Acta Diabetologica

, Volume 52, Issue 4, pp 677–685 | Cite as

The social burden of hypoglycemia in the elderly

  • Antonio Nicolucci
  • Basilio Pintaudi
  • Maria Chiara Rossi
  • Roberto Messina
  • Francesco Dotta
  • Simona Frontoni
  • Salvatore Caputo
  • Renato Lauro
Original Article



The study aimed to evaluate the frequency of episodes of symptomatic hypoglycemia (SH) in elderly patients with type 2 diabetes and their impact on quality of life.


The study was conducted in 12 Italian regions. Participants filled in a questionnaire collecting data on socio-demographic and clinical characteristics and episodes of SH occurred in the last 4 weeks. The questionnaire included validated scales measuring fear of hypoglycemia (FHQ), psychological well-being (WHO-5), and diabetes-related distress (PAID-5).


Overall, 1,323 participants were involved (mean age 70.0 ± 8.7, 47.6 % male, disease duration 15.6 ± 11.7, 63.2 % treated with oral agents, 16.9 % with insulin alone, 14.4 % with insulin plus oral agents), of whom 44.6 % reported 1–3 episodes of SH and 23.8 % reported more than 3 episodes. Patients who reported SH had significantly higher levels of fear of hypoglycemia, lower psychological well-being, and higher diabetes-related distress (p < 0.0001 for all the scales). At multivariate analysis, the experience of more than 3 episodes of hypoglycemia was associated with a 13-fold higher risk of high fear of hypoglycemia (aOR = 13.3; CI 95 % 8.4–21.0), an almost 60-fold higher risk of high diabetes-related distress (PAID-5 score ≥40) (aOR = 59.1; CI 95 % 29.2–119.8), and a higher risk of low psychological well-being (WHO-5 <50) (aOR = 1.5; CI 95 % 0.9–2.4).


The occurrence of symptoms of hypoglycemia is very common among older adults with diabetes and their presence is associated with an extremely negative impact on quality of life. Minimizing the risk of hypoglycemia represents a high priority in the diabetes treatment of elderly people.


Hypoglycemia Elderly Quality of life Distress Fear of hypoglycemia 


Conflict of interest

The authors declare they have no conflict of interest.

Ethical standard

The study was reviewed by appropriate ethics committee and performed in accordance with the ethical standards laid down in an appropriate version of the 1964 Declaration of Helsinki.

Human and animal rights

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2008.

Informed consent

Informed consent was obtained from all patients for being included in the study.


