By now, Ora Larson recognizes what’s happening. “It feels like you’re shaking inside,” she said. “I’m speeded up. I’m anxious.” If someone asks whether she would like a salad for lunch, she doesn’t know how to respond.

She has had several such episodes this year, and they seem to be coming more frequently.

“She stares and gets a gray color and then she gets confused,” her daughter, Susan Larson, 61, said. “It’s really scary.”

Hypoglycemia occurs when levels of blood sugar, or glucose, fall too low; a reading below 70 milligrams per deciliter is an accepted definition. It can afflict anyone using glucose-lowering medications to control the condition.

But it occurs more frequently at advanced ages. “If you’ve been a diabetic for years, it’s likely you’ve experienced an episode,” said Dr. Sei Lee, a geriatrician at the University of California, San Francisco, who researches diabetes in older adults.

Ora Larson, 85, has had Type 2 diabetes for decades. Now her endocrinologist and her primary care doctor worry that hypoglycemia may cause falls, broken bones, heart arrhythmias and cognitive damage.

Both have advised her to let her hemoglobin A1c, a measure of average blood glucose over several months, rise past 7%. “They say, ‘Don’t worry too much about the highs — we want to prevent the lows,’” Susan Larson said.

But her mother has spent 35 years working to maintain an A1c below 7% — a common recommendation, the goal people sing and dance about in pharma commercials.

She faithfully injects her prescribed drug, Victoza, about three times a week and watches her diet.

So when her doctors recommended a higher A1c, she resisted.

“For someone who’s been so compliant all these years,” her daughter said, ”it’s like they changed the rules.”

In fact, they have.

More than a decade ago, the American Geriatrics Society called for a hemoglobin A1c of 7.5% to 8% for most older adults with diabetes, and 8% to 9% for those contending with multiple chronic illnesses and limited life expectancy. (Ora Larson has multiple sclerosis and hypertension.)

Other medical societies and advocacy groups, including the American Diabetes Association and the Endocrine Society, have also revised their guidelines upward for older patients.

Relaxing aggressive treatment can involve stopping a drug, lowering a dose or switching to another medication — an approach called de-intensification.

The advent of effective new diabetes drugs — GLP-1 receptor agonists (like Ozempic) and SGLT2 inhibitors (like Jardiance) — has further altered the landscape. Some patients can substitute these safer medications for risky older ones.

But the new drugs can also complicate decisions, because not all older patients can switch — and for those who can, insurance companies may balk at the new medications’ high price tags and deny coverage.

So de-intensification is proceeding, but too gradually.

A 2021 study of Medicare beneficiaries with diabetes, for instance, looked at patients who had gone to an emergency room or been hospitalized because of hypoglycemia. Fewer than half had their medication regimens de-intensified within 100 days.

“Nursing home residents are the ones that get into trouble,” said Dr. Joseph Ouslander, editor-in-chief of The Journal of the American Geriatrics Society.

Another 2021 study, of Ontario nursing homes, found that more than half of residents taking drugs for Type 2 diabetes had A1c levels below 7%. Those with the greatest cognitive impairment were being treated most aggressively. Ouslander has calculated, based on a national study, that roughly 40,000 emergency room visits annually resulted from overtreatment of diabetes in older adults from 2007 to 2011. He thinks the numbers are likely to be much higher now.

A brief primer: Diabetes can cause such grievous complications — heart attacks, stroke, vision and hearing loss, chronic kidney disease, amputations — that so-called strict glycemic control makes sense in young adulthood and middle age.

But tight control, like every medical treatment, involves a period of time before paying off in improved health. With diabetes, it’s a long time, probably eight to 10 years.

Older people already contending with a variety of health problems may not live long enough to benefit from tight control any longer. “It was really important when you were 50,” Lee said. “Now, it’s less important.”

Hypoglycemia can make people sweaty, panicky, fatigued. When hypoglycemia is severe, “people can lose consciousness,” said Dr. Scott Pilla, an internist and diabetes researcher at Johns Hopkins. “They can become confused. If they’re driving, they could have an accident.”

Even milder hypoglycemic events “can become a qualify-of-life issue if they’re happening frequently,” causing anxiety in patients and possibly leading them to limit their activities, he added.