Hypoglycemia In Older Patients Research Articles

1223-P: Frequency and Predictors of Level 2 Time Above Range (TAR) in Older Adults with Type 2 Diabetes on Insulin Therapy—Data from the HYPOAGE Prospective Study

Background: Although type 2 diabetes (T2D) is very common in older patients, there is a lack of real-life data on blood glucose control in this specific population. We aimed to determine the frequency and predictors of hyperglycemia in older patients with T2D on insulin therapy by using continuous glucose monitoring (CGM). Methods: HYPOAGE is prospective multicenter study including 146 insulin-treated older adults aged 75 and older, with T2D for at least 1 year and treated with insulin for at least 6 months. All patients benefited from ambulatory blinded CGM for 28 consecutive days with FreeStyle Libre Pro® sensor. All participants underwent a geriatric and diabetic assessment. Multivariable logistic regressions were used to identify factors associated with level 2 time above range (TAR)[glucose concentration >13.9 mmol/L] > 10%. Results: The mean age of the 141 analyzed patients was 81.5±5.3 years and 56.7% were male, 102 participants (72.3%) were considered as complex and 39 (27.7%) as healthy after geriatric assessment. The mean baseline HbA1c was 7.9±1.0% and 43 patients (30%) had TAR (level 2) > 10%. Compared to patients with level 2 TAR ≤ 10%, patients with higher TAR were older (83.5 [5.7] vs 80.6 [4.9] years), with lower BMI (28.0 [5.5] vs 31.3 [6.1] kg/m2), higher HbA1c (8.6 [0.9] vs 7.6 [0.9] %), and a less frequent healthy geriatric status (14.0 vs 33.7%). In multivariate analyses, TAR (level 2) > 10% remains only significantly associated with HbA1c (OR: 3.08 for 1% increase [1.72-5.50], p=0.0002) and BMI (OR: 0.92 [0.84-1.00], p=0.0496). Conversely, HbA1c was not significantly associated with hypoglycemia (i.e. level 2 time below range [glucose concentration < 3.0 mmol/L]). Conclusions: In this real-life study, 30% of older patients are above the TAR target recommended by the ATTD 2019 consensus (< 10% for level 2) HbA1C is a better predictor of time spent in hyperglycemia than of hypoglycemia in older patients on insulin therapy. Disclosure B.Cariou: Board Member; Eli Lilly and Company, Novartis, Research Support; Sanofi, Speaker's Bureau; Abbott, AstraZeneca, Novo Nordisk, Sanofi. S.Hadjadj: Consultant; Bayer Inc., Novo Nordisk, Valbiotis, Research Support; AstraZeneca, Novartis, Speaker's Bureau; Abbott Diagnostics, Boehringer-Ingelheim. A.Boureau: Board Member; Pfizer Inc. Hypoage study group: n/a. Funding Sanofi

Time trends (2012-2020) in glycated hemoglobin and adherence to the glycemic targets recommended for elderly patients by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee among memory clinic patients with diabetes mellitus.

To investigate the changes in the glycated hemoglobin (HbA1c) levels and the relative status of the glycemic control related to the new glycemic targets recommended by the Japan Diabetes Society/Japan Geriatrics Society Joint Committee in 2016 in patients with diabetes mellitus visiting a memory clinic from 2012 to 2020. This cross-sectional study included 1,436 patients aged ≥65 years with diabetes. Patients were categorized into three categories as follows: category I, intact cognitive function and activities of daily living (ADL); category II, mild cognitive deficits or impaired instrumental ADL; and category III, moderate to severe cognitive impairment or impaired basic ADL. Trends in HbA1c levels, glycemic control status (optimally/poorly/excessively controlled) and proportion of individuals receiving drugs potentially associated with severe hypoglycemia among all patients and categories (I, II or III) from 2012 to 2020 were examined using linear, logistic and multinominal logistic regression models adjusted for confounding factors. Between 2012 and 2020, the HbA1c levels, as well as the proportion of patients with poor glycemic control, increased, whereas the proportion of patients with excessive glycemic control and those receiving drugs potentially associated with severe hypoglycemia decreased. Increased levels of HbA1c and decreased proportions of individuals under excessive glycemic control might reflect recent treatment strategies that avoid hypoglycemia in older patients. Given the adverse complications associated with hyperglycemia, more flexible and individualized glycemic targets based on comprehensive assessments, including vascular complications and comorbidities, might be necessary.

