Blood sugar: How low should we go?

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It s a given that the high blood sugar levels (hyperglycemia) in diabetes can lead to severe consequences down the road neuropathy, kidney failure, blindness, and heart disease, for example but it s also the case that treating hyperglycemia can be problematic. If treating high blood sugar is too aggressive, it can cause severe low blood sugar hypoglycemia which can result in dizziness and loss of consciousness. Moreover, the level of sugar that causes such symptoms varies quite a bit from patient to patient. Now, a new study suggests that aggressive treatment of older people for hyperglycemia may confer an additional risk an increased probability of dementia.

As reported in today s JAMA Internal Medicine, Dr. Kristine Jaffe and colleagues followed 783 older adults (74 years old, on average) with diabetes for up to twelve years. Initially, all had tests to exclude those with dementia. During the follow-up period, 7.8 percent of participants had a reported hypoglycemic event, and 18.9 percent developed dementia.

The researchers determined that those who had had incidents of hypoglycemia had a significant 2-fold increased risk of developing dementia as compared to those who had not. Conversely, the individuals who developed dementia had a significant three-fold greater risk of having hypoglycemic incidents than did non-demented participants.

In an associated commentary, Drs Lipska and Montori of Yale University, note Older patients are at higher risk of hypoglycemia and impaired cognition is a risk factor for hypoglycemia, and may result in diminished ability to self-manage DM, but serious hypoglycemia may also, in turn, be associated with a risk of dementia. They suggest that perhaps the emphasis placed on reducing hyperglycemia to low levels in diabetic patients may be too great at least in older persons, and especially among those with dementia or mild cognitive impairment. The solution they suggest is a more individualistic approach, one that takes into account the patient s circumstances, goals and preferences .

ACSH s Dr. Gil Ross agrees. He adds Diabetes can be difficult to manage, but the results of this study suggest that one size does not fit all when it comes to preventing severe hyperglycemia while avoiding the consequences of hypoglycemia in the elderly. This is especially important given that we don t really know how carefully to regulate blood sugar in the elderly to prevent them from developing the consequences of diabetes, whereas we do know the harm that can be caused by too low levels of blood sugar.