Hypoglycemia Common, Rivaling CVD, in Old-Age Diabetes

Marlene Busko

December 12, 2013

A new study sheds light on the clinical course of type 2 diabetes in patients in their 60s, 70s, or 80s. Hypoglycemia has emerged as a common nonfatal complication, following cardiovascular disease. And perhaps not surprisingly, mortality increased steeply with advancing age.

These findings, from the Diabetes and Aging Study, were published online December 9 in JAMA Internal Medicine.

This is the first description of the course of diabetes in older people based on contemporary data, from the 2000s as opposed to the1990s, Elbert S. Huang, MD, from the University of Chicago, Illinois, told Medscape Medical News. Strikingly, it shows that "hypoglycemia — a side effect of diabetes treatments — has now emerged as the number 2 or number 3 major complication in older people," he said. In particular, patients in their 80s who have had diabetes for over 10 years are "a group to be very careful with when treating their diabetes," since they are at highest risk of hypoglycemia, he added.

The descriptions of the "slightly different trajectories" in the 4-year course of diabetes in older people should help guide individualized patient treatment, which has been stressed in recent guidelines, Dr. Huang noted.

Indeed, the most recent recommendations on this particular group of patients (type 2 diabetic patients aged 70 years or older) were issued just last week by the International Diabetes Federation (IDF), to coincide with the World Diabetes Congress 2013 in Melbourne, Australia. They stress that older patients with diabetes are not a homogenous group and that treatment must be tailored, taking into account functional status, including mental and physical competence. They also recognize that hypoglycemia is a "significant" issue among older-aged individuals with diabetes and stress the importance of management of medicines, with one of the targets being to reduce polypharmacy.

Younger vs Older Seniors, Recent vs Long-time Diabetes

Nearly 12 million people with diabetes in the United States are 60 years or older, and this number is expected to double in the next 20 years, due to an aging and overweight/obese population, Dr. Huang and colleagues write.

Studies of Medicare patients in the 1990s identified that older patients with diabetes commonly suffered from coronary artery disease (CAD) and stroke, but hypoglycemia was less common. But since the late 1990s, the rapid evolution of diabetes care — for example, the widespread prescribing of ACE inhibitors and statins to such patients — has meant that the clinical course of diabetes in older patients has changed,

In order to examine this, the researchers aimed to examine diabetes complications and mortality in older individuals in a contemporary cohort of 72,310 patients with type 2 diabetes who were age 60 and older in 2004 who were enrolled in the Kaiser Permanente integrated healthcare delivery system in Northern California.

The participants were divided into 3 age categories (60–69, 70–79, and 80 and older) and 2 duration-of-diabetes categories (9 years or less, 10 years or more). About half of the patients were male, about half were non-Hispanic whites, and 14.5% were age 80 and older. They were followed for 4 years.

The study outcomes were acute hyperglycemic or hypoglycemic events, microvascular complications (end-stage renal disease [ESRD], severe diabetic eye disease, peripheral arterial disease [PAD], and lower-limb amputation), CAD, stroke, congestive heart failure, and mortality.

Among older adults who had diabetes for a short time, the most common nonfatal complications were CAD, heart failure, and stroke, followed by eye disease and hypoglycemia. Among those who had had diabetes for a longer time, rates for hypoglycemia were similar to those for CAD and stroke.

For each age group, rates of complications increased dramatically with duration of diabetes. Rates of cardiovascular complications, hypoglycemia, and mortality increased steeply with advancing age, whereas rates of microvascular complications remained stable or declined.

Complications and Mortality in Older Adults With Short- vs Long-Duration Type 2 Diabetes*

Outcome Age 60 – 69 Age 70 – 69 Age > 80
Short duration Long duration Short duration Long duration Short duration Long duration
Hypoglycemia 3.03 9.62 5.03 15.88 6.22 19.60
Hyperglycemia 0.78 1.85 0.82 1.76 1.11 2.35
CAD 8.48 15.15 11.47 18.98 15.09 24.09
Stroke 5.41 8.51 9.83 14.62 17.79 18.90
Heart failure 6.83 13.83 12.64 23.86 24.24 33.10
PAD 1.68 4.02 2.41 4.90 3.08 5.67
ESRD 2.00 7.92 2.60 7.64 2.38 5.75
Amputation 1.01 3.94 1.28 4.26 1.72 3.92
Eye disease 5.82 20.26 6.16 14.97 7.99 14.89
Mortality 19.61 33.21 42.69 65.87 105.2 132.90

*Expressed as events per 1000 person-years
Short duration: <9 years
Long duration: >10 years or more
Amputation:  lower limb amputation

Based on these observations, "we need to probably move away from the single-minded focus on glucose control, because that certainly is very important for preventing some of the complications of diabetes, but it is potentially the source of hypoglycemia," Dr. Huang concluded.

JAMA Intern Med. Published online December 9, 2013. Abstract

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