Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients

Autonomic Dysfunction from Diagnosis to Treatment

Autonomic disorders can present with hypotension, gastrointestinal, genitourinary symptoms, and heat intolerance. Diabetes is the most common causes of autonomic failure, and management should focus on glucose control to prevent developing autonomic symptoms. The most prevalent cause of dysautonomia, or autonomic dysfunction, is Postural Orthostatic Tachycardia Syndrome (POTS). Autonomic testing characterizes causes for nonspecific symptoms but is not necessary in patients with classic presentations. Treatment for autonomic dysfunction and failure focus on discontinuing offending medications, behavioral modification, and pharmacologic therapy to decrease symptom severity. Autonomic failure has no cure; therefore, the focus remains on improving quality of life.

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Management of Hyperglycemia in Older Adults with Type 2 Diabetes

The increasing incidence of type 2 diabetes in the general population as well as enhanced life expectancy has resulted in a rapid rise in the prevalence of diabetes in the older population. Diabetes causes significant morbidity and impairs quality of life. Managing diabetes in older adults is a daunting task due to unique health and psychosocial challenges. Medical management is complicated by polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Health care providers now have several traditional and contemporary pharmacologic agents to manage diabetes. Avoidance of hypoglycemia is critical; however, evidence-based guidelines are lacking due to the paucity of clinical trials in older adults. For many in this population, maintaining independence is more important than adherence to published guidelines to prevent diabetes complications. The goal of diabetes care in older adults is to enhance the quality of life without subjecting these patients to intrusive and complicated interventions. Recent technological advancements such as continuous glucose monitoring systems can have crucial supplementary benefits in the geriatric population.

Hypoglycaemia in older home-dwelling people with diabetes- a scoping review

Background

Hypoglycaemia is associated with cognitive and functional decline in older people with diabetes. Identification of individuals at risk and prevention of hypoglycaemia is therefore an important task in the management of diabetes in older home-dwelling individuals. The purpose of this scoping review was to map the literature on hypoglycaemia in home-dwelling older people with diabetes.

Methods

This scoping review included original research articles on hypoglycaemia in older (≥ 65 years) individuals with diabetes from developed countries. A broad search of the databases Cinahl, Embase and Medline was performed in July 2018. The report of the scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews.

Results

Our database search identified 577 articles of which 23 were eligible for inclusion. The identified literature was within four areas: 1) incidence of hypoglycaemia in older home-dwelling people with diabetes (11/23 articles), 2) risk factors of hypoglycaemia (9/23), 3) diabetes knowledge and self-management (6/23) and 4) consequences of hypoglycaemia for health care use (6/23). The majority of the literature focused on severe hypoglycaemia and the emergency situation. The literature on diabetes knowledge and management related to preventing adverse events relevant to older home-dwellers, was limited. We found no literature on long-term consequences of hypoglycaemia for the use of home health care services and the older persons’ ability to remain home-dwelling.

Conclusions

We identified a lack of studies on prevention and management of hypoglycaemia in the older individuals’ homes. Such knowledge is of utmost importance in the current situation where most western countries’ governmental policies aim to treat and manage complex health conditions in the patient’s home. Future studies addressing hypoglycaemia in older individuals with diabetes are needed in order to tailor interventions aiming to enable them to remain home-dwelling as long as possible.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01961-6.

Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis

Background

Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care.

Methods

Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley’s checklist for survey designs. A thematic synthesis was then conducted of the collected studies.

Results

Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians.

Conclusions

This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0753-2) contains supplementary material, which is available to authorized users.

Are we missing hypoglycaemia? Elderly patients with insulin-treated diabetes present to primary care frequently with non-specific symptoms associated with hypoglycaemia

INTRODUCTION

We assessed if patients with known hypoglycaemia present on other occasions with non-specific symptoms associated with (but not diagnosed as) hypoglycaemia, potentially representing missed hypoglycaemia.

METHODS

335 primary care records (5/2/12-4/2/13) from patients aged >65 (79 on insulin, 85 on sulphonylureas, 121 on metformin only, 50 without diabetes) were assessed for hypoglycaemia episodes and consultations with non-specific symptoms, "hypo clues".

