Understanding Hypoglycemia and Diabetes Management in Older Adults

The Personal Struggle: Ora Larson’s Experience with Hypoglycemia

Ora Larson, an 85-year-old woman living with Type 2 diabetes for decades, has recently experienced frequent episodes of hypoglycemia, a condition where blood sugar levels drop dangerously low. She describes the sensation as feeling "shaky inside" and "anxious," often leaving her confused and disoriented. These episodes have become more frequent, worrying her daughter, Susan, who observes her mother’s grayish pallor and confusion during these events. Ora’s healthcare providers are concerned that hypoglycemia could lead to falls, broken bones, heart arrhythmias, or even cognitive damage. Despite their advice to relax her blood sugar targets, Ora is hesitant to change her approach after decades of strict glycemic control.

The Medical Perspective: Hypoglycemia and Its Risks

Hypoglycemia, defined as a blood glucose level below 70 milligrams per deciliter, is a common side effect of diabetes medications, especially in older adults. Dr. Sei Lee, a geriatrician at the University of California, San Francisco, explains that long-term diabetic patients are more likely to experience hypoglycemic episodes. While maintaining tight blood sugar control is often recommended, it can pose significant risks for older adults, particularly those with multiple chronic conditions like Ora, who also has multiple sclerosis and hypertension.

Shifting Guidelines: A New Approach to Diabetes Management

Over the past decade, medical societies, including the American Geriatrics Society, have revised their guidelines for older adults with diabetes. They now recommend higher hemoglobin A1c targets—ranging from 7.5% to 8% or even 8% to 9% for those with limited life expectancy or multiple illnesses. This shift reflects a growing recognition that tight glycemic control, while beneficial for younger patients, may not provide the same long-term benefits for older adults and can instead increase the risk of hypoglycemia and other complications.

The Role of Medications: Old and New

The treatment of diabetes has evolved significantly with the introduction of newer medications like GLP-1 receptor agonists (e.g., Ozempic) and SGLT2 inhibitors (e.g., Jardiance), which offer fewer hypoglycemia risks and additional benefits for heart and kidney health. However, these drugs can be expensive, and insurance coverage is not always guaranteed. Older medications, such as insulin and sulfonylureas, are still widely used but are known to cause hypoglycemia. For older adults, the goal is often to simplify medication regimens and reduce the risk of dangerous side effects while managing blood sugar levels.

The Challenges of Diabetes Management in Older Adults

Managing diabetes in older adults is complex, as it requires balancing blood sugar control with the risks of hypoglycemia and other complications. Studies show that many older patients, particularly those in nursing homes, are overtreated, with A1c levels below 7% despite guidelines suggesting higher targets. Dr. Joseph Ouslander, a geriatrician at Florida Atlantic University, notes that overtreatment can lead to serious consequences, including emergency room visits and hospitalizations. Additionally, older patients often face challenges such as frailty, cognitive impairment, and multiple chronic conditions, making personalized treatment plans essential.

Rethinking Control: The Importance of Tailored Care

As people age, the benefits of tight glycemic control diminish, while the risks of hypoglycemia and other complications increase. Dr. Lee emphasizes that older adults and their healthcare providers must reevaluate their goals, focusing less on strict blood sugar control and more on preventing dangerous lows and improving quality of life. Ora Larson’s story highlights the need for open communication between patients and providers to create treatment plans that align with individual priorities and health status. By acknowledging the shifting landscape of diabetes management, older adults and their caregivers can work together to find a balanced approach that prioritizes safety, well-being, and independence.