Common causes and treatment of hypoglycemia in older patients with diabetes at Thanh Nhan hospital

Objectives: To determine common causes and treatment of hypoglycemia in oler patients with diabetes at Thanh Nhan hospital. Methods: A cross-sectional study on 1215 diabetic patients treated at Thanh Nhan Hospital from November 2018 to May 2019. Subjects were interviewed according to a uniform medical record. Hypoglycemia was diagnosed according to the ADA 2018 criteria: blood glucose ≤ 3.9 mmol/l. Results: the most common cause of hypoglycemia was a reduced diet (49.6%); eating late (24.1%); skipping meals (9.3%); overdose, wrong insulin regimen due to patients (7.4%); overdose and wrong insulin regimen by doctor (4.2%). The proportion of patients receiving intravenous hypertonic glucose injection/infusion was 7.7%; eating foods containing glucose was 63.1%; eating foods containing carbonhydrat was 29.2%. The majority of patients with symptoms of hypoglycemia lasting within 15 minutes accounted for 56.3%, the number of patients with hypoglycemia lasting more than 60 minutes accounted for 0.9%. Conclusions: The common cause of hypoglycemia in the study subjects was mainly related to the patient's diet. The treatment of the patient's hypoglycemia was not completely correct. Therefore, medical staff should have measures to advise and educate about the causes as well as how to manage hypoglycemia for this subject regularly

The Risk Factors of Severe Hypoglycemia in Older Patients with Dementia and Type 2 Diabetes Mellitus.

Background: The adequate glycemic control and risk factors for hypoglycemia in older patients with dementia and type 2 diabetes mellitus (T2DM) remain unclear. This study aimed to analyze the status of glycemic control and determine the risk of hypoglycemia among these groups. Methods: A hospital admission record due to hypoglycemia through an emergency room with glucose supplementation in the Chang Gung Memorial Hospital was identified as a hypoglycemic event. Patients with dementia and T2DM without hypoglycemic events throughout the study period were defined as the control group. We gathered patients aged ≥65 years with a diagnosis of Alzheimer’s dementia (AD) and T2DM between 2001 and 2018 in the Chang Gung Research Database (CGRD). We extracted data included medication use, diagnoses, and biochemistry data from hospital records. Results: A total of 3877 older patients with dementia and T2DM with regular visits to the outpatient department were enrolled in this study. During the two-year follow-up period, 494 participants (12.7%) experienced hypoglycemia. Multivariable logistic multivariable regression models for hypoglycemic events showed that metformin had a protective effect (odds ratio (OR) = 0.75, p = 0.023), insulin had the highest risk (OR = 4.64, p < 0.001). Hemoglobin A1c (HbA1c) levels were not correlated with hypoglycemic events (OR = 0.95, p = 0.140). Patients with hypoglycemic episodes had a significantly higher proportion of ≥2 Charlson Comorbidity Index scores than those without hypoglycemic episodes (83.2% versus 56.4%, p < 0.001). Conclusions: Drug regimen affects hypoglycemic episodes but not HbA1c in older patients with dementia and T2DM. In addition, patients with more comorbidities experience an increased risk of hypoglycemia.

Individualisation of glycaemic management in older people with type 2 diabetes: a systematic review of clinical practice guidelines recommendations.