RESULTS

27/79(34%) insulin-treated patients had >1 documented hypoglycaemia episode, compared to 4/85(5%) sulphonylurea-treated patients, 2/121(2%) metformin-only treated patients, and none without diabetes, p<0.001. "Hypo clue" consultations were common: 1.37 consultations/patient/year in insulin-treated patients, 0.98/patient/year in sulphonylurea-treated, 0.97/patient/year in metformin only-treated, and 0.78/patient/year in non-diabetic patients, p=0.34. In insulin-treated patients with documented hypoglycaemia, 20/27(74%) attended on another occasion with a "hypo clue" symptom, compared to 21/52(40%) of those without hypoglycaemia, p=0.008. No significant difference in the other treatment groups. Nausea, falls and unsteadiness were the most discriminatory symptoms: 7/33(21%) with hypoglycaemia attended on another occasion with nausea compared to 14/302(5%) without hypoglycaemia, p=0.002; 10/33(30%) vs 36/302(12%) with falls, p=0.007; and 5/33(15%) vs 13/302(4%) with unsteadiness, p=0.023.

CONCLUSIONS

Non-specific symptoms are common in those >65 years. In insulin-treated patients at high hypoglycaemia risk, nausea, falls and unsteadiness should prompt consideration of hypoglycaemia.

Hypoglycaemia in the over 75s: Understanding the predisposing factors in type 2 diabetes (T2DM)

INTRODUCTION

Hypoglycaemia has been recognised as a problem in the treatment for type 2 diabetes. Here we describe how levels of HbA1C and treatment with a sulphonylurea or insulin relate to risk of significant hypoglycaemia.

METHODS

Incident hypoglycaemia as recorded for the previous 10 years was determined from the GP records for patients with T2DM aged 75 years or more.

RESULTS

The anonymised GP records of 5974 T2DM patients (2934 men and 3040 women) aged 75 years or more were analysed. Mean age of the men was 81.0 (95% confidence interval (CI) 80.9-81.2) years and of the women was 82.2 (95% CI 82.0-82.4) years. Hypoglycaemic events of significance were recorded in 4.9% of men and 5.1% of women. The prevalence of hypoglycaemia was higher in those with a higher concurrent HbA1C. HbA1C for those people with a recorded significant hypoglycaemic attack(s) was 57.9 (95% CI 56.4-59.4) mmol/mol compared to those with no history of hypoglycaemic episodes at 51.6 (95% CI 51.3-52.0) mmol/mol (p<0.002). Even for those on sulphonylurea and/or insulin treatment, hypoglycaemia prevalence increased with HbA1C: for patients with an HbA1C of <48mmol/mol, age and gender adjusted hypoglycaemia prevalence was 11.1%, for HbA1C of 48-57mmol/mol, prevalence 9.9%, for HbA1C 58-67mmol/mol prevalence, 13.2% and for HbA1C 68mmol/mol or more, prevalence of hypoglycaemia was 16.1%. There was a slight fall in HbA1C by age (normalised β -0.069, p<0.001) and no difference by level of social disadvantage. Treatment with a sulphonylurea or insulin very significantly increased the likelihood of a hypoglycaemic episode: odds ratio (OR) 8.94 (95% CI 6.45-12.42), p<0.001, independent of age, BMI, Townsend index and gender.

CONCLUSION

Prevalence of hypoglycaemia was greater in those individuals with higher HbA1C and in those on sulphonylurea/insulin treatment. Our findings suggest that it is variance in blood glucose rather than overall lower blood glucose levels that predisposes older people to hypoglycaemia.

Management of Diabetes in Long-term Care and Skilled Nursing Facilities: A Position Statement of the American Diabetes Association

Diabetes is more common in older adults, has a high prevalence in long-term care (LTC) facilities, and is associated with significant disease burden and higher cost. The heterogeneity of this population with regard to comorbidities and overall health status is critical to establishing personalized goals and treatments for diabetes. The risk of hypoglycemia is the most important factor in determining glycemic goals due to the catastrophic consequences in this population. Simplified treatment regimens are preferred, and the sole use of sliding scale insulin (SSI) should be avoided. This position statement provides a classification system for older adults in LTC settings, describes how diabetes goals and management should be tailored based on comorbidities, delineates key issues to consider when using glucose-lowering agents in this population, and provides recommendations on how to replace SSI in LTC facilities. As these patients transition from one setting to another, or from one provider to another, their risk for adverse events increases. Strategies are presented to reduce these risks and ensure safe transitions. This article addresses diabetes management at end of life and in those receiving palliative and hospice care. The integration of diabetes management into LTC facilities is important and requires an interprofessional team approach. To facilitate this approach, acceptance by administrative personnel is needed, as are protocols and possibly system changes. It is important for clinicians to understand the characteristics, challenges, and barriers related to the older population living in LTC facilities as well as the proper functioning of the facilities themselves. Once these challenges are identified, individualized approaches can be designed to improve diabetes management while lowering the risk of hypoglycemia and ultimately improving quality of life.

