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Hypoglycemia in the elderly: Watch for atypical symptoms
We read with interest the review article by Keber and Fiebert, “Diabetes in the elderly: Matching meds to needs” (J Fam Pract. 2018;67:408-410,412-415). The authors have provided a timely overview of antidiabetes medications for elderly people with type 2 diabetes mellitus (T2DM) and their relative risks for hypoglycemia.
We’d like to add to this important conversation.
Aging, per se, modifies the glycemic thresholds for autonomic symptoms and cognitive impairment; in older nondiabetic men (mean + SD: age 65 ± 3 years), autonomic symptoms and cognitive dysfunction commence at identical glycemic thresholds (3 ± 0.2 mmol/L [54 ± 4 mg/dL]). By contrast, in younger men (age 23 ± 2 years), a significant gap is observed between the glycemic threshold for symptom generation (3.6 mmol/L [65 mg/dL]) and the onset of cognitive dysfunction (2.6 mmol/L [47 mg/dL]).1,2 The simultaneous occurrence of symptoms and cognitive impairment in older people may adversely affect their ability to recognize and treat hypoglycemia promptly.
In addition, hypoglycemia in older T2DM patients often presents with atypical neurologic symptoms, including incoordination and ataxia, slurring of speech, and visual disturbances, which either are not identified as hypoglycemia or are misdiagnosed as other medical disorders (eg, transient ischemic attack).3 Knowledge about hypoglycemia symptoms is poor, in both elderly people with diabetes and their relatives and caregivers, which compromises the ability to identify hypoglycemia and provide effective treatment.4 Education about the possible presentations of hypoglycemia and its effective treatment is essential for older patients and their relatives.
Jan Brož, MD
Prague, Czech Republic
1. Meneilly GS, Elahi D. Physiological importance of first-phase insulin release in elderly patients with diabetes. Diabetes Care. 1998;21:1326-1329.
2. Matyka K, Evans M, Lomas J, et al. Altered hierarchy of protective responses against severe hypoglycemia in normal aging in healthy men. Diabetes Care. 1997;20:135-141.
3. Jaap AJ, Jones GC, McCrimmon RJ, et al. Perceived symptoms of hypoglycaemia in elderly type 2 diabetic patients treated with insulin. Diabet Med. 1998;15:398-401.
4. Thomson FJ, Masson EA, Leeming JT, et al. Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients. Age Ageing. 1991;20:404-406.
We read with interest the review article by Keber and Fiebert, “Diabetes in the elderly: Matching meds to needs” (J Fam Pract. 2018;67:408-410,412-415). The authors have provided a timely overview of antidiabetes medications for elderly people with type 2 diabetes mellitus (T2DM) and their relative risks for hypoglycemia.
We’d like to add to this important conversation.
Aging, per se, modifies the glycemic thresholds for autonomic symptoms and cognitive impairment; in older nondiabetic men (mean + SD: age 65 ± 3 years), autonomic symptoms and cognitive dysfunction commence at identical glycemic thresholds (3 ± 0.2 mmol/L [54 ± 4 mg/dL]). By contrast, in younger men (age 23 ± 2 years), a significant gap is observed between the glycemic threshold for symptom generation (3.6 mmol/L [65 mg/dL]) and the onset of cognitive dysfunction (2.6 mmol/L [47 mg/dL]).1,2 The simultaneous occurrence of symptoms and cognitive impairment in older people may adversely affect their ability to recognize and treat hypoglycemia promptly.
In addition, hypoglycemia in older T2DM patients often presents with atypical neurologic symptoms, including incoordination and ataxia, slurring of speech, and visual disturbances, which either are not identified as hypoglycemia or are misdiagnosed as other medical disorders (eg, transient ischemic attack).3 Knowledge about hypoglycemia symptoms is poor, in both elderly people with diabetes and their relatives and caregivers, which compromises the ability to identify hypoglycemia and provide effective treatment.4 Education about the possible presentations of hypoglycemia and its effective treatment is essential for older patients and their relatives.
Jan Brož, MD
Prague, Czech Republic
We read with interest the review article by Keber and Fiebert, “Diabetes in the elderly: Matching meds to needs” (J Fam Pract. 2018;67:408-410,412-415). The authors have provided a timely overview of antidiabetes medications for elderly people with type 2 diabetes mellitus (T2DM) and their relative risks for hypoglycemia.
We’d like to add to this important conversation.
Aging, per se, modifies the glycemic thresholds for autonomic symptoms and cognitive impairment; in older nondiabetic men (mean + SD: age 65 ± 3 years), autonomic symptoms and cognitive dysfunction commence at identical glycemic thresholds (3 ± 0.2 mmol/L [54 ± 4 mg/dL]). By contrast, in younger men (age 23 ± 2 years), a significant gap is observed between the glycemic threshold for symptom generation (3.6 mmol/L [65 mg/dL]) and the onset of cognitive dysfunction (2.6 mmol/L [47 mg/dL]).1,2 The simultaneous occurrence of symptoms and cognitive impairment in older people may adversely affect their ability to recognize and treat hypoglycemia promptly.
In addition, hypoglycemia in older T2DM patients often presents with atypical neurologic symptoms, including incoordination and ataxia, slurring of speech, and visual disturbances, which either are not identified as hypoglycemia or are misdiagnosed as other medical disorders (eg, transient ischemic attack).3 Knowledge about hypoglycemia symptoms is poor, in both elderly people with diabetes and their relatives and caregivers, which compromises the ability to identify hypoglycemia and provide effective treatment.4 Education about the possible presentations of hypoglycemia and its effective treatment is essential for older patients and their relatives.
Jan Brož, MD
Prague, Czech Republic
1. Meneilly GS, Elahi D. Physiological importance of first-phase insulin release in elderly patients with diabetes. Diabetes Care. 1998;21:1326-1329.
2. Matyka K, Evans M, Lomas J, et al. Altered hierarchy of protective responses against severe hypoglycemia in normal aging in healthy men. Diabetes Care. 1997;20:135-141.
3. Jaap AJ, Jones GC, McCrimmon RJ, et al. Perceived symptoms of hypoglycaemia in elderly type 2 diabetic patients treated with insulin. Diabet Med. 1998;15:398-401.
4. Thomson FJ, Masson EA, Leeming JT, et al. Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients. Age Ageing. 1991;20:404-406.
1. Meneilly GS, Elahi D. Physiological importance of first-phase insulin release in elderly patients with diabetes. Diabetes Care. 1998;21:1326-1329.
2. Matyka K, Evans M, Lomas J, et al. Altered hierarchy of protective responses against severe hypoglycemia in normal aging in healthy men. Diabetes Care. 1997;20:135-141.
3. Jaap AJ, Jones GC, McCrimmon RJ, et al. Perceived symptoms of hypoglycaemia in elderly type 2 diabetic patients treated with insulin. Diabet Med. 1998;15:398-401.
4. Thomson FJ, Masson EA, Leeming JT, et al. Lack of knowledge of symptoms of hypoglycaemia by elderly diabetic patients. Age Ageing. 1991;20:404-406.