3.0.0.0 HY­PO­GLYCEMIA

Older adults are at high­er risk of hy­po­glycemia for many rea­sons, in­clud­ing in­sulin deficien­cy ne­ces­si­tat­ing in­sulin ther­a­py and pro­gres­sive renal insufficien­cy. In ad­di­tion, older adults tend to have high­er rates of unidentified cog­ni­tive deficits, caus­ing difficulty in com­plex self-‍care ac­tiv­i­ties (e.g., glu­cose mon­i­tor­ing, ad­just­ing in­sulin doses, etc.). These cog­ni­tive deficits have been as­so­ci­at­ed with in­creased risk of hy­po­glycemia, and, con­verse­ly, se­vere hy­po­glycemia has been linked to in­creased risk of de­men­tia (20). There­fore, it is im­por­tant to rou­tine­ly screen older adults for cog­ni­tive dys­func­tion and dis­cuss find­ings with the pa­tients and their care­givers.

Hy­po­glycemic events should be dili­gent­ly mon­i­tored and avoid­ed, where­as glycemic tar­gets and phar­ma­co­log­ic in­ter­ven­tions may need to be ad­just­ed to ac­com­mo­date for the chang­ing needs of the older adult (2). Of note, it is im­por­tant to pre­vent hy­po­glycemia to re­duce the risk of cog­ni­tive de­cline (20) and other major ad­verse out­comes. In­ten­sive glu­cose con­trol in the Ac­tion to Con­trol Cardiovas­cu­lar Risk in Di­a­betes-Mem­o­ry in Di­a­betes study (AC­CORD MIND) was not found to benefit brain struc­ture or cog­ni­tive func­tion dur­ing fol­low-‍up (14). In the Di­a­betes Con­trol and Com­pli­ca­tions Trial (DCCT), no significant long-‍term de­clines in cog­ni­tive func­tion were ob­served, de­spite par­tic­i­pants’ rel­a­tive­ly high rates of recur­rent se­vere hy­po­glycemia (21). To achieve the ap­pro­pri­ate bal­ance be­tween glycemic con­trol and risk for hy­po­glycemia, it is im­por­tant to care­ful­ly as­sess and reas­sess pa­tients’ risk for wors­en­ing of glycemic con­trol and func­tion­al de­cline.