Review of Hypoglycemia in the Older Adult: Clinical Implications and Management

The aging of the population is a worldwide phenomenon. The prevalence of diabetes rises with increasing age, so the personal and financial costs of diabetes in the aging population have become significant burdens. In 2012, 104 billion (59%) of the estimated $176 billion in United States healthcare expenditures attributable to diabetes were utilized by patients older than 65 years of age [American Diabetes Association (1)]. With improvement in diabetes management and better glycemic control in the general population, there is an increase in the prevalence of hypoglycemia, which is the complication of the treatment of diabetes. Older adults with diabetes have a higher risk for hypoglycemia due to altered adaptive physiologic responses to low glucose levels. These patients also have comorbidities, such as cognitive and functional loss, that interfere with prompt identification and/or appropriate treatment of hypoglycemia. Older adults who suffer from hypoglycemia also have increased risk for falls, fall-related fractures, seizures and comas and exacerbation of chronic conditions, such as cognitive dysfunction and cardiac events. Thus, hypoglycemia in the older adult must be proactively avoided to decrease significant morbidity and mortality. Education of the patients and caregivers is important in prevention and treatment of hypoglycemia. In this article, we discuss the important aspects and unique challenges pertaining to hypoglycemia in older population. We also highlight the risks, consequences and prevention and management strategies for hypoglycemia that can be used by healthcare providers caring for older populations.

Optimal glycaemic control in elderly people with type 2 diabetes: what does the evidence say?

The global prevalence of type 2 diabetes mellitus (T2DM) is rising in an ageing population through a combination of lifestyle changes and greater longevity. However, by excluding participants aged over 70 years, most major interventional trials on which current diabetes therapeutic guidelines are based have failed to provide specific evidence to support the prescribed management of diabetes in elderly people. While diabetes per se has a significant impact on the elderly person, the side effects of medications, particularly hypoglycaemia, prevent optimisation of diabetes treatment. Hypoglycaemia is associated with significant morbidity, to which elderly people are often more vulnerable because of factors such as the effects of ageing, progressive renal impairment, frailty, polypharmacy and cognitive decline. T2DM is associated with accelerated cognitive decline in some individuals, and recurrent severe hypoglycaemia has been implicated as a potential contributory factor. Although the evidence for selection of appropriate glycaemic targets in elderly patients is sparse, it is now acknowledged that prevention of hypoglycaemia must influence individualisation of treatment goals in this vulnerable group. This should also be reflected by the choice of anti-diabetes agents that are initiated when diet and lifestyle advice is ineffective. Recently developed international guidelines, which have specifically addressed the management of diabetes in elderly people, highlight the importance of a pragmatic management approach rather than attempting to achieve a generic glycated haemoglobin goal and are summarised in this article.

Knowledge of hypoglycemia and its associated factors among type 2 diabetes mellitus patients in a Tertiary Care Hospital in South India

INTRODUCTION

Hypoglycemia being the rate limiting complication in the attainment of strict glycemic control in diabetes management, in this study, we intended to study the knowledge of its symptoms, target blood levels during treatment and ways of prevention among type 2 diabetes patients attending Outpatient Department (OPD) of a medical college hospital.

MATERIALS AND METHODS

Every fifth patient attending the OPD during the 4 months between March and June 2013 was interviewed using a questionnaire.

RESULTS

The study included 366 type 2 diabetic patients, of which 76.5% were females. The target fasting and postprandial blood glucose levels while on treatment was known to 135 (36.9%) and 126 (34.4%) patients, respectively. The common symptoms of hypoglycemia known to the study subjects were dizziness (81.4%), weakness (73.8%), and drowsiness (72.1%). Overall, 242 (66.1%) diabetic patients had good knowledge on hypoglycemia (knowledge of at least three symptoms of hypoglycemia together with at least one precipitating factor and at least one remedial measure). Higher age, illiteracy, low socioeconomic status were associated with poor knowledge whereas treatment with insulin along with oral hypoglycemic agents was associated with good knowledge on hypoglycemia. Sex and duration of disease were not associated with knowledge on hypoglycemia.

CONCLUSION

Although the knowledge on symptoms of hypoglycemia, precipitating factors, remedial measures are high in this study, the target blood levels, complications were known to just a third of them. There is a knowledge gap on important aspects of hypoglycemia among type 2 diabetic patients.

