Ambiguous symptoms may disguise hypoglycemia in elderly patients
medwireNews: Research suggests that older diabetes patients, particularly those using insulin, often have nonspecific symptoms of hypoglycemia that are overlooked by healthcare providers.
And another study in the same journal – Primary Care Diabetes – suggests that patients most at risk are not necessarily those with low glycated hemoglobin (HbA1c) levels.
In the first study, Suzy Hope (Royal Devon & Exeter Hospital, UK) and colleagues found that, during primary care consultations, people older than 65 years often mentioned nonspecific symptoms that could have been caused by hypoglycemia – yet there was no evidence in the records that hypoglycemia had been considered as a cause, despite the lack of any other explanation.
This was almost equally as likely to occur for 79 insulin-treated patients as for 85 using sulfonylureas, 121 using metformin, and 50 age-matched patients without diabetes.
However, documented hypoglycemic episodes were most frequent in patients with insulin-dependent diabetes, and insulin-treated patients with previous episodes had significantly more consultations with mention of a possible unrecognized hypoglycemia episode than did those without previous episodes, at 74% versus 40%.
The symptoms most closely associated with possible unrecognized episodes in these patients were nausea, falls, and unsteadiness, which the researchers say is in line with other published studies. “[A]s such, insulin-treated patients presenting with these symptoms should be reviewed with hypoglycaemia in mind,” they write.
By contrast, among patients receiving sulfonylureas or metformin, the frequency of consultations with possible missed episodes was not influenced by whether they had previous documented episodes.
Of note, although physicians are advised to relax HbA1c targets in older patients to reduce hypoglycemia risk, there was no association between these two variables in this study. And in the second study, based on the records of 5974 type 2 diabetes patients aged 75 years or older, the rate of severe hypoglycemia events requiring third-party assistance or resulting in collapse actually rose with increasing HbA1c levels.
Even among patients treated with insulin or sulfonylureas, and thus at the highest risk for hypoglycemia, the highest rate of hypoglycemia – 16.1% – was found for those with HbA1c levels of 68 mmol/mol or higher. The association remained significant after accounting for age and gender, with these patients having a 2.3-fold increased risk for hypoglycemia relative to those with HbA1c levels of 48 mmol/mol or below.
“This suggests that erratic and variable glycaemia more than sustained lower blood glucose readings may be a factor in predisposing patients to significant hypoglycaemia,” say Mark Livingston (Walsall Manor Hospital, UK) and study co-authors.
They comment that “efforts to improve the safety of glucose lowering therapies need to be directed not only to patients achieving near-normal glycaemia but also to patients with suboptimally controlled type 2 diabetes.”
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