Recommendations for individualised glycaemic management in older people with type 2 diabetes (T2D) have recently been provided in clinical practice guidelines (CPGs) issued by major scientific societies. The aim of this systematic review is to compare the content of these recommendations concerning health assessment, targets for glycaemic control, lifestyle management and glucose-lowering therapy across CPGs. The CPGs on T2D management in people aged ≥65years published in English after 2015 by major scientific societies were systematically reviewed in accordance with the PRISMA statement. The quality of the CPGs included was assessed using the AGREE-II tool. The recommendations for individualised glycaemic management were extracted, and their level of evidence (LOE) and strength of recommendation recorded. Three CPGs of high methodological quality were included, namely those from the American Diabetes Association 2020, the Endocrine Society 2019 and the Diabetes Canada Expert Committee 2018. They made 27 recommendations addressing individualised glycaemic management, a minority of which (40%) had a high LOE. Comparison of the 27 recommendations identified some discrepancies between CPGs, e.g. the individualised values of HbA1c targets. The 13 strong recommendations addressed 10 clinical messages, five of which are recommended in all three CPGs, i.e. assess health status, screen for cognitive impairment, avoid hypoglycaemia, prioritise drugs with low hypoglycaemic effects and simplify complex drug regimens. Although there is a consensus on avoiding hypoglycaemia in older patients with T2D, significant discrepancies regarding individualised HbA1c targets exist between CPGs.

Common causes and treatment of hypoglycemia in older patients with diabetes at Thanh Nhan hospital

Objectives: To determine common causes and treatment of hypoglycemia in oler patients with diabetes at Thanh Nhan hospital. Methods: A cross-sectional study on 1215 diabetic patients treated at Thanh Nhan Hospital from November 2018 to May 2019. Subjects were interviewed according to a uniform medical record. Hypoglycemia was diagnosed according to the ADA 2018 criteria: blood glucose ≤ 3.9 mmol/l. Results: the most common cause of hypoglycemia was a reduced diet (49.6%); eating late (24.1%); skipping meals (9.3%); overdose, wrong insulin regimen due to patients (7.4%); overdose and wrong insulin regimen by doctor (4.2%). The proportion of patients receiving intravenous hypertonic glucose injection/infusion was 7.7%; eating foods containing glucose was 63.1%; eating foods containing carbonhydrat was 29.2%. The majority of patients with symptoms of hypoglycemia lasting within 15 minutes accounted for 56.3%, the number of patients with hypoglycemia lasting more than 60 minutes accounted for 0.9%. Conclusions: The common cause of hypoglycemia in the study subjects was mainly related to the patient's diet. The treatment of the patient's hypoglycemia was not completely correct. Therefore, medical staff should have measures to advise and educate about the causes as well as how to manage hypoglycemia for this subject regularly

Severe Hypoglycemia in Older Patients with Type 2 Diabetes Who Are Initiating Insulin

Evidence suggests that, in people with type 2 diabetes, risk for severe hypoglycemia does not necessarily differ between those who use long-acting

Meta-Analysis: Association Between Hypoglycemia and Serious Adverse Events in Older Patients Treated With Glucose-Lowering Agents.

AimsWe conducted a meta-analysis of serious adverse events (dementia, macro- and micro-vascular events, falls and fractures, and death) associated with hypoglycemia in older patients treated with glucose lowering drugs.Materials and MethodsMeta-analysis of studies reporting on hypoglycemia and adverse events. The search included studies from two previously published systematic reviews, and an updated search of MEDLINE and EMBASE from April 2014 to November 2019. We assessed study validity based on ascertainment of hypoglycemia, adverse events and adjustment for confounders, and conducted a random effects meta-analyses, assessing heterogeneity using the I2 statistic.ResultsWe included 44 studies involving 2,507,434 participants. Most of the studies used adjusted analysis for confounders and hypoglycaemic events were typically identified based on healthcare databases (severe events). Hypoglycemia was associated with increased likelihood of death in a meta-analysis of eighteen studies, pooled OR 2.02 (95% Confidence Interval 1.75–2.32). Studies assessing mortality signal a time-response relationship with a higher risk of adverse events occurring within the first 90 days after hypoglycemia. Our meta-analysis of nine studies demonstrated that hypoglycaemic episodes were associated with dementia – pooled OR 1.50 (95% CI 1.29–1.74). Our meta-analysis of nineteen studies demonstrated associations between hypoglycaemia and macrovascular complications, pooled OR 1.81 (95% CI 1.70–1.94), and microvascular complications (two studies) pooled OR 1.77 (95% CI 1.49–2.10). There is also an association between hypoglycemia and cardiovascular death (six studies) – pooled OR 2.11 (95% CI 1.55 to 2.87). Similarly, our meta-analysis of six studies demonstrated an association between hypoglycemia and falls and fractures, pooled OR 1.78 (95% CI 1.44–2.21) and 1.68 (95% CI 1.37–2.07) respectively.ConclusionThis meta-analysis confirms previously reported concerns of serious harm following hypoglycemia, especially in the immediate time period after a hypoglycaemic event. Avoidance of hypoglycaemic episodes should be a priority in this vulnerable population.