Disease burden evaluation of fall-related events in the elderly due to hypoglycemia and other diabetic complications: a clinical review

A hypoglycemia-induced fall is common in older persons with diabetes. The etiology of falls in this population is usually multifactorial, and includes microvascular and macrovascular complications and age-related comorbidities, with hypoglycemia being one of the major precipitating causes. In this review, we systematically searched the literature that was available up to March 31, 2014 from MEDLINE/PubMed, Embase, and Google Scholar using the following terms: hypoglycemia; insulin; diabetic complications; and falls in elderly. Hypoglycemia, defined as blood glucose <4.0 mmol/L (70 mg/dL) requiring external assistance, occurs in one-third of elderly diabetics on glucose-lowering therapies. It represents a major barrier to the treatment of diabetes, particularly in the elderly population. Patients who experience hypoglycemia are at a high risk for adverse outcomes, including falls leading to bone fracture, seizures, cognitive dysfunction, and prolonged hospital stays. An increase in mortality has been observed in patients who experience any one of these events. Paradoxically, rational insulin therapy, dosed according to a patient’s clinical status and the results of home blood glucose monitoring, so as to achieve and maintain recommended glycemic goals, can be an effective method for the prevention of hypoglycemia and falls in the elderly. Contingencies, such as clinician-directed hypoglycemia treatment protocols that guide the immediate treatment of hypoglycemia, help to limit both the duration and severity of the event. Older diabetic patients with or without underlying renal insufficiency or other severe illnesses represent groups that are at high risk for hypoglycemia-induced falls and, therefore, require lower insulin dosages. In this review, the risk factors of falls associated with hypoglycemia in elderly diabetics were highlighted and management plans were suggested. A target hemoglobin A1c level between 7% and 8% seems to be more appropriate for this population. In addition, the first-choice drugs should have good safety profiles and have the lowest probability of causing hypoglycemia – such as metformin (in the absence of significant renal impairment) and incretin enhancers – while other therapies that may cause more frequent hypoglycemia should be avoided.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients

AIM

Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program.

METHODS

We used the point prevalence approach by checking for fasting blood glucose, glycated hemoglobin and other routine biochemical tests. Eating status was evaluated by the Functional Outcome Swallowing Scale. Details about the diabetes disease management program are given in the text.

RESULTS

A total of 86 (36%) of the 234 patients on the study day were diabetics. Of these, 80 were eligible for the study. Their mean fasting blood glucose was 143.1 ± 60.6 mg/dL. The mean glycated hemoglobin level was 7.23 ± 1.39%.

CONCLUSION

No case of hypoglycemia was detected on the examination day, or during the preceding 3 weeks. No significant difference was found among the different Functional Outcome Swallowing Scale categories. These results are within satisfactory range for this category of patients suggesting that our diabetes disease management program contributes to a better glycemic control.

Hypoglycaemic symptoms and hypoglycaemia threshold in older people with diabetes--a patient perspective

OBJECTIVES

To investigate patients' views about their lowest tolerable blood glucose level and explore symptoms they may develop below that level.

DESIGN

A semi-structured patient interview.

SETTING

Outpatient clinic for older people (≥75 years) with diabetes.

PARTICIPANTS

Patients attending an outpatient clinic over a six months period who are monitoring their blood glucose at home and able to participate in interview.

RESULTS

Sixty one patients gave answers to the interview questions. Mean (SD) age was 82.3 (3.9) years and 33 (54%) were females. All patients indicated that they were usually aware when hypoglycaemia occurs but the symptoms reported were mostly non specific. The threshold for hypoglycaemia was 5 mmol/L in 13 (21%) patients, 6 mmol/L in 14 (23%) patients, 7 mmol/L in 13 (21%) patients, 8 mmol/L in 17 (28%) patients and 9 mmol/L in 4 (7%) patients. There was no significant difference between patients who were symptomatic at a higher blood glucose level (>6 mmo/L) and those who developed symptoms at a lower level (≤6 mmol/L).

CONCLUSION

Older people with diabetes who seem to be aware of hypoglycaemia report mostly non specific symptoms. The threshold of experiencing hypoglycaemic symptoms appears to be higher than the usually defined <4 mmol/L.

Fear of hypoglycaemia in patients with type 1 diabetes: do patients and diabetologists feel the same way?

AIM

This study described and compared the perception of hypoglycaemia in both patients with type 1 diabetes and diabetologists.

METHODS

This was an observational cross-sectional study undertaken in France in 2011. Data for what hypoglycaemia represents and practices related to it were collected using a questionnaire completed by patients with type 1 diabetes (all>12 years of age) and their diabetologists. Agreement between patients and physicians was evaluated by the intraclass correlation coefficient (ICC) and Gwet's coefficient (GC).

