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Aging and disease    2015, Vol. 6 Issue (2) : 156-167     DOI: 10.14336/AD.2014.0330
Review Article |
Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty
Abdelhafiz Ahmed H1, Rodríguez-Mañas Leocadio2, Morley John E.3, Sinclair Alan J4,*()
1Department of Elderly Medicine, Rotherham General Hospital, England, Moorgate Road, Rotherham, UK
2Hospital Universitario de Getafe, Department of Geriatrics and School of Health Sciences, Universidad Europea de Madrid, Spain
3Divisions of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, USA
4Institute of Diabetes for Older People (IDOP), University of Bedfordshire, Luton LU2 8LE, UK
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Abstract  

Recurrent hypoglycemia is common in older people with diabetes and is likely to be less recognized and under reported by patients and health care professionals. Hypoglycemia in this age group is associated with significant morbidities leading to both physical and cognitive dysfunction. Repeated hospital admissions due to frequent hypoglycemia are also associated with further deterioration in patients’ general health. This negative impact of hypoglycemia is likely to eventually lead to frailty, disability and poor outcomes. It appears that the relationship between hypoglycemia and frailty is bidirectional and mediated through a series of influences including under nutrition. Therefore, attention should be paid to the management of under nutrition in the general elderly population by improving energy intake and maintaining muscle mass. Increasing physical activity and having a more conservative approach to glycemic targets in frail older people with diabetes may be worthwhile.

Keywords hypoglycemia      frailty      old age     
Corresponding Authors: Sinclair Alan J     E-mail: sinclair.5@btinternet.com
About author:

present address: Kunming Biomed International, Kunming, Yunnan, 650500, China

Issue Date: 25 March 2015
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Abdelhafiz Ahmed H
Rodríguez-Mañas Leocadio
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Sinclair Alan J
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Abdelhafiz Ahmed H,Rodríguez-Mañas Leocadio,Morley John E., et al. Hypoglycemia in Older People - A Less Well Recognized Risk Factor for Frailty[J]. Aging and disease, 2015, 6(2): 156-167.
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http://www.aginganddisease.org/EN/10.14336/AD.2014.0330     OR     http://www.aginganddisease.org/EN/Y2015/V6/I2/156
1) Symptomatic hypoglycemia:Hypoglycemic episode needing assistance of a third party.
2) Documented symptomatic hypoglycemia:Symptomatic hypoglycemia and plasma glucose level ≤3.9 mmol/l.
3) Probable symptomatic hypoglycemia:Symptomatic hypoglycemia but not documented a plasma glucose level.
4) Asymptomatic hypoglycemia:No symptoms of hypoglycemia but documented plasma glucose level ≤3.9 mmol/l.
5) Relative hypoglycemia:Symptomatic hypoglycemia but plasma glucose level is >3.9 mmol/l.*
Table 1  The Workgroup classification of hypoglycemic events [2].
• Symptoms are non-specific.
• Easily misdiagnosed, e. g. stroke, vertigo or visual disturbance.
• Misinterpreted as dementia-related symptoms e.g agitation or behavior change.
• Atypical presentation e.g. confusion or passive delirium.
• Little warning or unawareness of autonomic symptoms.
• Patients with dementia are unable to communicate their feelings or symptoms.
Table 2  Difficulties in recognizing hypoglycemia in older people.
• General physical function decline.
• Reduced ability in performing activities of daily living.
• Complete dependence.
• Frequent falls.
• Increased risk of fractures including hip fracture.
• Frequent hospitalisations.
• Increased risk of vascular disease.
• Impaired cognitive function.
• Increased risk of dementia.
• Increased fear and anxiety.
• Increased social isolation.
• Behavioural changes.
• Increased panic attacks.
• Increased risk of frailty.
• Increased risk of disability.
• Increased risk of mortality.
Table 3  Chronic consequences of hypoglycemia in older people.
Figure 1.  Dead in the Bed Syndrome and Hypoglycemia
F: Are you Fatigued?
R: Resistance: Can you walk up a flight of stairs?
A: Ambulation: Can you walk a block?
I: Do you have more than 5 Illnesses?
L: Have you Lost 5% of weight in the last 6 months?
Table 4  Phenotypic criteria for diagnosis of frailty - The FRAIL Scale* [47]
Figure 2.  Hypoglycemia and Frailty - Risk Factors, Complications and Consequences.
• Old age
• Malnutrition
• Multiple
comorbidities •
Acute illness •
Insulin or sulfonylurea therapy
• History of hypoglycaemia
• Care home residency
• Recent hospitalisation
• Hypoglycaemia unawareness
• Blunted counter regulatory responses
• Chronic hepatic or renal dysfunction
• Stroke or transient ischaemic attack
• Multiple medications (≥5)
• Dementia •
Depression •
Heart failure •
Social isolation
Table 5  Risk factors for hypoglycemia. [15, 74]
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