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Quality, Safety & Value


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For Clinicians

Hypoglycemia Risk:  Intensive management of diabetes increases the risk of hypoglycemia 1, 2. Elderly patients are at high risk for hypoglycemia, and more likely to require assistance or hospitalization as a result.  Cognitive impairment increases the risk of hypoglycemia 3. Insulins (13.9%) and oral hypoglycemics (10.7%) were among the top 4 drug classes implicated in emergency department visits and hospitalizations 4. 

Choosing Wisely: American Geriatrics Society Recommendation: “Avoid using medications to achieve A1C < 7.5% in most adults age 65 and older; moderate control is generally better.” 5 

Overtreatment of Elderly Veterans appears to be common3:

·        38% of Veterans > 65 years of age had A1C < 7

·        7.5% of Veterans > 65 years had hypoglycemia documented in past 2 years 

·        14% of patients with dementia had hypoglycemia documented in past 2 years 

Patients at Greatest Risk for Hypoglycemia:

·        A1C < 6.0 (~4x risk); < 6.5 (2.25x risk) or < 7.0 (~2x risk)6

·        Treatment with insulin (5x risk) or a sulfonylurea (2x risk) (glyburide, glipizide, etc.)

·        Age > 75

·        Cognitive impairment 

Recommendations: Review patients at greatest risk for hypoglycemia, as outlined above

·        Identify individualized A1C goal  based on patient preferences, complications, and co-morbidities

·        Reduce or eliminate unwarranted medications, focusing on insulins or sulfonylureas first as they pose the greatest risk for hypoglycemia

·        In general, prefer not using newer diabetes agents with goal of relaxing the A1c target based on safety and evidence- lowering doses of existing medications preferred 


·        Patel A, McMahon S, Chalmers J et al:  Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-72.

·        Bonds DE, Miller ME, Bergenstal RM, et al: The association between symptomatic, severe hypoglycemia and mortality in type 2 diabetes: Retrospective epidemiological analysis of the ACCORD study. BMJ 2010; 340:b3409.

·        Feil DG, Rajan M, Soroka O, et al: Risk of hypoglycemia in older Veterans with dementia and cognitive impairment: Implications for practice and policy. J Am Geriatr Soc 2011;59(12):2263-72.

·        Budnitz DS, Lovegrove MC, Shehab N, Richard CL: Emergency hospitalizations for adverse drug events in older Americans.  N Engl J Med 2011: 365: 2002-12.


·        Tseng CL,Soroka O, Maney M, et al: Assessing potential glycemic overtreatment in persons at hypoglycemic risk. JAMA Intern Med 2014: 174(2):259-68.