RESULTS

A total of 485 patients were enrolled by 118 diabetologists. Half the patients thought that hypoglycaemia was always symptomatic. According to both patients and diabetologists, hypoglycaemia impaired quality of life, caused anxiety and was disturbing, especially at night. Clinical symptoms of hypoglycaemia (sweating, shakiness, anxiety) were linked to patient's age and diabetes duration. Regarding hypoglycaemia frequency, agreement was good for severe hypoglycaemia (GC: 0.61 and 0.72 for diurnal and nocturnal hypoglycaemia, respectively) and poor for mild hypoglycaemia (ICC: 0.44 and 0.40, respectively). Diabetologists correctly evaluated the impact of hypoglycaemia on quality of life, but overestimated the hypoglycaemia-induced burden and anxiety. Counteractive behaviours were frequent: 23% of patients decreased their insulin dose, 20% increased their sugar intake and 12% ate extra snacks. Diabetologists were generally aware of these measures, but not of how often patients used them.

CONCLUSION

Diabetologists and patients do not share enough information about hypoglycaemia. Fear of hypoglycaemia and counteractive behaviours should be looked for by diabetologists. Systematic advice and specially adapted education should also be provided to increase patients' awareness of hypoglycaemia.

Drug-induced hypoglycaemia in type 2 diabetes

INTRODUCTION

Hypoglycaemia is a side effect caused by some therapies for type 2 diabetes, which can cause physical, social and psychological harm. Hypoglycaemia also prevents attainment of treatment goals and satisfactory glycaemic control.

AREAS COVERED

The risk of hypoglycaemia associated with commonly prescribed therapies, including metformin, sulphonylureas, dipeptidyl peptidase-4 enzyme (DPP-4) inhibitors, glucagon-like peptide-1 (GLP-1) agonists and thiazolidinediones, is reviewed in this paper (insulin-induced hypoglycaemia is not included). Other medications that are frequently co-prescribed in type 2 diabetes are also discussed, including anti-hypertensive drugs, antibiotics and fibrates, along with various important patient-related risk factors.

EXPERT OPINION

Hypoglycaemia is a common and potentially dangerous side effect of some medications used for type 2 diabetes. The risk of hypoglycaemia should always be considered when selecting and implementing a therapy, with a focus on the individual. Future research into new therapies should measure the frequency of hypoglycaemia prospectively and accurately. Hypoglycaemia has been shown to be a potentially life-threatening metabolic stress; therefore therapies that effectively manage diabetes without the risk of hypoglycaemia are likely to be favoured in the future.

Hypoglycemia revisited in the acute care setting

Hypoglycemia is a common finding in both daily clinical practice and acute care settings. The causes of severe hypoglycemia (SH) are multi-factorial and the major etiologies are iatrogenic, infectious diseases with sepsis and tumor or autoimmune diseases. With the advent of aggressive lowering of HbA1c values to achieve optimal glycemic control, patients are at increased risk of hypoglycemic episodes. Iatrogenic hypoglycemia can cause recurrent morbidity, sometime irreversible neurologic complications and even death, and further preclude maintenance of euglycemia over a lifetime of diabetes. Recent studies have shown that hypoglycemia is associated with adverse outcomes in many acute illnesses. In addition, hypoglycemia is associated with increased mortality among elderly and non-diabetic hospitalized patients. Clinicians should have high clinical suspicion of subtle symptoms of hypoglycemia and provide prompt treatment. Clinicians should know that hypoglycemia is associated with considerable adverse outcomes in many acute critical illnesses. In order to reduce hypoglycemia-associated morbidity and mortality, timely health education programs and close monitoring should be applied to those diabetic patients presenting to the Emergency Department with SH. ED disposition strategies should be further validated and justified to achieve balance between the benefits of euglycemia and the risks of SH. We discuss relevant issues regarding hypoglycemia in emergency and critical care settings.

Medically minimising the impact of hypoglycaemia in type 2 diabetes: a review

INTRODUCTION

Some therapies for type 2 diabetes (T2DM) are limited by hypoglycaemia, and this underestimated side effect carries an associated morbidity and financial burden. Large trials that have examined strict glycaemic control and cardiovascular outcomes in T2DM have highlighted the potential harm of exposure to hypoglycaemia in people with coronary heart disease.

AREAS COVERED

The responses to, and the morbidity associated with, hypoglycaemia in T2DM are discussed with identification of people most at risk of severe hypoglycaemia. The evidence base for non-pharmacological strategies and the risks of hypoglycaemia associated with various treatment modalities are examined. This review provides the clinician with a rational approach to the selection of different anti-diabetes drugs to minimize the risk of hypoglycaemia.