How Significant Is Severe Hypoglycemia in Older Adults With Diabetes?

Severe hypoglycemia is a devastating event in the lives of people with diabetes treated with insulin and/or insulin secretogogues. Severe hypoglycemia is defined as an episode in which the person with diabetes requires the assistance of another to increase blood glucose, usually by administration of glucagon or contacting a medical professional. These occurrences are not rare. More than 10% of adult patients in the T1D Exchange registry reported at least one episode of severe hypoglycemia over the past 12 months (1). These events elicit profound fear in patients with diabetes. By depriving the brain of glucose, severe hypoglycemia acutely alters brain function, resulting in neuroglycopenic symptoms, seizures, or even death. The impact extends beyond the acute event. The Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation (ADVANCE) trial reported that patients with type 2 diabetes who experience severe hypoglycemia were at higher risk for a major macrovascular event or death over the subsequent 12 months (2). As the population ages, there remains a critical need to understand the significance and impact of severe hypoglycemia in older patients with diabetes. In this issue of Diabetes Care , complementary articles provide new insights into the consequences of severe hypoglycemia in older adults. Lacy et al. (3) report that severe hypoglycemia is associated with reduced cognitive function in older adults with type 1 diabetes, and Standl et al. (4) confirm the bidirectional nature of the association between severe hypoglycemia and cardiovascular (CV) events in adults with type 2 diabetes. Both investigations …

183 Risk of Hypoglycaemia in Older Patients in Residential Care on Oral Hypoglycaemic Medication

Abstract Background Diabetes mellitus (DM) is common in older patients in residential care(RC) with prevalence ranging from 11-36%.Guidlines(1) on glucose targets to avoid the risk of hypoglycaemia or hyperglycaemia respectively in older people recommend avoiding a fasting glucose on treatment of 6mmol/L or a random glucose level higher than 11.0mmol/L. An HbA1c of 53to 59mmol/mol(7-7.5%) should be aimed for although this may need adjusting in RC and StoppFrail guidelines suggest a target of HbA1c of &lt;8%(64mmol/mol). We assessed the prevalence, drug treatment and glycaemic control in 107 older patients in residential care at two sites in Dublin. Methods Patients with DM were identified from review of medical notes. Hypoglycaemic treatment whether oral hypoglycemic drugs(OHD) or insulin, capillary blood glucose measurements(CBGM) over the previous 28 day period, HbA1c values and weight change over the previous year respectively were tabulated from patient records. Results Sixteen patients (15%) aged 66-93 were documented with DM. Eight (50%) were on no hypoglycaemic treatment in whom OHD had been discontinued in 2 patients over the previous 6 months because of risk of hypoglycaemia.. Six patients (38%) were only on OHD, whilst 2 were on insulin. Of the 6 patients on OHD, CABGM were below 6mmol/L in 3 patients (50%) with no values above 11mmol/L. All 3 patients had lost weight ( 2.5-6.8Kg) over the previous year and HbA1c levels were below 53mmol/mol (7%) in all 3 patients. Conclusion Although our numbers are small, 50% of our patients in residential care on OHD are at risk of hypoglycemia possibly related to weight loss. Reducing or discontinuing their OHD may be appropriate.

