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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 22  |  Issue : 1  |  Page : 18-21

Risk factors for hypoglycemia in the elderly: A cross-sectional analytical study


Department of Medicine, St. John's Medical College, Bengaluru, Karnataka, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Jyothi Idiculla
Department of Medicine, St. John's Medical College, Bengaluru - 560 034, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9903.202004

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  Abstract 

Background: Hypoglycemia is a side effect of stringent diabetes control especially in the geriatric population above sixty, who constitute approximately 90 million of the Indian population. This study was undertaken to explore the risk factors of hypoglycemia in elderly inpatients. Methods: Fifty patients who were found to have hypoglycemia either at admission or while admitted were enrolled. Their risk factors were compared with fifty age- and sex-matched inpatients admitted to medical wards who did not experience hypoglycemia. Results: The duration of diabetes was significantly longer (12.2 ± 7.9 vs. 9.4 ± 6.7 years; P = 0.023) in the group which experienced hypoglycemia. The mean glycated hemoglobin was significantly lower in the group which experienced hypoglycemia (6.73 ± 1.02 vs. 7.57 ± 1.39; P = 0.001). Of the fifty patients who developed hypoglycemia 26 were asymptomatic. Infection and renal failure were significantly higher in the study group. On multivariate analysis, infection was the only significant precipitating factor. Conclusion: With stringent blood glucose control elderly patients are at high risk of hypoglycemia. The risk is higher if the patients have renal failure and infection. Attempts should be made to identify such patients and to tailor their diabetic therapy to prevent hypoglycemic episodes.

Keywords: Elderly diabetics, hypoglycemia, risk factors


How to cite this article:
George M, Mathew B, Idiculla J. Risk factors for hypoglycemia in the elderly: A cross-sectional analytical study. J Mahatma Gandhi Inst Med Sci 2017;22:18-21

How to cite this URL:
George M, Mathew B, Idiculla J. Risk factors for hypoglycemia in the elderly: A cross-sectional analytical study. J Mahatma Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Sep 23];22:18-21. Available from: https://www.jmgims.co.in/text.asp?2017/22/1/18/202004


  Introduction Top


Hypoglycemia is a known side effect of intensive glucose control as evidenced by major epidemiological studies.[1],[2] It is well known that geriatric patients may have reduced physiological responses to hypoglycemia while they harbor a number of precipitating factors.[3] In addition to the deleterious effects on the brain and the heart, hypoglycemia is also implicated in nocturnal deaths.[4] Despite guidance to ease the glycated hemoglobin (HbA1c) levels in elderly diabetics, hypoglycemia remains a dreaded complication.[5] A recent publication by Tseng et al. has revealed shocking statistics on the over-treatment of the elderly diabetics at the Veterans Health Administration facilities in the USA.[6] Of the 205,857 patients aged more than 75 years and presenting with serum creatinine level of >2 mg/dL or cognitive dysfunction, 50% had HbA1c levels <7.5% and 11.3% had HbA1c levels of <6%. It is disheartening to note that there is a paucity of data on this topic from India, where the elderly population constitutes more than a million.[7] The present study is designed to describe various risk factors predisposing elderly patients with diabetes mellitus, to hypoglycemia, and identify the symptoms occurring during a hypoglycemic episode, in comparison with sex- and age-matched controls who did not experience hypoglycemia.


  Methods Top


A descriptive comparative study was conducted at the St. John's Medical College Hospital, Bengaluru, India, under approval from the Institutional Ethics Committee. Fifty patients who experienced hypoglycemia formed the study group, and fifty age- and sex-matched patients were enrolled for the control group. The inclusion criteria for the study required that patients are of age ≥60 years, are known to have diabetes mellitus and have a blood sugar level of ≤70 mg/dL. The included patients were admitted to the hospital with hypoglycemia or developed hypoglycemia in the hospital. Age- and sex-matched diabetic patients of age ≥60 years, admitted during the same period were included as controls.

All of the patients who fulfilled the inclusion criteria were enrolled into the study after signing a valid informed consent. Patient data were filled into the prescribed pro forma which included details of age, demographics, duration of diabetes mellitus, details of treatment of diabetes at the time of hypoglycemia, details of the hypoglycemic episode (symptoms, severity, glucose level, risk factors identified, treatment, and outcome), comorbidities, polypharmacy, and alcohol use. Similar data were also collected for the control group which consisted of elderly diabetics who did not develop hypoglycemia during their hospital stay. Blood glucose, serum creatinine, HbA1c, and liver function tests were performed at the NABL-accredited laboratories of the Department of Biochemistry of the hospital. All emergency blood glucose readings were done using standardized glucometers in the respective medical wards.

Statistical analysis

All statistical analyses were conducted using SPSS statistical software package (IBM, USA, Version 16). Unpaired two-tailed t-tests were used for the comparison of means of study and control groups. Chi-square [2] test was used to compare the frequency of events between the groups. Further, univariate and multivariate logistic regression has been utilized to determine the clinical predictors of hypoglycemia.