EXPERT OPINION

When managing T2DM, insulin and insulin secretagogues should be used judiciously and glycaemic targets individualized to avoid hypoglycaemia. Incretin mimetics present a lower risk of hypoglycaemia with similar efficacy as traditional agents in treating hyperglycaemia. The potential relationship between hypoglycaemia and precipitation of acute cardiovascular events is a highly topical area of research and may help determine what glycaemic targets are appropriate in people with T2DM.

Management of hyperglycemia in geriatric patients with diabetes mellitus: South Asian consensus guidelines

Asia is home to four of the world's five largest diabetic populations, two of them being South Asian nations, namely, India and Pakistan. This problem is compounded by a substantial rise in the elderly population in Asian countries. On the other hand, the heterogeneous health condition and multiple co-morbidities make the care of chronic disease in the elderly a challenging task. The aim of the South Asian Consensus Guidelines is to provide evidence-based recommendations to assist healthcare providers in the rational management of type 2 diabetes mellitus in the elderly population. Current Guidelines used systematic reviews of available evidence to form its key recommendations. No evidence grading was done for the purpose of this manuscript. The clinical questions of the guidelines, the methodology of literature search, and medical writing strategy were finalized by consultations in person and through mail. The South Asian Consensus guideline emphasizes tailoring of glycemic goals for patients based on age, co-morbid conditions especially that of cardiovascular system, risk of hypoglycemia, and life expectancy. It also recommends cautious use of available pharmacotherapy in geriatric patients with diabetes. The primary principle of diabetes therapy should be to achieve euglycemia, without causing hypoglycemia. Appropriate use of modern insulins and oral drugs, including incretin mimetics will help physicians achieve this aim.

Drug-induced hypoglycaemia: an update

Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.

Severe sulfonylurea-induced hypoglycemia: a problem of uncritical prescription and deficiencies of diabetes care in geriatric patients

OBJECTIVE

Severe sulfonylurea-induced hypoglycemia (SH) remains a life-threatening and under-reported condition. We investigated the incidence of SH and clinical characteristics of patients with type 2 diabetes mellitus (T2DM) to demonstrate typical risk constellations.

METHODS

In a prospective population-based observational study, all consecutive cases of SH in the period 2000 - 2009 in a German area with 200,000 inhabitants were registered. Severe hypoglycemia was defined as a symptomatic event requiring treatment with intravenous glucose and was confirmed by a blood glucose measurement of < 50 mg/dl.

RESULTS

A mean incidence of seven episodes of SH per year and 100,000 inhabitants was registered. The 139 hypoglycemic individuals had been treated with glimepiride (n = 98), glibenclamide (n = 40) or gliquidone (n = 1). No preparation showed a constant dose-effect relationship, SH occurring within a wide dose range. The patients were characterized as follows: age 77.5 + or - 9.4 years, duration of diabetes 11 + or - 7 years, body mass index 26.3 + or - 4.9 kg/m(2), HbA1c 6.6 + or - 1.3%, creatinine clearance 46 + or - 24 ml/min with renal insufficiency in 73% and co-medication 7 + or - 3 drugs. Two-thirds of all subjects lived independently at home whereas a third were cared for by a home nursing service or received care in nursing homes. In all, 30% had participated in diabetes education programs. In 31%, systematic blood glucose monitoring was performed.

CONCLUSIONS

Uncritical prescription of sulfonylureas neglecting crucial contraindications - particularly renal insufficiency - and deficiencies of diabetes care contributed substantially to the risk of SH in the mainly geriatric patients. There is a need for alternative therapeutic concepts that minimize the risk of hypoglycemia in geriatric patients with T2DM.

Self management and patient understanding of diabetes in the older person

AIM

To examine knowledge and management of diabetes by older people.

METHODS

A representative sample of 1047 people with Type 2 diabetes, aged 75 years and over, were asked a series of questions relating to their diabetes management and their understanding of self management. The impact of cognitive impairment and socio-economic status were assessed.

RESULTS

The majority of people, 1015 (96.9%), were under the care of a health professional and 1018 (97.2%) were taking insulin, tablets, controlling their diet or a combination. Cognitive impairment (Mini-Mental State Examination ≤ 23) was found in 235 (22.5%) people. Recent eye, foot and dietician assessment was reported by 813 (77.7%), 836 (79.7%) and 326 (31.1%) people, respectively. A quarter overall and 70% of those taking insulin tested their blood glucose. In the insulin group, 78 (54.2%) reported hypoglycaemia and those with cognitive impairment gave more incorrect responses when asked about diabetes management. Socio-economic status made very little difference to any of these outcomes.

