The Unseen Burden: Undiagnosed Hypoglycemia and the Need for <scp>CGM</scp> in Long‐Term Geriatric Care

I was deeply impressed by the recent article “Agreement Between Fingerstick Blood Glucose and Continuous Glucose Monitor Measures Among Long-Term Care Facility Residents” by Khan et al. [1]. The authors have provided a critical and timely analysis that brings to light a significant and often overlooked issue in long-term geriatric care. The study offers compelling evidence that warrants further discussion on several fronts: First, the evidence presented is striking: while fingerstick blood glucose (FBG) exhibits nearly perfect specificity, its sensitivity remains startlingly low—merely 13%–20%—leading to the systematic under-detection of roughly four out of every five hypoglycemic events. That this under-detection remains consistent across resident-level, day-level, and 8-h interval analyses—with persistently weak phi coefficients—underscores a profound diagnostic blind spot in current LTCF protocols. Second, the revelation that FBG failed entirely to detect hypoglycemic episodes between 2:00 p.m. and 9:59 p.m. is particularly concerning. These periods often precede evening care routines or occur during staff transitions, meaning missed interventions could result in adverse outcomes ranging from falls and cardiovascular events to hospitalizations and preventable mortality—especially among residents with cognitive impairments who cannot communicate symptoms effectively [2, 3]. Third, I appreciate the inclusion of demographic detail and the authors' methodological rigor in deploying masked Continuous Glucose Monitor (CGM) to reduce behavioral bias. Yet, the limited sample in Cohort 1 (two White female residents) versus broader diversity in Cohort 2 warrants attention. The generalizability of these findings to broader LTCF populations—including diverse racial, cultural, or gender groups—could benefit from further exploration. Moreover, it would be valuable for future studies to assess whether unblinded CGM (real-time feedback) might influence staff responses and result in improved detection and management of hypoglycemia. In conclusion, this study highlights critical limitations in current glucose monitoring practices within long-term care facilities. The substantial under-detection of hypoglycemia by FBG measures suggests that the current reliance on electronic health record (EHR) data alone is inadequate for patient safety. The findings reinforce the urgent need to move beyond traditional methods. Integrating CGM as a new standard of care could provide a more comprehensive and accurate picture of a resident's glycemic status [4]. This shift would not only enhance the detection of hypoglycemic events but also support timely and appropriate therapy adjustments, ultimately improving resident safety and quality of life. Insights into how demographic factors, sensor unblinding, and individualized adaptation of monitoring protocols could shape future care models would further enrich the discussion initiated by this important work. The author is solely responsible for the content of this letter. The author declares no conflicts of interest. This publication is linked to a related reply article by Khan et al. To view this article, visit https://doi.org/10.1111/jgs.70147.