番茄社区

BERLIN -- Hypoglycemia in older people with comorbid diabetes and dementia was tied to higher risk of mortality, researchers reported here.

In a retrospective cohort study led by Katharina Mattishent, MBBS, of the University of East Anglia in the U.K., hypoglycemia was associated with a 66% higher rate of mortality in patients age 65 and older with diabetes and comorbid dementia compared with those who did not have hypoglycemia (adjusted HR 1.66, 95% CI 1.51-1.81).

More interestingly, however, when a patient with diabetes with at least one episode of hypoglycemia also had comorbid dementia, the risk of all-cause mortality was 67% higher than in patients with just diabetes and hypoglycemia (aHR 1.67, 95% CI 1.54-1.80), the researchers reported at the annual meeting of the European Association for the Study of Diabetes (EASD).

Although prior studies have already identified that older patients with diabetes with hypoglycemia are at higher risk for adverse events, including mortality, these new findings underscore the detrimental effects that comorbid dementia adds to this equation, Mattishent told 番茄社区.

"Co-existing dementia can be a marker of increasing frailty, so it is not surprising that there is an increased risk of mortality in this vulnerable group." She said that clinicians should have suspected this association, although the extent of the related risk may be somewhat surprising.

"However, the true extent of harm from hypoglycemia has never been studied in such a large population. We believe the serious consequences of hypoglycemia may have been underestimated, and our findings will prove to be an eye-opener."

Drawing upon the United Kingdom Clinical Practice Research Datalink database, the researchers assessed data on nearly 20,000 patients with new or existing diabetes -- defined as filling a prescription for a glucose-lowering drug. Using health records spanning 10 years, the team classified patients into the following three groups:

• Group 1: Those with dementia and diabetes, but without hypoglycemia
• Group 2: Those with dementia and diabetes and with at least one episode of hypoglycemia
• Group 3: Those with diabetes and hypoglycemia, but without a diagnosis of dementia

Although the clinical characteristics of all three groups were generally similar, those with dementia, diabetes, and hypoglycemia reported a higher use of insulin.

During this follow-up period, 82% of those with dementia, diabetes, and hypoglycemia died, compared with 63% of those without hypoglycemia (group 1) and 53% of those without dementia (group 3).

"The results of our study highlight the importance of management strategies tailored towards avoidance of hypoglycemic episodes rather than just chasing tight glycemic targets in this vulnerable group. We suggest that a two-pronged approach of de-intensification of management regimes and intensification of monitoring should be considered as a means to reduce hypoglycemia," Mattishent said.

This recommendation is reflected in the American Diabetes Association's current clinical practice guidelines advising more lax upper glucose limits for older adults -- particularly that among those with diabetes and poorer cognitive status, a target HbA1c goal of 8%-8.5% is recommended in order to avoid hypoglycemia. Additionally, the guidelines also recommend that screening for early detection of mild cognitive impairment and dementia should begin at age 65 for patients with diabetes.

Better monitoring is key for this population, and healthcare providers should consider use of a continuous glucose monitor to help identify hypoglycemia, Mattishent said.

"We recognize that this would necessitate a major change in the current approach to using continuous glucose monitoring. In this particular patient group it could be considered for intermittent use, especially when a new medication is introduced that carries a high risk of hypoglycemia, or when the dose of an existing medication is increased."

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