Outcomes and healthcare resource utilization associated with medically attended hypoglycemia in older patients with type 2 diabetes initiating basal insulin in a US managed care setting

Objective: To assess health outcomes and the economic burden of hypoglycemia in older patients with type 2 diabetes initiating basal insulin (BI).Research design and methods: Medicare Advantage claims data were extracted for patients with type 2 diabetes initiating BI and patients were stratified into two groups: those with medically attended hypoglycemia during the first year of BI treatment (HG group) and those without (non-HG group). Main outcome measures were hospitalization, mortality, healthcare utilization and costs 1 year before and 1 year after BI initiation.Results: Of 31,035 patients included (mean age 72 years [SD 9.2]), 3066 (9.9%; HG group) experienced hypoglycemia during 1 year post-BI initiation. After adjustment for demographic, comorbidity and medication history, hypoglycemia was associated with risk of hospitalization (HR 1.59; 95% CI: 1.53–1.65) and death (HR 1.50; 95% CI: 1.40–1.60). Healthcare utilization was higher pre-index and showed greater increases post-BI initiation in the HG vs. the non-HG group. Per-patient healthcare costs were substantially higher for the HG group than the non-HG group, both pre-index ($54,057 vs. $30,249, respectively) and post-BI initiation ($75,398 vs. $27,753, respectively).Conclusions: Based on available claims data, hypoglycemia during the first year of BI treatment is associated with risk of hospitalization or death in older people, increasing healthcare utilization and costs. Due to the observational nature of this study, causality cannot be attributed, and further prospective studies into the effect of hypoglycemia on health outcomes in this population are warranted.

Meta-analysis: Association between hypoglycaemia and serious adverse events in older patients

AimsWe aimed to conduct a meta-analysis of serious adverse events (macro- and microvascular events, falls and fractures, death) associated with hypoglycaemia in older patients. MethodsWe searched MEDLINE and EMBASE spanning a ten-year period up to March 2015 (with automated PubMed updates to October 2015). We selected observational studies reporting on hypoglycaemia and associated serious adverse events, and conducted a meta-analysis. We assessed study validity based on ascertainment of hypoglycaemia, adverse events and adjustment for confounders. ResultsWe included 17 studies involving 1.86 million participants. Meta-analysis of eight studies demonstrated that hypoglycemic episodes were associated with macrovascular complications, odds ratio (OR) 1.83 (95% confidence interval [CI] 1.64, 2.05), and microvascular complications in two studies OR 1.77 (95% CI 1.49, 2.10). Meta-analysis of four studies demonstrated an association between hypoglycaemia and falls or fractures, OR 1.89 (95% CI 1.54, 2.32) and 1.92 (95% CI 1.56, 2.38) respectively. Hypoglycaemia was associated with increased likelihood of death in a meta-analysis of eight studies, OR 2.04 (95% Confidence Interval 1.68, 2.47). ConclusionOur meta-analysis raises major concerns about a range of serious adverse events associated with hypoglycaemia. Clinicians should prioritize individualized therapy and closer monitoring strategies to avoid hypoglycaemia in susceptible older patients.

Bi-directional interaction between hypoglycaemia and cognitive impairment in elderly patients treated with glucose-lowering agents: a systematic review and meta-analysis.

To examine the bi-directional relationship, whereby hypoglycaemia is a risk factor for dementia, and where dementia increases risk of hypoglycaemia in older patients with diabetes mellitus treated with glucose-lowering agents. We searched MEDLINE and EMBASE over a 10-year span from 2005 to 2015 (with automated PubMed updates to August 2015) for observational studies of the association between hypoglycaemia and cognitive impairment or dementia in participants aged >55 years. Assessment of study validity was based on ascertainment of hypoglycaemia, dementia and risk of confounding. We conducted random effects inverse variance meta-analyses, and assessed heterogeneity using the I(2) statistic. We screened 1177 citations, and selected 12 studies, of which nine were suitable for meta-analysis. There were a total of 1,439,818 participants, with a mean age of 75 years. Meta-analysis of five studies showed a significantly increased risk of dementia in patients who had hypoglycaemic episodes: pooled odds ratio 1.68 [95% confidence interval (CI) 1.45, 1.95]. We also found a significantly increased risk of hypoglycaemia in patients with dementia: pooled odds ratio from five studies 1.61 (95% CI 1.25, 2.06). Limitations of the study were heterogeneity in the meta-analysis, and uncertain ascertainment of dementia and hypoglycaemic outcomes and temporal relationships. Publication bias may have favoured the reporting of more significant findings. Our meta-analysis shows a bi-directional relationship between cognitive impairment and hypoglycaemia in older patients. Glucose-lowering therapy should be carefully tailored and monitored in older patients who are susceptible to cognitive decline.

