expectancy, advanced diabetes complications, or extensive comorbidity (Diabetes Care 2010;33 [suppl 1]). In practice, this has been interpreted as a goal of less than 8%. But no study has ever clearly demonstrated that raising the HbA1c target actually reduces the risk of hypoglycemia, said Dr. Munshi, director of the Joslin Diabetes Center geriatric programs at Beth Israel Deaconess Medical Center, Boston. The current study included patients older than 69 years (mean, 75 years) and with a HbA1cgreater than 8%. The patients took a mean of eight medications per day, with 55%) on insulin alone and another 38% on insulin plus one or more oral agents. Two-thirds had type 2 diabetes, and the rest had type 1. Patients performed four fingerstick glucose measurements per day and kept daily diaries of hypoglycemic symptoms, diet, and physical activity. One or more hypoglycemic events occurred in 26 of the 40 patients. The 26 patients who experienced hypoglycemia (glucose less than 70 mg/dL) did not differ from the 14 without such events in patient characteristics including age, diabetes duration, HbA1c, or insulin treatment. There was also no difference between those who did and did not have hypoglycemia in cognitive dysfunction, depression, falls in the past 6 months, number of medications, hypertension, or vision/hearing problems. Of the 26 with hypoglycemia, 12 had HbA1c levels above 9%. “Even a high A1c doesn't preclude lows. Hemoglobin A1c measures the mean. There are wide fluctuations in this population,” Dr. Munshi noted. Surprisingly, 58% of the study's 102 hypoglycemic episodes occurred among the 16 patients with type 2 diabetes, with a mean duration of nocturnal hypoglycemia nearly twice that of the hypoglycemia in the type 1 patients (2.9 vs. 1.6 hours). “Even the type 2 patients had wide glycemic excursions,” she said. Also of concern, 95 of the 102 episodes (were not recognized by fingerstick testing or by the patients' symptoms. Moreover, there was no significant relationship between severity of hypoglycemia and age, type of diabetes, duration, HbA1c, treatment, or living alone. “I believe that elderly patients with other comorbidities are unable to follow complex insulin regimens appropriately and end up having wide fluctuations in their glucose values. If a treatment regimen is designed with consideration for an elderly patient's self-care abilities, risk of hypoglycemia can be reduced,” Dr. Munshi said in an interview. In nursing home settings, education of nursing staff to adapt insulin regimens to changes in overall health, fluctuating appetite, and physical activity – for example, by holding short-acting insulin if the patient refuses a meal – is probably the best way to avoid large fluctuations, she commented. And when available, CGM can be extremely helpful for elderly patients. “I think CGM can be a great tool for pattern recognition and assessment of risk of hypoglycemia in elderly patients who are on complex insulin regimens without consideration of glycemic control,” Dr. Munshi said. This study was funded by the American Diabetes Association. Dr. Munshi stated that she had no conflicts of interest.

Approach to Managing Hypoglycemia in Elderly Patients with Diabetes

Hypoglycemia is a common clinical problem in elderly patients with diabetes. Aging modifies the counterregulatory and symptomatic responses to hypoglycemia. 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. The presenting features of hypoglycemia may be atypical and misinterpreted, resulting in delayed treatment. Morbidity is greater in elderly patients, and the risk of progression to severe hypoglycemia is high because of their altered symptom profile, diminished symptom intensity, and altered glycemic thresholds. Hypoglycemia seems to be the main limiting factor in their glycemic control. In this article we discuss strategies to prevent hypoglycemic episodes.

The risk factors of nocturnal hypoglycemia in elderly patients with type 2 diabetes

This study was to evaluate the risk factors of nocturnal hypoglycemia in elderly patients with type 2 diabetes by continuous glucose monitoring system. Fifty-one type 2 diabetic patients aged 60 or above were enrolled and the episodes of nocturnal hypoglycemia were documented. The risk factors of nocturnal hypoglycemia were analyzed by logistic regression and the cut-off of glucose levels at bedtime for nocturnal hypoglycemia was evaluated. There were twenty-two patients with total 681 nocturnal hypoglycemic episodes. Logistic regression analysis showed that the lowest glucose level at bedtime was the risk factor of nocturnal hypoglycemia (OR=0.36, 95% CI:0.13-1.00, P<0.05), while the gender, age, diabetes duration, therapy regimen, the highest and average glucose levels at bedtime were not associated to nocturnal hypoglycemia. Receiver operating characteristic curve (ROC) showed that the bedtime glucose at≤6.2 mmol/L was the best cut-off point for predicting nocturnal hypoglycemia. Key words: Diabetes mellitus, type 2; Hypoglycemia

Therapeutic options for elderly diabetic subjects: open label, randomized clinical trial of insulin glargine added to oral antidiabetic drugs versus increased dosage of oral antidiabetic drugs

Glycemic control in elderly persons with type 2 diabetes mellitus (T2DM) is challenging because they are more likely to have other age-associated medical conditions and to experience hypoglycemia during intensive therapy. A best therapeutic strategy for these patients has not yet been defined. We investigated the efficacy and safety of adding once-daily insulin glargine to patients' current oral antidiabetic drugs (OAD) regimen, compared to increasing the OAD doses. The study enrolled patients aged 65 years or more, with poor glycemic control. Patients were randomized to two groups and entered a 3-week titration period in which their actual therapy was adjusted to meet the study's glycemic goals, by either adding insulin glargine to current therapy (group A, 27 patients) or increasing current OAD dosages (group B, 28 patients). Thereafter, therapies were continued unchanged for a 24-week observation period. The mean therapeutic dosage of insulin glargine in group A was 14.9 IU/day (SD = 5.0 IU/day). During the observation period, mean levels of glycosylated hemoglobin (HbA1c) reduced by 1.5% in group A and 0.6% in group B (P = 0.381). An HbA1c level <7.0% was achieved by five patients in each group. Mean fasting blood glucose levels reduced by 29 and 15% in groups A and B, respectively (P = 0.029). Group A had fewer total hypoglycemic events (23 vs. 79, P = 0.030) and fewer patients experiencing any such event (9 vs. 17, P = 0.045). Neither a serious hypoglycemic event nor other adverse event occurred. These results suggest that, compared to increasing OAD dosage, the addition of insulin glargine to current OAD therapy is as effective but safer in terms of the risk for hypoglycemia in elderly patients with T2DM.