  Results Top


Fifty patients who were documented to have hypoglycemia (study group) and fifty age- and sex-matched inpatients who did not develop hypoglycemia (control group) were enrolled into the study. The mean age of patients was similar in both the groups (70 ± 7.08 years). In both groups, there were 27 males and 23 females. The baseline characteristics of subjects in the two groups are compared in [Table 1]. The usage of antidiabetic medications in both groups is listed in [Table 2]. In Group 1, the most commonly used sulfonylurea was glimepiride (24%), followed by gliclazide (14%), glipizide (4%), and glibenclamide (4%).
Table 1: Baseline characteristics Group 1 versus 2

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Table 2: Antidiabetic drugs Group 1 versus 2

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Twenty-one patients were brought to the hospital with hypoglycemia, and 29 developed hypoglycemia while in the hospital. [Table 3] lists the time of occurrence of hypoglycemia in these patients. Of the 50 patients, 26 were asymptomatic and low blood glucose was detected on routine monitoring, 5 had autonomic symptoms, 10 neuroglycopenic symptoms, and 9 had both the symptoms at the time of hypoglycemia. The duration of diabetes was significantly longer in patients who were unaware of hypoglycemia in the study group (12.2 ± 7.9 vs. 9.4 ± 6.7 years; P = 0.023). The mean HbA1c was significantly lower in the group which experienced hypoglycemia (6.73 ± 1.02 vs. 7.57 ± 1.39; P = 0.001).
Table 3: Time of occurrence of hypoglycemic episode

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Thirty-eight patients were treated with intravenous dextrose and four with oral glucose. Eight patients needed the only adjustment in dosage of medications. All of the patients recovered without any observable sequelae. [Table 4] summarizes precipitating factors in the study as well as control groups. On comparison, infection and renal failure were significantly higher in the study group. On application of multiple logistic regression analysis, only infection emerged as a significant precipitating factor.
Table 4: Comparison of precipitating factors in Group 1 versus 2

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  Discussion Top


Hypoglycemia in the elderly is an under-reported and under-recognized complication of glycemia. In the elderly, multiple factors contribute to low blood glucose levels and consequent effects on various organs.[8] The present study compares fifty elderly diabetic patients who developed hypoglycemia to a similar number who did not. Their mean age was identical, while HbA1c is lower in patients who experienced hypoglycemia (6.7% vs. 7.5%, P = 0.001). Major clinical trials, such as ACCORD, ADVANCE, VADT, and SDIS have all demonstrated up to 3-fold increase in patients on intensive glucose control.[9],[10],[11],[12] Mean HbA1c in the study group was 6.7 versus 7.5 in the control group, reiterating the influence of intensified glucose targets on precipitating low glucose levels.

In this study, the duration of diabetes was noted to be significantly higher in the study group, compared to that of the control group. In addition, autonomic symptoms were experienced in only 5 of the 50 patients who developed hypoglycemia. Twenty-six patients were asymptomatic, and nine had only neuroglycopenic symptoms. Longer duration of diabetes has been observed to be associated with asymptomatic hypoglycemic episodes in the UK Hypoglycemia Study.[13] The presence of autonomic neuropathy in such patients is a contributory factor for the absence of autonomic responses.[9],[14] In the elderly, the levels of glucose at which counter-regulatory hormones are released are lower.[15] Hypoglycemia-associated autonomic failure which was initially thought to occur in type 1 diabetics, has now been observed in type 2 also.[16]

Nocturnal hypoglycemia (occurring between 8 pm and 8 am) was observed in 24 patients. This pattern of hypoglycemia is now known to be associated with convulsions, coma, dead-in-bed syndrome, and various cognitive dysfunctions in those who recover from the condition.[4],[17],[18] This condition is usually asymptomatic and may precipitate fatal cardiac arrhythmias.[18],[19] The recovery of patients appeared to be near complete in the present study, but in-depth testing of cognitive function and neuroimaging are required for a better assessment of the sequelae. However, severe hypoglycemia is known to have long-term consequences.[19]

Polypharmacy in the elderly is now recognized as a risk factor for morbidity.[8],[20] Drug–drug interactions may result in hazardous consequences. Antihypertensive drugs, such as angiotensin-converting enzyme inhibitors may cause hypoglycemia, beta-blockers hypoglycemic unawareness, and some other antihypertensives are known to cause postural hypotension.[21] All these may work together in inducing hypoglycemia and potentiating its ill effects. In the present study, polypharmacy was higher in the study group.

