Preventing Hypoglycemia in the Older Adult with Diabetes

Preventing Hypoglycemia in the Older Adult with Diabetes - #65

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Managing diabetes in older adults in an outpatient setting.

Older adult with diabetes in an outpatient setting.

Apply key concepts regarding diabetes in older adults to adjust glucose targets and modify/ monitor therapy.

 #1: Understand the Targets

A completely “healthy” older adult may aim for a “great” Hemoglobin A1c (HbA1c), i.e. <6.5%, “as long as significant hypoglycemia does not become a barrier”. 9 This statement from the American Diabetes Association requires the fullest attention of any provider managing diabetes in an older adult. It is essential to recognize that HbA1c is an average, and it has to be interpreted as such.


The following table is based on the estimate average glucose equivalent (eAG) per HbA1c.10


HbA1c (%)

Corresponding estimated average glucose (mg/dl)












A target HbA1c of 7.5% is an average equivalent eAG of 169mg/dl. The range of values making up that average is crucial.  Patients with very similar characteristics, and thus same HbA1c target, can have two completely different scenarios:

  • Patient A has morning fasting glucose values around 120mg/dl, and the rest of the day values around 160mg/dl.  He is on target and well controlled.

  • Patient B has values ranging from 50 to 200, and has the same HbA1c on laboratory test results.  Here, the “on target” HbA1c would be at the expense of hypoglycemic events, putting the patient at risk.


#2: Understand your Patient

Hypoglycemic events require a clear understanding of their etiology to prevent/avoid recurrence.

  • Did the patient accidently forget that he had injected the correct dose (thereby injecting twice)?

  • Was he interrupted during a meal and could not finish eating?

  • Is the event a marker of cognitive decline?

  • Was there a different reason?


In patients with cognitive decline or other functional loss (e.g. vision, dexterity), the situation is beyond the pharmacokinetics/ pharmacodynamics, and dosage and effect of medication and requires exploration of non-formal (i.e. family, caregivers, friends) or formal (i.e. home health nurse) assistance. 


#3: Prevent Hypoglycemic Events

Severe hypoglycemia is defined as any hypoglycemic event associated with loss of consciousness and/or the need for assistance.  It is the provider’s responsibility to address those events and to try to prevent future events. The following are initial steps:


  • Understand the safety profile of pharmacologic agents 8

    • < > The Beers’ criteria 12 for medications identify glyburide as a “no-no” option for managing diabetes in older adults given an increased risk of hypoglycemia.  We recommend discontinuing glyburide in any older adult, review the prior 2 recommendations, switching to the “safer” sulfonylureas if an agent is still indicated. Caution is still recommended, especially in patients with renal or hepatic impairment. If possible, use a non-sulfonylurea agent with less hypoglycemic risk, especially if in combination with insulin. Once a patient requires a basal bolus regimen, hence relying in exogenous insulin, an insulin secretagogue may add little benefit, hence sulfonylureas are not to be added to basal bolus regimen, and ought to be removed from the medication list.

      Alpha-glucosidase inhibitors: while the use of miglitol or acarbose is limited, given their tolerability and modest HbA1c reduction (0.5-1%), they are reasonable agents for a few selected cases. These agents still have mild hypoglycemic risk, which is increased when in combination with sulfonylureas.

    • Glucagon-like peptide-1 receptor agonists: these agents may be helpful in weight reduction, a critical component for management of type 2 diabetes,  however, they present a risk for hypoglycemia and require proper monitoring.

    • < > while synthetic insulins (long-acting and short-acting) may not be as effective in lowering glucose than older non-synthetic (neutral protamine Hagedorn or regular insulin), the former may be associated with less hypoglycemia.13,14

      Adjust medicationsto decrease hypoglycemic risk

      • An older person with an HbA1c of ~7.5% would have a corresponding eAG of ~169.If this person has glucometer blood glucose readings close to, or below, 100mg/dl, that indicates the patient must have some values above 200mg/dl (to make up for the eAG).Yet, more concerning, the low normal values are too close to the threshold for hypoglycemia. This is a key item to recognize, as the medication regimen ought to be decreased to avoid future hypoglycemia.


