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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 56-58

Risk factors of hypoglycaemia in elderly diabetic patients: A case–Control study from a Tertiary Hospital


Department of Family Medicine, VPS Lakeshore Hospital, Kochi, Kerala, India

Date of Web Publication10-May-2018

Correspondence Address:
Dr. Muhammed Jasim Abdul Jalal
Department of Family Medicine, VPS Lakeshore Hospital, Nettoor P.O, Maradu, NH 47-Byepass, Kochi - 682 040, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_36_17

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  Abstract 


Background: Hypoglycaemia is a side effect of strict diabetes control, especially in the geriatric population above sixty, who constitute approximately 100 million of the Indian population. This study was undertaken to explore the risk factors of hypoglycaemia in elderly inpatients. Materials and Methods: Fifty patients who were found to have hypoglycaemia 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 hypoglycaemia. Results: The duration of diabetes was significantly longer (13.4 ± 9.2 vs. 8.1 ± 5.7 years; P = 0.012) in the group which experienced hypoglycaemia. The mean glycated haemoglobin was significantly lower in the group which experienced hypoglycaemia (6.33 ± 1.12 vs. 7.61 ± 1.17; P = 0.002). Of the 50 patients who developed hypoglycaemia 28 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 strict blood glucose control, elderly patients are at high risk of hypoglycaemia. The risk is higher if the patients have renal failure and infection. Diabetic therapy in elderly people should be adjusted in such a way to prevent hypoglycaemia.

Keywords: Geriatrics, hypoglycaemia, old age, type 2 diabetes mellitus


How to cite this article:
Jalal MJ, Basheer S, Nisha NK, Shobha P. Risk factors of hypoglycaemia in elderly diabetic patients: A case–Control study from a Tertiary Hospital. J Diabetol 2018;9:56-8

How to cite this URL:
Jalal MJ, Basheer S, Nisha NK, Shobha P. Risk factors of hypoglycaemia in elderly diabetic patients: A case–Control study from a Tertiary Hospital. J Diabetol [serial online] 2018 [cited 2018 Jul 20];9:56-8. Available from: http://www.journalofdiabetology.org/text.asp?2018/9/2/56/232227




  Introduction Top


Hypoglycaemia is a serious adverse effect of strict diabetes control. Elderly patients have reduced physiological responses to hypoglycaemia due to several precipitating factors. Hypoglycaemia can even cause nocturnal death apart from its disastrous effect on brain and heart.[1] Even though, there are guidelines to keep glycated haemoglobin (HbA1c) levels at a flexible range in elderly diabetics; hypoglycaemia still remains the major complication.[2] The aim of our study was to analyse various risk factors predisposing geriatric population with diabetes mellitus to hypoglycaemia, in comparison with age- and sex-matched controls who did not experience hypoglycaemia.


  Materials and Methods Top


A case–control study was conducted at the VPS Lakeshore Hospital, Kochi, India. Fifty patients who experienced hypoglycaemia was enrolled as the study group, and fifty age- and sex-matched patients formed the control group. Patients of age ≥60 years, known to have diabetes mellitus and those with a blood sugar level of ≤70 mg/dL were included as cases in the study. These patients were admitted to the hospital with hypoglycaemia or developed hypoglycaemia while in the hospital. Age- and sex-matched diabetic patients of age ≥60 years, admitted during the same period were included as controls. A valid informed consent was obtained from all the cases and controls before the study. Study pro forma included details of age, demographics, duration of diabetes mellitus, details of treatment of diabetes at the time of hypoglycaemia, details of the hypoglycaemic episode (symptoms, severity, glucose level, identified risk factors, treatment and outcome), comorbidities, polypharmacy and alcohol use.

Blood glucose, HbA1c, serum creatinine and liver function tests were performed at the NABH-accredited biochemistry laboratory of the hospital. All emergency blood glucose readings were done using standardised glucometers in the respective medical wards.

All statistical analyses were conducted using SPSS statistical software package (Version 16, Unicom Systems), IBM Corporation International Business Machines Corporation, (Armonk, New York, United States). Unpaired two-tailed t-tests were used for the comparison of means of study and control groups. Chi-square test was used to compare the frequency of events between the groups. Further, univariate and multivariate logistic regression was utilised to determine the clinical predictors of hypoglycaemia.


  Results Top


Fifty patients with documented hypoglycaemia (study group) and fifty age- and sex-matched inpatients who did not develop hypoglycaemia (control group) were studied. There were 22 males and 28 females in both the groups with a mean age of 68 ± 5.02 years. The diabetic history and details regarding the medications among the 2 groups were compared [Table 1]. Antidiabetic medications in both groups were extensively studied [Table 2]. In the study group, the most commonly used sulfonylurea was glimepiride (29%), followed by gliclazide (17%), glipizide (3%) and glibenclamide (2%). Twenty-eight patients were brought to the hospital with hypoglycaemia, and twenty-two developed hypoglycaemia while in the hospital. Hypoglycaemic episodes and its time of occurrence were compared [Table 3]. Of the 50 patients, 20 (40%) were asymptomatic and low blood glucose was detected on routine monitoring, 10 (20%) had autonomic symptoms, 8 (16%) neurological symptoms, and 9 (18%) had both the symptoms at the time of hypoglycaemia.
Table 1: The diabetic history and medications