The risk factors and precipitating factors of hypoglycemia in the study group concur with previous observations.[14] These include dietary factors, less physical activity, alcohol intake, medication errors, hepatic, renal and intestinal dysfunctions, hypocortisolism, hypothyroidism, and central and peripheral nervous disorders. Over-zealous administration of insulin and oral hypoglycemic agents is a major etiological factor for hypoglycemia in the elderly. In this study, though many of these factors were evident in the study group, on multivariate analysis infection emerged as a major risk factor for hypoglycemia. This needs special attention as infections in the elderly may not manifest with florid features as in a younger adult.[22]

There was no significant association between the occurrence of hypoglycemia and the use of any drug or combination of drugs. Although the use of metformin is reported to be associated with lesser incidence of hypoglycemia, multivariate analysis in the present study did not support this possibility. Small sample size may have contributed to this finding. It is also to be noted that tight glycemic control and precipitating factors may result in low blood glucose levels in the elderly irrespective of the drug regime.


  Conclusion Top


The present study reveals that hypoglycemia in the elderly is multifactorial. The longer duration of diabetes, polypharmacy, and various risk factors independently and in combination raise the risk. It should also be remembered that in a patient who has experienced symptomatic hypoglycemia, fear of hypoglycemia is a gruesome after-effect.[23] Awareness of these factors among medical professionals and caregivers is quintessential. As observed by Andrews et al., overtreatment of diabetes in the elderly is a risky business and physicians should use their discretion to decide the dosage.[24] The ADA has modified their target levels of HbA1c based on the observations made by major trials, reiterating the need to focus on the quality of life. In the present study, it was observed that the above recommendations were not adhered to in the elderly who developed low blood glucose levels (study group). In addition to focusing on this issue, polypharmacy should be regulated and infections in the elderly identified and treated appropriately.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med 1993;329:977-86.  Back to cited text no. 1
    
2.
Intensive blod-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53.  Back to cited text no. 2
    
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Brierley EJ, Broughton DL, James OF, Alberti KG. Reduced awareness of hypoglycaemia in the elderly despite an intact counter-regulatory response. QJM 1995;88:439-45.  Back to cited text no. 3
    
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Koltin D, Daneman D. Dead-in-bed syndrome – A diabetes nightmare. Pediatr Diabetes 2008;9:504-7.  Back to cited text no. 4
    
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American Diabetes Association. Executive summary: Standards of medical care in diabetes-2014. Diabetes Care 2014;37 Suppl 1:S5-13.  Back to cited text no. 5
    
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Tseng CL, Soroka O, Maney M, Aron DC, Pogach LM. Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med 2014;174:259-68.  Back to cited text no. 6
    
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Census of India – India at a Glance: Broad Age Groups. Available from:   Back to cited text no. 7
    
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Duckworth W, Abraira C, Moritz T, Reda D, Emanuele N, Reaven PD, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2009;360:129-39.  Back to cited text no. 10
    
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UK Hypoglycaemia Study Group. Risk of hypoglycaemia in types 1 and 2 diabetes: Effects of treatment modalities and their duration. Diabetologia 2007;50:1140-7.  Back to cited text no. 13
    
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Kalra S, Mukherjee JJ, Venkataraman S, Bantwal G, Shaikh S, Saboo B, et al. Hypoglycemia: The neglected complication. Indian J Endocrinol Metab 2013;17:819-34.  Back to cited text no. 14
    
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Cryer PE. Diverse causes of hypoglycemia-associated autonomic failure in diabetes. N Engl J Med 2004;350:2272-9.  Back to cited text no. 16
    
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Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP Jr., Selby JV. Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 2009;301:1565-72.  Back to cited text no. 17
    
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McAulay V, Frier BM. Hypoglycaemia. In: Sinclair AJ, Finucane P, editors. Diabetes in Old Age. 2nd ed. Chichester, U K: John Wiley and Sons; 2001. p. 133-52.  Back to cited text no. 18
    
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Frier BM, Schernthaner G, Heller SR. Hypoglycemia and cardiovascular risks. Diabetes Care 2011;34 Suppl 2:S132-7.  Back to cited text no. 19
    
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Available from: http://www.acponline.org/about_acp/chapters/ga/13-bland.pdf. [Last cited on 2011 Apr l4].  Back to cited text no. 20
    
21.
Vue MH, Pharm D, Setter SM. Drug-induced glucose alterations part 1: Drug-induced hypoglycemia. Diabetes Spectr 2011;24  Back to cited text no. 21
    
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Crossley KB, Peterson PK. Infections in the elderly. Clin Infect Dis 1996;22:209-15.  Back to cited text no. 22
    
23.
Leiter LA, Yale JF, Chiasson JL, Harris SB, Kleinstiver P, Sauriol L. Assesment of the impact of fear of hypoglycaemia episodes on glycaemic and hypoglycaemic management. Can J Diabetse2005; 29:186-92.  Back to cited text no. 23
    
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Andrews MA, O'Malley PG. Diabetes overtreatment in elderly individuals: risky business in need of better management. JAMA 2014;311:2326-7.  Back to cited text no. 24
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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