Hypoglycaemia in elderly patients with diabetes mellitus: causes and strategies for prevention.

Achieving target glycaemic goals while avoiding hypoglycaemia is a major challenge in the management of elderly patients with diabetes mellitus. Repeated episodes of hypoglycaemia may cause extreme emotional distress in such patients, even when the episodes are relatively mild. Moreover, evidence is mounting that hypoglycaemia among elderly patients is a very real and costly health concern. The strongest predictors of severe hypoglycaemia in the elderly are advanced age, recent hospitalisation and polypharmacy. Education is the key to preventing recurrent or severe hypoglycaemia. As such, there should be close coordination of care between the patient, physician and all other healthcare providers in identifying the cause of hypoglycaemia in elderly patients, and appropriate steps should be taken to prevent further episodes. Prevention of hypoglycaemia has the potential to improve psychosocial aspects of elderly health, including enhanced quality of life, boosted confidence, improved compliance with antidiabetic regimens and avoidance of long-term complications. Since the elderly population represents a unique group, it is imperative to focus on the aetiologies that are exclusive to this group. Advanced age itself is a risk factor for hypoglycaemia, and elderly patients with comorbidities are at increased risk when they are hospitalised. Elderly patients with diabetes often have compromised renal function, which intereferes with drug elimination and thus predisposes them to prolonged life-threatening hypoglycaemia. In addition, patients on five or more prescription medications are prone to drug-associated hypoglycaemia. Although sulfonylurea-associated hypoglycaemia is common, drugs such as ACE inhibitors and nonselective beta-adrenoceptor antagonists can also predispose patients to hypoglycaemia. Greater attention should be paid to the avoidance of hypgolycaemia in nursing home residents. Recurrent hypoglycaemia in elderly patients is not only detrimental to achieving good glycaemic control, it is also a substantial economic burden. Once the causes of hypoglycaemia have been identified, it is crucial to formulate and institute a prevention plan. Firstly, global evaluation of the patient should be carried out to identify possible predisposing risk factors. Secondly, target glycaemic goals should be tailored to each patient. Thirdly, selection of antidiabetic agents should be judicious, then patients and family should be educated to recognise and treat hypoglycaemia. Finally, coordinated care should be provided to identify, treat and prevent hypoglycaemia.

Differential Effects of Human and Animal Insulin on the Responses to Hypoglycemia in Elderly Patients With NIDDM

Recent studies suggest that insulin-dependent diabetes mellitus patients switched from animal to human insulin may have decreased awareness of hypoglycemic warning symptoms. The risk of severe or fatal hypoglycemia associated with the treatment of diabetes increases with age. We conducted these studies to determine if awareness of hypoglycemic warning symptoms was greater with animal than with human insulin in elderly patients with diabetes. Nonobese elderly patients with non-insulin-dependent diabetes mellitus (NIDDM) (n = 13; age, 74 +/- 1 years; body mass index, 26.6 +/- 0.7 kg/m2) underwent paired hyperinsulinemic glucose clamp studies (insulin infusion rate 60 mU.m-2.min) in random order. In one study, regular human insulin was infused, and in the other study, regular beef/pork insulin was infused. In all studies, plasma glucose was decreased from fasting levels to 5 mmol/l during the first 60 min and was then allowed to fall to 4.4, 3.8, 3.3, and 2.8 mmol/l in each subsequent hour. Subjects were blinded as to which study they were undergoing. In each study, a hypoglycemic symptom checklist was administered, and counterregulatory hormones were measured every 15 min. Neuropsychological tests were performed every hour. Counterregulatory hormone responses to the two insulin preparations were similar. Autonomic (P < 0.05) and neuroglycopenic (P < 0.01) symptom scores were significantly higher during the beef/pork insulin studies. The responses on the neuropsychological tests were not significantly different. We conclude that beef/pork insulin results in greater awareness of hypoglycemic warning symptoms than does human insulin in elderly patients with NIDDM.

Differential effects of human and animal insulin on the responses to hypoglycemia in elderly patients with NIDDM

Differential effects of human and animal insulin on the responses to hypoglycemia in elderly patients with NIDDM

SEVERE HYPOGLYCEMIA IN ELDERLY PATIENTS RECEIVING THERAPEUTIC DOSES OF TOLBUTAMIDE.

Severe hypoglycemia occurred without warning in three elderly diabetic subjects while they were receiving moderate therapeutic doses of tolbutamide. The clinical picture of the condition mimicked cerebral vascular accident, thereby leading to diagnostic confusion. Severe hypoglycemia during tolbutamide therapy is apparently quite rare. Because of the large number of elderly people taking tolbutamide, in evaluating apparent cerebral vascular accidents in this group, a high index of suspicion of drug-induced hypoglycemia is recommended.