  1. 1.
    Kahn SE, Cooper ME, Del Prato S (2014) Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. Lancet 383(9922):1068–1083. doi: 10.1016/S0140-6736(13)62154-6 PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Gill TM, Gahbauer EA, Han L, Allore HG (2010) Trajectories of disability in the last year of life. N Engl J Med 362(13):1173–1180. doi: 10.1056/NEJMoa0909087 PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Stahn A, Pistrosch F, Ganz X, Teige M, Koehler C, Bornstein S, Hanefeld M (2014) Relationship between hypoglycemic episodes and ventricular arrhythmias in patients with type 2 diabetes and cardiovascular diseases: silent hypoglycemias and silent arrhythmias. Diabetes Care 37(2):516–520. doi: 10.2337/dc13-0600 PubMedCrossRefGoogle Scholar
  4. 4.
    Nordin C (2014) The proarrhythmic effect of hypoglycemia: evidence for increased risk from ischemia and bradycardia. Acta Diabetol 51(1):5–14. doi: 10.1007/s00592-013-0528-0 PubMedCrossRefGoogle Scholar
  5. 5.
    Malabu UH, Vangaveti VN, Kennedy RL (2014) Disease burden evaluation of fall-related events in the elderly due to hypoglycemia and other diabetic complications: a clinical review. Clin Epidemiol 14(6):287–294. doi: 10.2147/CLEP.S66821 CrossRefGoogle Scholar
  6. 6.
    Whitmer RA, Karter AJ, Yaffe K, Quesenberry CP Jr, Selby JV (2009) Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus. JAMA 301(15):1565–1572PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Pilotto A, Noale M, Maggi S, Addante F, Tiengo A, Perin PC, Rengo G, Crepaldi G (2014) Hypoglycemia is independently associated with multidimensional impairment in elderly diabetic patients. Biomed Res Int. doi: 10.1155/2014/906103 Google Scholar
  8. 8.
    Kong AP, Yang X, Luk A, Ma RC, So WY, Ozaki R, Ting R, Cheung K, Ho CS, Chan MH, Chow CC, Chan JC (2014) Severe hypoglycemia identifies vulnerable patients with type 2 diabetes at risk for premature death and all-site cancer: the Hong Kong diabetes registry. Diabetes Care 37(4):1024–1031. doi: 10.2337/dc13-2507 PubMedCrossRefGoogle Scholar
  9. 9.
    Bonds DE, Miller ME, Bergenstal RM, Buse JB, Byington RP, Cutler JA, Dudl RJ, Ismail-Beigi F, Kimel AR, Hoogwerf B, Horowitz KR, Savage PJ, Seaquist ER, Simmons DL, Sivitz WI, Speril-Hillen JM, Sweeney ME (2010) The association between symptomatic, severe hypoglycaemia and mortality in type 2 diabetes: retrospective epidemiological analysis of the ACCORD study. BMJ 8(340):b4909. doi: 10.1136/bmj.b4909 CrossRefGoogle Scholar
  10. 10.
    Tsujimoto T, Yamamoto-Honda R, Kajio H, Kishimoto M, Noto H, Hachiya R, Kimura A, Kakei M, Noda M (2014) Prediction of 90-day mortality in patients without diabetes by severe hypoglycemia: blood glucose level as a novel marker of severity of underlying disease. Acta Diabetol [Epub ahead of print]Google Scholar
  11. 11.
    Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL (2006) National surveillance of emergency department visits for outpatient adverse drug events. JAMA 296(15):1858–1866PubMedCrossRefGoogle Scholar
  12. 12.
    Lundkvist J, Berne C, Bolinder B, Jonsson L (2005) The economic and quality of life impact of hypoglycemia. Eur J Health Econ 6(3):197–202PubMedCrossRefGoogle Scholar
  13. 13.
    Barendse S, Singh H, Frier BM, Speight J (2012) The impact of hypoglycaemia on quality of life and related patient-reported outcomes in type 2 diabetes: a narrative review. Diabet Med 29(3):293–302PubMedCrossRefGoogle Scholar
  14. 14.
    Cryer PE (2002) Hypoglycaemia: the limiting factor in the glycaemic management of Type 1 and Type 2 diabetes. Diabetologia 45:937. doi: 10.1111/j.1464-5491.2011.03416.x PubMedCrossRefGoogle Scholar
  15. 15.
