Hypoglycaemia in Older Adults with Diabetes: Pathophysiology, Prevention, and Personalized Care in an Aging Population

Abstract

Managing diabetes in older adults requires balancing long-term glycaemic control with the prevention of hypoglycaemia, to which this population is particularly vulnerable owing to frailty, multimorbidity and cognitive decline. Guidelines recommend individualized glucose targets for older adults, particularly those with multimorbidity or increased hypoglycaemia risk. For individuals with frailty or cognitive impairment, relaxed HbA1c targets are often appropriate to reduce the risk of adverse events. While HbA1c is widely used, it has important limitations in this population due to its inability to reflect daily glucose fluctuations. Continuous glucose monitoring (CGM) or self-monitoring of blood glucose provide more granular data to guide therapy. This review explores the pathophysiology, complications, and management of hypoglycaemia in older adults, emphasizing individualized care, safer pharmacotherapies (e.g. DPP-4 inhibitors, GLP-1 receptor agonists, ultra-long-acting insulins), and emerging technologies (continuous glucose monitoring, artificial Intelligence-guided insulin delivery and telehealth).