Risk of Hypoglycemia in Older Veterans with Dementia and Cognitive Impairment: Implications for Practice and Policy

Objectives To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment. Design Cross‐sectional database analysis of veterans aged 65 years and older stratified according to dementia, cognitive impairment, age, antiglycemic medications, and glycosylated hemoglobin (Hba1c) level. Setting Research database with linked clinical, laboratory, pharmacy, and International Classification of Diseases, Ninth Revision, Clinical Modification, codes. Participants Four hundred ninety‐seven thousand nine hundred veterans aged 65 and older with diabetes mellitus who obtained services from the Department of Veterans Affairs in fiscal years (FYs) 2002 and 2003. Measurements Hypoglycemia, the outcome variable, was identified from outpatient visits, emergency department and inpatient admission codes in FY2003. Independent variables (FY2002–03) included dementia and cognitive impairment, comorbid conditions, extended care and nursing home stays, demographics, antiglycemic medication, and HbA1c levels. Results Prevalence of combined dementia and cognitive impairment was 13.1% for individuals aged 65 to 74 and 24.2% for those aged 75 and older. Mean HbA1c levels were 7.0 ± 1.3% for all participants and 6.9 ± 1.3% for those with dementia. The proportion of participants taking insulin was higher in those with dementia or cognitive impairment (30%) than in those with neither condition (24%). Of all participants taking insulin, more with dementia (26.5%) and cognitive impairment (19.5%) were hypoglycemic than of those with neither condition (14.4%). For all participants, unadjusted odds ratios (ORs) for hypoglycemia were 2.42 (95% confidence interval (CI) = 2.36–2.48) for dementia and 1.72 (95% CI = 1.65–1.79) for cognitive impairment; adjusted ORs were 1.58 (95% CI = 1.53–1.62) for dementia and 1.13 (95% CI = 1.08–1.18) for cognitive impairment. Conclusion Diabetes mellitus was managed more intensively in older veterans with dementia and cognitive impairment, and dementia and cognitive impairment were independently associated with greater risk of hypoglycemia.