Risk of Hospitalization for Hypoglycemia inOlder Patients with Diabetes Using Antipsychotic Drugs.

Antipsychotics may disrupt metabolic regulation in patients with diabetes mellitus. The risk of hypoglycemia in older users of antipsychotics with diabetes is largely unknown. Therefore, we investigated the association between the use of antipsychotic drugs and hypoglycemia requiring hospital admission in older patients with diabetes. In a nested case-control study using community pharmacy records linked to hospital admission data in the Netherlands (1998-2008), a cohort of 68,314 patients at least 65 years with diabetes was studied. Cases were patients from the study cohort with a first hospital admission for hypoglycemia; up to five comparison subjects were selected for each case. Exposure to antipsychotic drugs was the primary determinant of interest. Logistic regression analysis was performed to estimate the strength of the association between antipsychotic drug use and hypoglycemia, taking into account potential confounders. Eight hundred fifteen patients were admitted to hospital for hypoglycemia. Current use of antipsychotic drugs was associated with an increased risk of hypoglycemia compared with non-use (adjusted OR: 2.26; 95% CI: 1.45-3.52; Wald χ(2)= 13.08, df= 1, p≤0.001), especially in the first 30 days of treatment (adjusted OR: 7.65; 95% CI: 2.50-23.41; Wald χ(2)=12.72, df= 1, p≤0.001) and with higher doses (adjusted OR: 8.20; 95% CI: 3.09-21.75; Wald χ(2)= 17.90, df= 1, p≤0.001). Use of antipsychotic drugs by older patients with diabetes mellitus was associated with an increased risk of hospitalization for hypoglycemia. Our findings suggest that glucose levels should be monitored closely after initiation of antipsychotic drugs.

The analysis of risk factors for hypoglycaemia in older patients with type-2 diabetes

ObjectiveTo study the characteristic features of risk factors for hypoglycaemia in older patients with type-2 diabetes.MethodsOne hundred and ninety seven type-2 diabetes patients aged 60 and above with or without...

Monitoring and controlling the patient with non-insulin-dependent diabetes mellitus

While the prevention of acute metabolic decompensation is no longer a serious problem in treating patients with non-insulin-dependent diabetes mellitus (NIDDM), target organ complications can have serious consequences, including blindness, renal failure, neuropathy, amputation, coronary artery disease, and stroke. The bulk of current evidence suggests that these complications can be minimized or perhaps even avoided by carefully monitoring and controlling the patient's blood glucose levels. Although criteria and standards of control differ widely in various centers, in general acceptable-to-good control in the NIDDM patient would consist of average fasting blood glucose (FBG) levels of <140 mg/dL and peak postprandial glucoses of <220 to 250 mg/dL. Treatment aimed at attaining these blood glucose levels should begin with dietary management and exercise prescription. General health measurements such as control of blood pressure and avoidance of smoking are especially important in the diabetic patient. When these approaches prove ineffectual, the addition of an oral hypoglycemic agent, preferably a second-generation sulfonylurea is indicated. Glipizide and glyburide are both excellent drug choices, although glyburide may cause hypoglycemia in older patients due to its longer half-life and especially in those with renal insufficiency because of accumulation of biologically active metabolites. In certain well-selected cases, the addition of insulin to oral sulfonylurea therapy may offer improved results over the use of either therapeutic modality alone. The advent of self blood glucose monitoring and periodic glycohemoglobin assessments, now well established in diabetic management, represents a major step forward in the endeavor to optimize standards of blood glucose control in the diabetic population.