CONCLUSIONS

Most older people with diabetes, regardless of their socio-economic status, are under the care of a healthcare professional and use medication or diet to manage their disease. Large numbers also attend foot and eye examinations. However, over one fifth of older people with diabetes have cognitive impairment. Older people had a reasonable understanding of their diabetes management but this was worse in those people with cognitive impairment.

Insulin use in elderly diabetic patients

The prevalence of type 2 diabetes is increasing among older adults as is their diabetes-related mortality rate. Studies suggest that tighter glucose control reduces complications in elderly patients. However, too low a glycosylated hemoglobin (HbA_1c) value is associated with increased hypoglycemia. Moreover, the appropriateness of most clinical trial data and standards of care related to diabetes management in elderly patients is questionable given their heterogeneity. Having guidelines to safely achieve glycemic control in elderly patients is crucial. One of the biggest challenges in achieving tighter control is predicting when peak insulin action will occur. The clinician’s options have increased with new insulin analogs that physiologically match the insulin peaks of the normal glycemic state, enabling patients to achieve the tighter diabetes control in a potentially safer way. We discuss the function of insulin in managing diabetes and how the new insulin analogs modify that state. We offer some practical considerations for individualizing treatment for elderly patients with diabetes, including how to incorporate these agents into current regimens using several methods to help match carbohydrate intake with insulin requirements. Summarizing guidelines that focus on elderly patients hopefully will help reduce crises and complications in this growing segment of the population.

Diabetes in the elderly

We are approaching an epidemic of diabetes in the elderly. This epidemic and its associated complications will have a significant impact on quality of life in this age group. Recent studies suggest that diabetes can be prevented in a large number of patients with appropriate interventions. It seems that diabetes in this age group is metabolically distinct. As a result, the approach to therapy in the elderly differs from that in younger patients. Unfortunately, we still have huge gaps in our understanding of the pathogenesis and treatment of diabetes in the aged, and further studies are needed urgently.

Hypoglycemia in type 2 diabetes: a critical review

Hypoglycemia is the most important barrier to tight glycemic control. Although severe hypoglycemia is uncommon, milder events can occur so often that they represent a deterrent to intensifying treatment. High-risk patient behaviors are the most important cause for episodes for which a cause can be identified. Because symptoms are an unreliable way of establishing the diagnosis, SMBG should be considered for the patients at highest risk, particularly as they approach their glycemic targets. SMBG is superior to HbA1c in forecasting the hypoglycemia rate because it provides information about glucose variability--an independent risk factor. Patient education and medication changes are potential ways of reducing the hypoglycemia rate. However, it remains to be proven that patient education is beneficial in this regard.

Hypoglycemia in stable, insulin-treated veterans with type 2 diabetes: a prospective study of 1662 episodes

We evaluated the incidence, severity, and predisposing risk factors for hypoglycemic episodes in subjects with type 2 diabetes.

METHODS

We conducted a prospective observational study of Southwest veterans with stable, insulin-treated type 2 diabetes who were randomly selected from pharmacy databases. Electronically recorded self-monitored blood glucose (SMBG) results were collected during 12 months of routine monitoring. We defined hypoglycemia as an SMBG reading < or =60 mg/dl. Subjects graded the severity of each hypoglycemic episode: 0=asymptomatic, 1=mild/moderate symptoms, 2=severe, with mental impairment or need for assistance. Subjects also reported any predisposing factors for each hypoglycemic episode.

RESULTS

We enrolled 344 subjects, mean (S.D.) age of 65.5 (9.7) years, 96.5% were men, and 35.2% were minorities. During an average follow-up of 41.2 (8.6) weeks, 176 subjects (51.2%) documented at least one hypoglycemic reading for a total of 1662 episodes. These subjects had a median of six (interquartile range 2-14.9) hypoglycemic episodes. The mean hypoglycemic blood glucose reading was 49.7 (7.5) mg/dl and the mean symptom score was 0.84 (0.45). Nearly 80% of episodes were symptomatic, 3.4% were severe. Subjects identified a cause for 45.2% of episodes: 53.3% of these were attributed to missing a meal, 23.8% to exercise, and 1.6% followed a medication increase.

CONCLUSIONS

A high proportion of stable, insulin-treated subjects developed hypoglycemic episodes, but severe hypoglycemia occurred infrequently. Medication increases were rarely identified as causing hypoglycemic episodes. Efforts to achieve tight glycemic control should recognize that patient behaviors commonly cause hypoglycemia.

Factors affecting hypoglycemia awareness in insulin-treated type 2 diabetes: The Diabetes Outcomes in Veterans Study (DOVES)

OBJECTIVE

To identify clinical factors that affect hypoglycemia perception in type 2 diabetes.