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Table 2: Antidiabetic drugs

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Table 3: Time of occurrence of hypoglycaemic episode

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Forty patients (80%) were treated with intravenous dextrose and six (12%) with oral glucose. Four patients (8%) needed the only adjustment in dosage of medications. All of the patients recovered without any observable sequelae. Precipitating factors of hypoglycaemia were also studied [Table 4]. Infection and renal failure were statistically significant precipitating factors. Multiple logistic regression analysis showed infection as more significant precipitating factor.
Table 4: Comparison of precipitating of hypoglycaemia

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  Discussion Top


Hypoglycaemia in the elderly is rather underrecognised. Our aim was to focus on 50 elderly diabetic patients who developed hypoglycaemia and compare them with their control. Their mean age was identical. Mean HbA1c was lower in patients who experienced hypoglycaemia (6.33% in the study group versus 7.61% in the control group, P = 0.002) and correlates with the major clinical trials, such as ACCORD, ADVANCE, VADT and SDIS, where they have demonstrated up to 3-fold increase in patients on intensive glucose control.[3],[4],[5],[6]

In our study, duration of diabetes was noted to be significantly higher in the study group, compared to that of the control group. Association between asymptomatic hypoglycaemic episodes and duration of diabetes has been observed in the UK Hypoglycaemia Study.[7] Autonomic symptoms were experienced in only 10 of the 50 patients (20%) who developed hypoglycaemia. Twenty patients (40%) were asymptomatic. Eight (16%) had only neurological symptoms. Hypoglycaemia-associated autonomic failure occurs in type 1 as well as type 2 diabetes mellitus.[8]

Nocturnal hypoglycaemia (occurring between 8 pm and 8 am) was observed in 16 patients (32%). This is often associated with hypoglycaemic seizures, coma, and various cognitive dysfunctions even after recovery.[9] Our patients did not have seizures and coma sequelae. They showed a near complete recovery. Cognitive function tests and neuroimaging are required for a better assessment of the sequelae.

Drug interactions often result in hazardous consequences, and in this study, polypharmacy was higher in the study group. Antihypertensive drugs, such as angiotensin-converting enzyme inhibitors may cause hypoglycaemia. Beta-blockers cause hypoglycaemic unawareness.

In our study, infection emerged as a major risk factor for hypoglycaemia. This is important as infections in the elderly may not manifest with florid features as in a younger adult. Hence, tight glycaemic control and precipitating factors may result in low blood glucose levels in the geriatric population irrespective of the drug regime. Urinary tract infections were common in our study group. They were treated with antibiotics based on urine culture and sensitivity reports.  Escherichia More Details coli was the most common organism involved. Nitrofurantoin and piperacillin-tazobactam were the antibiotics used for the management of urinary tract infections. Renal functions were normal in these patients with urinary tract infections. Insulin therapy was initiated in all patients with urinary tract infections.


  Conclusion Top


Hypoglycaemia in the elderly is multifactorial. Awareness of the risk factors of hypoglycaemia in the geriatric population among medical professionals and caregivers is the cornerstone in the management of diabetes in elderly. Overtreatment of diabetes is a major risk factor of hypoglycaemia in the elderly. Hence, physicians should decide the dosage of antidiabetics judiciously.

HbA1c target levels in the geriatric population should be set as modified by the American Diabetes Association, based on the patient compliance without compromising the quality of life. In our study, it was observed that the above recommendations were not followed in the elderly who developed low blood glucose levels (study group). Regulations are needed as far as polypharmacy is considered. Early anticipation and prompt treatment of infections can prevent hypoglycaemia in elderly diabetics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Koltin D, Daneman D. Dead-in-bed syndrome – A diabetes nightmare. Pediatr Diabetes 2008;9:504-7.  Back to cited text no. 1
    
2.
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. 2
    
3.
Advance Collaborative Group, Patel A, MacMahon S, Chalmers J, Neal B, Billot L, et al. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72.  Back to cited text no. 3
    
4.
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. 4
    
5.
Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, Byington RP, Goff DC Jr., Bigger JT, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-59.  Back to cited text no. 5
    
6.
Reichard P, Britz A, Carlsson P, Cars I, Lindblad L, Nilsson BY, et al. Metabolic control and complications over 3 years in patients with insulin dependent diabetes (IDDM): The Stockholm diabetes intervention study (SDIS). J Intern Med 1990;228:511-7.  Back to cited text no. 6
    
7.
Heller SR, Choudhary P, Davies C, Emery C, Campbell MJ, Freeman J, et al. Risk of hypoglycaemia in types 1 and 2 diabetes: effects of treatment modalities and their duration. Diabetologia. 2007;50:1140-7. [Epub 2007 Apr 6].  Back to cited text no. 7
    
8.
Cryer PE. Diverse causes of hypoglycemia-associated autonomic failure in diabetes. N Engl J Med 2004;350:2272-9.  Back to cited text no. 8
    
9.
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. 9
    



 
 
    Tables

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



 

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