Preventable Hypoglycemia: A Cognitive Challenge in Diabetes Self-Management

A nurse talks to two patients.
A nurse talks to two patients.
Hypoglycemia is a serious problem for those with diabetes, and clinicians must educate their patients about the risks.

NEW ORLEANS — Diabetes self-care is complicated and cognitively demanding as it requires patients to always be aware of and address problems, including preventable hypoglycemia, under constantly changing circumstances. By educating patients, however, health care providers can help with these issues.

During a presentation at AADE 2015, the annual meeting of the American Association of Diabetes Educators, Linda Gottfredson, PhD, professor emeritus at the University of Delaware in Newark, and Kathy Stroh, MS, RD, LDN, CDE, of Westside Family Healthcare in Wilmington, Delaware, said that emergency department (ED) visits and hospitalizations due to hypoglycemia are on the rise, and clinicians have an essential role in educating patients about the risk factors.

For instance, the recently released National Action Plan for Adverse Drug Event (ADE) Prevention specifically cites insulin and sulfonylureas as drugs that have been linked to preventable adverse events.

“Severe hypoglycemia is preventable in many cases. Insulin and sulfonylureas are essential drugs. Some patients require these medications, but some are at risk for hypoglycemia by not using it correctly, including when and how much insulin to inject or failing to recognize when they are at risk for hypoglycemia,” Gottfredson said.

“Patient errors like these have been driving up ED visits and hospitalizations in recent years. Reducing patient errors is key to preventing hypoglycemia.”

Risk Factors

Diabetes educators can play an integral role in affecting the “select determinants” of preventable hypoglycemia, such as reducing adverse drug events, that are cited in the National Action Plan for Adverse Drug Event Prevention, the presenters said.

According to Stroh, who is co-author of AADE Practice Advisory “Special Considerations in the Management and Education of Older Persons with Diabetes,” adverse drug events can occur in any health care setting, including inpatient, outpatient and long-term care settings like nursing homes and group homes.

However, Stroh said, they tend to occur more often during transitions of care, such as transfer from a hospital to a nursing home or when there are changes in health care providers. Stroh explained that it is not uncommon for there to be inadequate transfer of information between providers, and patients may not understand how to manage their medications.

Other individual risk factors include certain comorbid conditions, such as depression, cognitive impairment, epilepsy, cardiovascular disease and advanced diabetes complications, like hypoglycemia unawareness and renal implant.

Age is also an added risk factor, according to Stroh, pointing out that older adults are two to three times more likely than younger patients to have an adverse drug event requiring a physician office visit or an ED visit. Older adults are also seven times more likely to have an adverse drug event requiring hospital admission.

Importance of Diabetes Self-Management Education

To prevent hypoglycemia, health care providers need to understand that it is not a simple issue as it involves many steps, said Gottfredson, who is also co-author of the AADE Practice Advisory “Special Considerations in the Management and Education of Older Persons with Diabetes.”

“Diabetes self-care is a complex, cognitively demanding job for patients,” Gottfredson told Endocrinology Advisor. “It requires continual vigilance, learning, reasoning, judgment, planning, anticipating and spotting problems, and then solving them in a timely and appropriate manner under constantly changing or frequently ambiguous circumstances that are unique to the individual.”

Gottfredson said effective diabetes self-management education (DSME) instruction hones in on critical errors that the patient seems most likely to make. DSME also tailors the content and complexity of instruction to bring high-priority learning within the patient’s cognitive reach. She noted that clinicians should never assume that anything is obvious or simple for the patient, which can be a common mistake.

Diabetes self-management also includes heavy cognitive demands, and endocrinologists first need to assess if a patient has the cognitive capability for all of the diabetes self-management tasks, according to Gottfredson.

“People span a wide range in overall cognitive ability, and hence, their ability to accurately learn and carry out complex mental tasks varies,” she said, adding that normal aging can also affect the brain and therefore the mental powers that patients with diabetes need to self-manage effectively.

Additionally, knowing where tasks stand in complexity and where patients stand in general cognitive ability help a clinician to assess cognitive errors across tasks and populations.

Putting complex ideas into simple words does not transform them into simple ideas, said Gottfredson, noting that educational psychology provides ready-made instructional tools that can introduce the basic components of a complex task in a logical, carefully ordered sequence that is paced according to the individual’s own learning ability.


  1. Gottfredson L, Stroh K. W01 – Diabetes Self-Management Education (DSME) for Preventable Hypoglycemia. Presented at: AADE 2015; Aug. 5-8, 2015; New Orleans.