Hypoglycemia in Older Adults: Special Risks and Prevention Plans

When blood sugar drops below 70 mg/dL, it’s called hypoglycemia. For most people, that means sweating, shakiness, or a racing heart-clear signals to grab a snack. But for older adults with diabetes, those warning signs often disappear. Instead, they might feel confused, dizzy, or just ‘off.’ By the time a family member notices something’s wrong, their blood sugar could already be below 40 mg/dL. This isn’t just inconvenient-it’s dangerous. In fact, older adults experience hypoglycemia more than twice as often as younger people with diabetes, and each episode raises their risk of falls, heart problems, and even death.

Why Older Adults Are at Higher Risk

The body’s ability to fight low blood sugar weakens with age. When glucose drops, healthy adults release epinephrine and glucagon to raise it back up. In older adults, this response is blunted by 30-50%. That means their bodies don’t react fast enough-or sometimes not at all. Add to that the fact that 15-25% of older adults with diabetes lose the ability to feel low blood sugar altogether, and you’ve got a silent threat.

Many older adults are also taking multiple medications. A 78-year-old with diabetes might also be on pills for high blood pressure, arthritis, heart failure, and depression. Some of those drugs, especially long-acting sulfonylureas like glyburide, can push blood sugar too low. Studies show glyburide increases severe hypoglycemia risk by 50% compared to safer alternatives like glipizide. The American Geriatrics Society lists glyburide as a potentially inappropriate medication for older adults-yet it’s still prescribed often.

Kidney and liver function also decline with age. Since many diabetes drugs are cleared by the kidneys, reduced function means those drugs stay in the body longer, increasing the chance of a low. People with an estimated glomerular filtration rate (eGFR) below 60 mL/min have a 2.7 times higher risk of severe hypoglycemia than those with normal kidney function.

What Hypoglycemia Looks Like in Older Adults

Forget the textbook symptoms. Older adults rarely sweat or shake when their blood sugar drops. Instead, hypoglycemia often shows up as:

• Sudden confusion or disorientation
• Slurred speech or difficulty finding words
• Unusual irritability or aggression
• Weakness, dizziness, or stumbling
• Loss of consciousness or seizures

These symptoms are easily mistaken for dementia, stroke, or just getting older. That’s why up to 60% of low blood sugar episodes in older adults go unnoticed-or unreported. A caregiver might think their loved one is being difficult when they refuse to eat, when in reality, their brain isn’t getting enough glucose to make decisions.

The Real Costs: Falls, Fractures, and Death

A single hypoglycemic episode in an older adult isn’t just a scare-it’s a medical event with lasting consequences. Each episode increases the risk of:

• 40% higher chance of falling
• 25% higher chance of breaking a hip
• 30% higher chance of having a heart attack or stroke

A five-year study of 782 older adults with diabetes found those who had a severe low were 2.5 times more likely to die during that time. Even after adjusting for other health problems, the risk stayed 40% higher. And it’s not just about dying-it’s about losing independence. Recurrent hypoglycemia doubles the risk of developing new cognitive decline within two years. Once memory and judgment start slipping, managing diabetes gets harder, which leads to more lows-and the cycle continues.

Medication Risks: What to Watch For

Not all diabetes drugs are equal when it comes to hypoglycemia risk. Here’s what you need to know:

• Sulfonylureas (glyburide, glimepiride): These force the pancreas to release more insulin, regardless of blood sugar levels. Glyburide is especially risky because it lasts too long in older bodies. Glipizide is a safer choice.
• Insulin: Long-acting insulins like glargine or detemir are better than older types, but dosing errors still happen. Many older adults take insulin without checking blood sugar regularly, leading to lows.
• GLP-1 agonists and SGLT2 inhibitors: These newer drugs rarely cause low blood sugar on their own and are often safer for older adults. They’re also weight-neutral or help with weight loss.
• Metformin: This is generally safe and doesn’t cause hypoglycemia unless taken with insulin or sulfonylureas.

The key is to review all medications every 6-12 months. Ask: Is this drug still necessary? Could it be switched to something safer? Can the dose be lowered?

Prevention Plan: What Actually Works

There’s no single fix, but a structured, personalized plan cuts hypoglycemia risk by nearly half. Here’s what works:

1. Set realistic blood sugar goals. For healthy older adults, aim for an A1c under 7%. For those with dementia, heart disease, or limited life expectancy, aim for 7.5-8.5%. Tight control isn’t worth the risk.
2. Use continuous glucose monitoring (CGM). CGM devices like Dexcom G7 or FreeStyle Libre 3 alert users when blood sugar is dropping-even before they feel symptoms. But only 15% of older adults use them, mostly because doctors don’t recommend them or Medicare won’t cover them unless the person uses insulin.
3. Teach caregivers how to respond. If someone can’t swallow, juice won’t help. Keep glucagon on hand. The new nasal glucagon (Baqsimi) is easy to use-just spray it in the nose. It works in seconds and doesn’t require an injection.
4. Check blood sugar before driving, meals, and bedtime. Skipping meals or walking after insulin can cause lows. Always test if you feel off.
5. Reduce or eliminate high-risk drugs. Studies show that reducing insulin or switching from glyburide to glipizide cuts severe lows by 46% in just six months-with almost no change in A1c.

One real case: A 79-year-old woman with dementia was on 40 units of insulin daily and had weekly lows. Her doctor cut her insulin in half and switched her to glipizide. Her A1c stayed at 7.8%. No more lows. No more hospital trips.

What Families Can Do Right Now

You don’t need to be a doctor to help. Here’s what you can do today:

• Keep fast-acting sugar (glucose tablets, juice boxes) in every room, the car, and your bag.
• Teach everyone in the house how to use nasal glucagon.
• Write down symptoms your loved one shows during lows-then share that list with their doctor.
• Ask: ‘Has anyone checked if my loved one is on glyburide?’ If yes, ask if it can be changed.
• Use the TRIM-HYPO survey (available online) to show how often lows are happening and how they affect daily life. This helps doctors take it seriously.

What’s Changing in 2026

The field is shifting fast. The American Diabetes Association now says ‘time in range’-how long blood sugar stays between 70 and 180 mg/dL-is more important than A1c for older adults. They recommend spending at least half the day (12 hours) in that range, and less than 1% of the time below 54 mg/dL.

Medicare is slowly expanding CGM coverage, but many older adults on sulfonylureas still can’t get it. New dual-hormone artificial pancreas systems (insulin + glucagon) are in clinical trials and may be available by 2026. But the biggest change isn’t technology-it’s mindset. Doctors are finally learning that for older adults, avoiding a low is more important than hitting a perfect A1c number.

Final Thought: Safety Over Perfection

The goal isn’t to keep blood sugar perfectly normal. It’s to keep the person safe, independent, and out of the hospital. For older adults, that means fewer pills, simpler routines, and more awareness-not tighter control. A blood sugar of 150 mg/dL is far less dangerous than a low of 40 mg/dL. And if you’re caring for someone with diabetes, remember: a low blood sugar episode isn’t just a medical event-it’s a warning sign that the treatment plan needs to change.