Hypoglycemia and risk of falls

Abstract

Falls and hypoglycemia are two geriatric syndromes that, in older adults with diabetes, reinforce one another and share a common blind spot: both are systematically underreported in clinical practice.

The Diabetes & Aging Study, which surveyed 2,158 adults aged 65 to 100 years with diabetes, found that 3.7% had experienced severe hypoglycemia and 39.2% at least one fall in the past year. Severe hypoglycemia was associated with a 70% higher prevalence of falls compared with those who had not experienced it; however, more than 85% of both events had no corresponding record in the clinical chart¹. This finding sits within a broader body of evidence: a meta-analysis of 44 studies and more than 2.5 million participants confirmed that hypoglycemia in older adults treated with glucose-lowering drugs is consistently associated with falls, fractures, cognitive decline, and mortality².

Several mechanisms explain this association: acute neuroglycopenia transiently impairs balance, gait, and reaction time; aging blunts the counterregulatory response, favoring hypoglycemia unawareness; and polypharmacy and frailty amplify the motor impact of each episode.

The American Diabetes Association's Standards of Care in Diabetes—2026 recommend approaching this population through the “4Ms” framework—mentation, mobility, medication, and what matters to the patient—and individualizing glycemic targets, prioritizing the avoidance of hypoglycemia over strict control in frail patients³. In this regard, technology also offers a concrete tool: the WISDM trial showed that continuous glucose monitoring reduced time with glucose <70 mg/dL from 5.1% to 2.7% in adults aged 60 years or older with type 1 diabetes, compared with a self-monitoring group that showed no change⁴.

In light of this evidence, clinical practice should include actively screening for hypoglycemia and falls at every visit with older adults, simplifying treatment regimens—with particular attention to long-acting sulfonylureas—and incorporating technology when available. Recognizing this bidirectional association, and no longer underreporting it, is an essential first step toward preventing an outcome that severely compromises our patients' functionality and quality of life.