Wednesday, December 12, 2012

Does age effect a person awareness of hypoglycemia?


Take home message from the November 18 post 
    Epinephrine produces the early warning symptoms of a dropping blood sugar. The loss of the
    epinephrine response to a falling glucose results in " hypoglycemia unawareness " and the 
    progression to the more severe stages of hypoglycemia. I have attached the Nov.18 post below

   for your review of some of the physiology associated with hypoglycemia.

      Does age effect a persons awareness of low blood sugars ?

   The answer is probably yes according to a few articles in Diabetes care*. 
     Zammitt NN, Frier BM . Diabetes Care. 2005; 28(12) 2948-2961
      Matyka NN et al. Diabetes care. 1997;20(2) : 135-141
    The studies were done  comparing non diabetic men age  23 +-3 years to "more mature " men  65 
     +- 3  years old.
      They compared the time lapse from the onset of  early warning symptoms of  sweating ,shaking  ,anxiety  to the development of of neurological symptoms , confusion, dizzy, headache  weakness , irritability ,belligerent behavior and sleepiness.

                                     Early warning symptoms begin                   Neurological symptoms begin
                                      with Glucose levels                                       with glucose levels

  men 23 +- 3 years          65mg/dl ( 3.6 mm/l )                                       47 mg/dl ( 2.6mm/l )

  men  65 +-3 years           55 mg/dl ( 3.1 mm/l )                                     50 mg/dl ( 2.8 mm/l )    

It appears that the reaction time available between the onset of early warning symptoms ( Glucose 55mg/dl ) and the onset of neurologic symptoms ( 50 mg/dl ) decreases with advancing age in non diabetic men. ( it is probable the same for men and women with diabetes)
This loss of early warning symptoms can also occur within a few years of developing insulin dependent diabetes regardless of age.
Take home message
 Older people have , in addition to the decreased awareness of developing hypoglycemia ,  less time to take corrective  measures to treat developing hypoglycemia.  
This development  can have a major impact on a older persons independence , leading to  a change in their living situation and  loss of their drivers license. 

Short Term vs Long Term Risk
  The risk associated with hypoglycemia is immediate , Short Term . Avoiding the risk of hypoglycemia is a major factor in setting A1c target goals .

It is good to remember that one benefit of getting older is that long term gets shorter , allowing the slight risk associated with of an A1c between  7 to 8 range to become less important .   

Have Fun , Be Smart  and remember getting a little older does have a few benefits
David Calder , MD                   

Question , Is there an increase in mortality associated with severe hypoglycemia ? 
The answer tomorrow. 

My tomorrows have become a little spread out  over the  last two months because of time constraints of work , buying  and remodeling a new home while preparing our current home for sale .

 For your review
NOV. 21 post
 Does lowering A1c result in increased hypoglycemi...


November 18 ,2012

                    A few definitions and a little physiology about low blood sugars

Diabetes and the Devil of low blood sugars

I have always felt that people with diabetes have to work a little harder each day to preserve their good health while being forced to walk a narrow path between 2 devils .  The Devils of high and the Devils of low blood sugars .The devil of high high glucose comes with known long term risk and the devil of low glucose levels , on the other side of the path , comes with immediate often severe consequences. This is the beginning of a 4 part discussion of hypoglycemia. Today, I will lay the ground work with a few definitions and  a little physiology .

 The American Diabetes Association's discussion of hypoglycemia. Position statement 2012
"Hypoglycemia is the leading limiting factor in the glycemic management of type 1 and type 2 diabetes.

Mild hypoglycemia - plasma glucose below 70 mg/dl

Severe hypoglycemia -
  ( where the individual requires the assistance of another person and cannot be treated with oral
    carbohydrate due to confusion or unconsciousness) should be treated using emergency glucagon kits)
Hypoglycemia unawareness
  (In type 1 diabetes and severely insulin deficient type 2 )
  These people of lost their awareness of the early warning signals of hypoglycemia

Joslin's Diabetes Mellitus thirteenth edition has a good chart on page 495 . It matches our bodies response and symptoms to decreasing blood glucose levels. I have adjusted the medical terminology slightly to meet the needs of this discussion.

 Counter regulatory hormones .
 These are hormones our body releases in an attempt to correct a falling  blood glucose  level.  Some of these hormones produce the early warning symptoms that we associate with hypoglycemia.

    Glucose level               Increase counter regulatory hormone         Effects and symptoms 
      < 70 mg/dl                         increase glucagon                                   increase in glucose from liver
      < 70  mg/d/                        increase Epinephrine                               increase glucose, feeling of 
                                                                                                                anxiety, sweating , shaking,
     < 65 mg/dl                          increase cortisol and growth hormone     increase glucose levels

     < 60 mg/dl                                                                                           neurological symptoms
                                                                                                                     confusion, dizzy
                                                                                                                     irritability , sleepy
                                                                                                                     belligerent behavior
      < 40                                                                                                        lethargy , Coma

Take home message
    Epinephrine produces the early warning symptoms of a dropping blood sugar. The loss of the
    epinephrine response to a falling glucose results in " hypoglycemia unawareness " and the 
    progression to the more severe stages of hypoglycemia.

Have Fun , Be Smart and avoid hypoglycemia
David Calder,MD

     Does lowering A1c result in increased risk of hypoglycemia in type 1 and type 2 diabetes ?
     Does age effect a persons awareness of hypoglycemia

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Your comments and questions are appreciated. David Calder,MD