    Speight J, Reaney MD, Barnard KD (2009) Not all roads lead to Rome-a review of quality of life measurement in adults with diabetes. Diabet Med 26(4):315–327. doi: 10.1111/j.1464-5491.2009.02682.x PubMedCrossRefGoogle Scholar
  16. 16.
    Depablos-Velasco P, Salguero-Chaves E, Mata-Poyo J, Derivas-Otero B, García-Sánchez R, Viguera-Ester P (2014) Quality of life and satisfaction with treatment in subjects with type 2 diabetes: results in Spain of the PANORAMA study. Endocrinol Nutr 61(1):18–26. doi: 10.1016/j.endonu.2013.05.005 PubMedCrossRefGoogle Scholar
  17. 17.
    Bech P, Gudex C, Johansen KS (1996) The WHO (ten) well-being index: validation in diabetes. Psychother Psychosom 65:183–190PubMedCrossRefGoogle Scholar
  18. 18.
    Hajos TR, Pouwer F, Skovlund SE, Den Oudsten BL, Geelhoed-Duijvestijn PH, Tack CJ et al (2013) Psychometric and screening properties of the WHO-5 well-being index in adult outpatients with Type 1 or Type 2 diabetes mellitus. Diabet Med 30:e63–e69. doi: 10.1111/dme.12040 PubMedCrossRefGoogle Scholar
  19. 19.
    Report Conference (2004) 2nd International DAWN Summit: a call-to-action to improve psychosocial care for people with diabetes. Pract Diabetes Int 21:201–208CrossRefGoogle Scholar
  20. 20.
    Peyrot M, Rubin RR, Lauritzen T, Snoek FJ, Matthews DR, Skovlund SE (2005) Psychosocial problems and barriers to improved diabetes management: results of the cross-national diabetes attitudes, wishes and needs (DAWN) study. Diabet Med 22:1379–1385PubMedCrossRefGoogle Scholar
  21. 21.
    Skovlund SE, Peyrot M (2005) The diabetes attitudes, wishes, and needs (DAWN) program: a new approach to improving outcomes in diabetes care. Diabetes Spectr 18:136–142. doi: 10.3109/13814788.2012.704360 CrossRefGoogle Scholar
  22. 22.
    International Diabetes Federation (2004) Putting people at the centre of care: DAWN in action. Diabetes Voice 49:1–49Google Scholar
  23. 23.
    Henkel V, Mergl R, Kohnen R, Maier W, Möller HJ, Hegerl U (2003) Identifying depression in primary care: a comparison of different methods in a prospective cohort study. BMJ 326:200–201PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    de Wit M, Pouwer F, Gemke RJ, Delemarre-van de Waal HA, Snoek FJ (2007) Validation of the WHO-5 Well-Being Index in adolescents with type 1 diabetes. Diabetes Care 30:2003–2006PubMedCrossRefGoogle Scholar
  25. 25.
    McGuire BE, Morrison TG, Hermanns N, Skovlund S, Eldrup E, Gagliardino J et al (2010) Short-form measures of diabetes-related emotional distress: the problem areas in diabetes scale (PAID)-5 and PAID-1. Diabetologia 53:66–69. doi: 10.1007/s00125-009-1559-5 PubMedCrossRefGoogle Scholar
  26. 26.
    Polonsky WH, Anderson BJ, Lohrer PA, Welch G, Jacobson AM, Aponte JE et al (1995) Assessment of diabetes-related distress. Diabetes Care 18:754–760PubMedCrossRefGoogle Scholar
  27. 27.
    Welch G, Weinger K, Anderson B, Polonsky WH (2003) Responsiveness of the problem areas in diabetes (PAID) questionnaire. Diabet Med 20:69–72PubMedCrossRefGoogle Scholar
  28. 28.
    Nicolucci A, Kovacs Burns K, Holt RI, Comaschi M, Hermanns N, Ishii H, Kokoszka A, Pouwer F, Skovlund SE, Stuckey H, Tarkun I, Vallis M, Wens J, Peyrot M (2013) DAWN2 Study Group. Diabetes attitudes, wishes and needs second study (DAWN2™): cross-national benchmarking of diabetes-related psychosocial outcomes for people with diabetes. Diabet Med 30(7):767–777. doi: 10.1111/dme.12245 PubMedCrossRefGoogle Scholar
  29. 29.