    • Recognize risk for hypoglycemia during transitions of care

      • Careful monitoring at each care transition (e.g. home to hospital, hospital to nursing home, nursing home to home) is essential to avoid medication errors and hypoglycemia.

      • Anticipate increased glucotoxicity (e.g., due to infection, steroids, stress or pain). While there can be a temporary need to increase pharmacologic interventions, when the initial insult “cools down”, medication doses may need to be decreased.

Recognize the increased risk for hypoglycemia in older adults with diabetes

Acquire practical approaches to decrease hypoglycemia in older adults with diabetes


  1. Wang J, Geiss LA, Williams DE, Gregg EW. Trends in emergency department visit rates for hypoglycemia and hyperglycemic crisis among adults with diabetes, United States, 2006-2011. PLoS One 2015; 2015; 10(8):e0134917.

  2. Nicolucci A, Pintaudi B, Rossi MA, et al. The social burden of hypoglycemia in the elderly. Acta Diabetol 2015; 52(4): 677-685.

  3. Kirkman SM, Briscoe VJ, Clark N, et al. Diabetes in older adults: A consensus report of the American Diabetes Association and the American Geriatrics Society. J Am Geriatr Soc 2012; 60(12): 2342-2356.

  4. Munshi MN, Segal AR, Suhl E, et al. Frequent hypoglycemia among elderly patients with poor glycemic control. Arch Intern Med 2011; 171: 362-364.

  5. Desouza C, Salazar H, Cheong B, Murgo J, Fonseca V. Association of hypoglycemia and cardiac ischemia. Diabetes Care 2003; 26(5): 1485-1489.

  6. Chow LS, Chen H, Miller ME, Marcovina SM, Seaquist ER. Biomarkers associated with severe hypoglycemia and death in ACCORD. Diabet Med 2015 Aug 11. doi: 10.1111/dme.12883. [Epub ahead of print]

  7. American Geriatrics Society. Guidelines for improving the care of older adults with diabetes mellitus: 2013 update. J Am Geriatr Soc 2013; 61: 2020-2026.

  8. Valencia WM, Florez H. Pharmacologic treatment of diabetes in older people. Diabetes, Obes & Metab 2014; 16: 1192-1203.

  9. American Diabetes Association. Glycemic targets. Sec 5. In Standards of Medical Care in Diabetes. Diabetes Care, 2016; 39(Suppl. 1): S39-S46.

  10. American Diabetes Association. Estimated Average Glucose, eAG. Available online

  11. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes, 2015: A patient-centered approach. Update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care 2015; 38: 140-149.

  12. The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc 2012; 60: 616-631.

  13. Home PD, Bolli GB, Mathieu C, et al. Modulation of insulin dose titration using a hypoglycemia-sensitive algorithm: insulin glargine versus neutral protamine Hagedorn insulin in insulin-naïve people with type 2 diabetes. Diabetes, Obes Metab 2015; 17: 15-22.

  14. Rosenstock J, Fonseca V, Schinzel S, Dain M-P, Mullins P, Riddle M. Reduced risk of hypoglycemia with once-daily glargine versus twice-daily NPH and number needed to harm with NPH to demonstrate the risk of one additional hypoglycemic event in type 2 diabetes: Evidence from a long-term controlled trial. J Diabetes Complications 2014; 28: 742-749.

  15. Whitmer RA, Karter AJ, Yaffe K, et al. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes. JAMA 2009; 301: 1565-1572.

  16. American Diabetes Association. Older Adults. Sec 9. In Standards of Medical Care in Diabetes. Diabetes Care, 2016; 39 (Suppl 1): S81-S85.

  17. Munshi MN, Florez H, Huang ES, et al. Management of diabetes in long-term care and skilled nursing facilities: A position statement of the American Diabetes Association. Diabetes Care 2016; 39: 308-318.

This GFF ___ my competence in geriatrics.

Willy Marcos Valencia, MD.

Physician Scientist

Director, Miami VA Metabolic Clinic

Miami VA Medical Center, Geriatrics Research, Education and Clinical Center (GRECC)


Voluntary Assistant Professor, Division of Epidemiology

University of Miami Miller School of Medicine – Department of Public Health Sciences