METHODS

Prospective observational study of 344 insulin-treated subjects randomly selected from pharmacy records at three large medical centers. At entry, subjects underwent an extensive psychological evaluation and then monitored their blood glucoses in their usual fashion for up to 52 weeks using a glucose meter capable of storing 1000 readings. For blood glucoses <or=3.33 mmol/l (60 mg/dl), subjects recorded the severity of symptoms in a log book. Symptoms were scored '0' if they were asymptomatic, '1' for symptoms that were mild-to-moderate, and '2' if the subject had a diminished level of consciousness or required the assistance of others. A mean blood glucose and mean symptom score were calculated for all hypoglycemic episodes detected by each patient.

RESULTS

One hundred seventy-six subjects (51.2%) had a median of 4.5 hypoglycemic events during 42.5+/-8.0 weeks of follow-up. The mean hypoglycemic blood glucoses and mean symptom scores were modestly correlated (r=0.153; P=0.043). After adjusting for blood glucose, symptom scores were lower in the elderly and higher in subjects with higher diabetes knowledge scores, microvascular complications, and higher entry hemoglobin A1c. Multiple linear regression showed that the latter three factors were independently predictive of higher symptoms.

CONCLUSIONS

Conventional clinical data may be useful in identifying patients with poor hypoglycemia perception. Patients with better long- and short-term glycemic control are at higher risk and may benefit from instruction on all aspects of hypoglycemia.

Hypoglycaemia in Elderly Patients with Diabetes Mellitus

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.

Diabetes in the elderly: problems of care and service provision

Diabetes is common in the elderly and old UK citizens, affecting between 10% and 25%. There is considerable associated morbidity and mortality, with dementia being a common problem. The diabetic elder is also at risk of drug side-effects. Most of the evidence base for treatment is based on trials performed in younger diabetic subjects or older nondiabetic subjects; however, we can practice evidence-biased medicine whilst awaiting the results of ongoing trials. The older persons national service framework (NSF) may share some similarities with the diabetes NSF; it was 1 year late, and had no clear funding, amongst several other worries. Residential care, which is more likely to be required by diabetic elders, is also under-funded with major concerns about the quality of care for the diabetic resident. The little evidence that we have regarding care of the older diabetic person also suggests inadequacies. Given the likelihood that we will have to manage with present resources, managed clinical networks may be one way to cope.

Symptoms of hypoglycaemia in people with diabetes

The symptoms of hypoglycaemia are fundamental to the early detection and treatment of this side-effect of insulin and oral hypoglycaemic therapy in people with diabetes. The physiology of normal responses to hypoglycaemia is described and the importance of symptoms of hypoglycaemia is discussed in relation to the treatment of diabetes. The symptoms of hypoglycaemia are described in detail. The classification of symptoms is considered and the usefulness of autonomic and neuroglycopenic symptoms for detecting hypoglycaemia is discussed. The many external and internal factors involved in the perception of symptoms are reviewed, and symptoms of hypoglycaemia experienced by people with Type 2 diabetes are addressed. Age-specific differences in the symptoms of hypoglycaemia have been identified, and are important for clinical and research practice, particularly with respect to the development of acquired hypoglycaemia syndromes in people with Type 1 diabetes that can result in impaired awareness of hypoglycaemia. In addition, the routine assessment of hypoglycaemia symptoms in the diabetic clinic is emphasized as an important part of the regular review of people with diabetes who are treated with insulin.

Diabetes in the elderly

Diabetes affects at least 20% of the population over the age of 65. Half of these patients are unaware that they have the disease. Diabetes in middle-aged subjects is characterized by an impairment in glucose induced insulin release, increased fasting hepatic glucose output and resistance to insulin mediated glucose disposal. In contrast, diabetes in the elderly is primarily associated with insulin deficiency. The presentation of diabetes in the aged is often non-specific. The elderly have an increased frequency of complications from diabetes. They are particularly susceptible to hypoglycaemia, because of reduced awareness of hypoglycaemic warning symptoms and altered release of counterregulatory hormones. Although no data are yet available from randomized controlled trials, there is abundant epidemiological evidence to suggest that adequate control of blood glucose can be expected to reduce the risk of long-term complications. A team approach is ideal for the management of the elderly patient with diabetes. Little data is available on which to base a diet and exercise prescription for elderly patients. Gliclazide appears to be the sulphonylurea of choice in the aged because it is associated with a lower frequency of hypoglycaemic reactions. Urine glucose testing is unreliable, and capillary glucose monitoring is preferred. Fructosamine may prove to be superior to haemoglobin A1C for monitoring long-term control.