    Östenson CG, Geelhoed-Duijvestijn P, Lahtela J, Weitgasser R, Markert Jensen M, Pedersen-Bjergaard U (2014) Self-reported non-severe hypoglycaemic events in Europe. Diabet Med 31(1):92–101. doi: 10.1111/dme.12261 PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Kulzer B, Seitz L, Kern W (2014) Real-world patient-reported rates of non-severe hypoglycaemic events in Germany. Exp Clin Endocrinol Diabetes 122(3):167–172. doi: 10.1055/s-0033-1363688 PubMedCrossRefGoogle Scholar
  31. 31.
    Brod M, Christensen T, Bushnell DM (2012) The impact of non-severe hypoglycemic events on daytime function and diabetes management among adults with type 1 and type 2 diabetes. J Med Econ 15(5):869–877. doi: 10.3111/13696998.2012.686465 PubMedCrossRefGoogle Scholar
  32. 32.
    Frier BM (2007) Living with hypoglycaemia. In: Frier BM (ed) Hypoglycaemia in Clinical Diabetes, 2nd edn. Wiley, ChichesterCrossRefGoogle Scholar
  33. 33.
    Kovacs Burns K, Nicolucci A, Holt RI, Willaing I, Hermanns N, Kalra S, Wens J, Pouwer F, Skovlund SE, Peyrot M (2013) DAWN2 study group. Diabetes attitudes, wishes and needs second study (DAWN2™): cross-national benchmarking indicators for family members living with people with diabetes. Diabet Med 30(7):778–788. doi: 10.1111/dme.12239 PubMedCrossRefGoogle Scholar
  34. 34.
    Akram K, Pedersen-Bjergaard U, Borch-Johnsen K, Thorsteinsson B (2006) Frequency and risk factors of severe hypoglycemia in insulin-treated type 2 diabetes: a literature survey. J Diabetes Complicat 20:402–408PubMedCrossRefGoogle Scholar
  35. 35.
    Gonzalez JS, Delahanty LM, Safren SA, Meigs JB, Grant RW (2008) Differentiating symptoms of depression from diabetes-specific distress: relationships with self-care in type 2 diabetes. Diabetologia 51(10):1822–1825. doi: 10.1007/s00125-008-1113-x PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Anderson RM, Funnell MM (2010) Patient empowerment: myths and misconceptions. Patient Educ Couns 79(3):277–282. doi: 10.1016/j.pec.2009.07.025 PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Alvarez-Guisasola F, Yin DD, Nocea G, Qiu Y, Mavros P (2010) Association of hypoglycemic symptoms with patients’ rating of their health-related quality of life state: a cross sectional study. Health Qual Life Outcomes 8:86. doi: 10.1186/1477-7525-8-86 PubMedCentralPubMedCrossRefGoogle Scholar
  38. 38.
    Bradley C, Speight J (2002) Patient perceptions of diabetes and diabetes therapy: assessing quality of life. Diabetes Metab Res Rev 18:S64–S69PubMedCrossRefGoogle Scholar
  39. 39.
    Gulli G, Frasson S, Borzì V, Fontanella A, Grandi M, Marengo C, Nicolucci A, Pastorelli R, Solerte B, Gatti A, Raimondo FC, Bonizzoni E, Gussoni G, Mazzone A, Ceriello A (2014) Effectiveness of an educational intervention on the management of type 2 diabetic patients hospitalized in Internal Medicine: results from the FADOI-DIAMOND study. Acta Diabetol 51(5):765–770. doi: 10.1007/s00592-014-0585-z PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2015

Authors and Affiliations

  • Antonio Nicolucci
    • 1
    • 2
  • Basilio Pintaudi
    • 2
  • Maria Chiara Rossi
    • 2
  • Roberto Messina
    • 3
  • Francesco Dotta
    • 1
    • 4
    • 5
  • Simona Frontoni
    • 1
    • 6
  • Salvatore Caputo
    • 1
    • 7
  • Renato Lauro
    • 1
  1. 1.Italian Barometer Diabetes ObservatoryUniversità Tor VergataRomeItaly
  2. 2.Department of Clinical Pharmacology and EpidemiologyFondazione Mario Negri SudS. Maria ImbaroItaly
  3. 3.FederAnzianiRomeItaly
  4. 4.Diabetes Unit, Department of Medicine, Surgery and NeuroscienceUniversity of SienaSienaItaly
  5. 5.Fondazione Umberto Di Mario ONLUSToscana Life SciencesSienaItaly
  6. 6.Dipartimento di Medicina dei SistemiUniversità degli Studi di Roma “Tor Vergata”RomeItaly
  7. 7.Servizio di Diabetologia, Policlinico GemelliUniversità CattolicaRomeItaly

Personalised recommendations