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.

The elder Ms. 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 percent. “They say, ‘Don’t worry too much about the highs — we want to prevent the lows,’” the younger Ms. Larson said.

But her mother has spent 35 years working to maintain an A1c below 7 percent — 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. She’s the oldest member of the Aqua for Arthritis class at a local pool in St. Paul, Minn.

So when her doctors recommended a higher A1c, she resisted. “I think it’s a bunch of hooey,” she said. “It didn’t make sense to me.”

“She got a lot of encouragement and recognition from her physicians for controlling her diabetes, staying on top of it,” her daughter explained. “They always praised her ‘tight control.’”

“For someone who’s been so compliant all these years, 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 percent for those contending with multiple chronic illnesses and limited life expectancy. (The elder Ms. 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, a geriatrician at Florida Atlantic University and the editor in chief of The Journal of the American Geriatrics Society.

Another 2021 study, of Ontario nursing homes, found that over half of residents taking drugs for Type 2 diabetes had A1c levels below 7 percent. Those with the greatest cognitive impairment were being treated most aggressively.

Dr. 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,” said Dr. Lee. “Now, it’s less important.”

Older diabetics don’t always welcome this news. “I thought they’d be happy,” Dr. Lee said, but they push back. “It’s almost like I’m trying to take something away from them,” he added.

The risk that tight control will also set off hypoglycemia increases as patients age.

It 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 quality-of-life issue if they’re happening frequently,” causing anxiety in patients and possibly leading them to limit their activities, he added.

Experts point to two kinds of older drugs particularly implicated in hypoglycemia: insulin and sulfonylureas like glyburide, glipizide and glimepiride.

For people with Type 1 diabetes, whose bodies cannot produce insulin, injections of the hormone remain essential. But the medication is “widely recognized as a dangerous drug” because of its hypoglycemia risk and should be carefully monitored, Dr. Lee said.

The sulfonylureas, he added, “are becoming less and less used” because, while less risky than insulin, they also cause hypoglycemia.

The great majority of older adults with diabetes have Type 2, which gives them more options. They can supplement the commonly prescribed drug metformin with the newer GLP-1 and SGLT2 drugs, which also have cardiac and kidney benefits. If necessary, they can add insulin to their regimens.

Among the new drugs’ more popular consequences, however, is weight loss.

“For older people, if they’re frail and not very active, we don’t want them losing weight,” Dr. Pilla pointed out. And both metformin and the GLP-1 and SGLT-2 medications can have gastrointestinal or genitourinary side effects.

For 15 years, Dan Marsh, 69, an accountant in Media, Pa., has treated his Type 2 diabetes by injecting two forms of insulin daily. When he takes too much, he said, he wakes up at night with “the damn lows,” and needs to eat and take glucose tablets.

Yet his A1c remains high, and last year doctors amputated part of a toe. Because he takes many other medications for a variety of conditions, he and his doctor have decided not to try different diabetes drugs.

“I know there’s other stuff, but we haven’t gone that way,” Mr. Marsh said.

With all the new options, including continuous glucose monitors, “figuring out the optimal treatment is becoming more and more difficult,” Dr. Pilla said.

Bottom line, though, “older people overestimate the benefit of blood-sugar lowering and underestimate the risk of their medications,” he said. Often, their doctors haven’t explained how the trade-offs shift with older age and accumulating health problems.

Ora Larson, who carries chewable glucose tablets with her in case of hypoglycemia (fruit juice and candy bars are also popular antidotes), intends to talk over her diabetes treatment with her doctors.

It’s a good idea. “The biggest risk factor for severe hypoglycemia is having had hypoglycemia before,” Dr. Lee said.

“If you have one episode, it should be thought of as a warning signal. It’s incumbent on your doctor to figure out, Why did this happen? What can we do so your blood sugar doesn’t go dangerously low?”

Casey and Mike Davidson always enjoyed drinking together.

The couple, both 49, met after college while working as consultants at the same firm. Romance blossomed over work happy hours, then time spent lingering over a bottle of wine on long dates.

In their mid-20s, the pair moved to Seattle and made a group of friends who were always up for a drink. Afternoons were for hiking, kayaking and sipping beers on Lake Union; evenings were for rollicking, boozy dinner parties.

But by their 30s, their drinking habits diverged. Ms. Davidson drank a bottle of wine by herself most nights, and felt increasingly uneasy about it, while Mr. Davidson settled into life as a self-described “single-beer-a-night drinker.”

“I was really defensive about my drinking,” Ms. Davidson said, adding, “I didn’t want him watching me every time I poured a third glass of wine.”

Like the Davidsons, many couples have had to grapple with the role alcohol plays in their partnership — even if neither party drinks to the point where it causes clear, consistent problems at home, or takes an obvious toll on their health. Their relationship may still receive a shock when one partner decides to cut back or quit altogether.

“It can drive a wedge between people in terms of how they socialize, how they relax and unwind, their bedroom activities,” said Ruby Warrington, the author of “Sober Curious.” “It can be really uncomfortable.”

We asked couples, and experts on substance use, how to navigate changing tolerances for drinking within a relationship.

Finding New Pathways for Connection

Ms. Davidson, who now lives in Redmond, Wash., never hit the kind of dramatic rock bottom people tend to associate with heavy drinking, but at 40 she quit for good, and now works as a sobriety coach.

She slept better and felt less anxious and foggy, but she also worried that her newfound sobriety might hurt her marriage. “It was scary for me to stop drinking, because I wondered how we would connect,” she said.

Research on alcohol and marital happiness suggests that couples who abstain and couples who drink heavily together tend to report comparable levels of relationship satisfaction.

But problems can arise when one partner drinks regularly and the other doesn’t, said Kenneth Leonard, director of the University at Buffalo’s Clinical and Research Institute on Addictions, who has studied the topic for decades. That lopsided dynamic can lead to relationship dissatisfaction and increased chances of divorce.

The reasons for that are likely to be complex, he said, though at a simple level, couples often drink to unwind and connect, and losing that may come with some cost initially. People often do not realize how ingrained alcohol is in their relationships, experts said, even if neither party has a substance use problem.

Julie Kraft, a licensed marriage and family therapist and co-author of “The Mindfulness Workbook for Addiction,” said a major upside of the “sober curious movement” and abstinence challenges like Dry January is that they offer opportunities for self-reflection.

“Am I using alcohol for stress relief?” she said. “Am I using it to feel more connected to my partner? Am I using it to avoid my partner?” One of the first things she discusses with couples looking to make changes is to brainstorm ways they might fill those spaces or needs.

The Davidsons found connection points that didn’t involve alcohol, like going to see live music on Saturday nights at a local cafe, browsing bookstores together and going to the movies.

Arthur Tindsley, 41, from Oxfordshire, England, also feared that sobriety would change his marriage. He grew up steeped in British pub culture, but in recent years, he and his wife have both looked critically at their drinking habits, going through long periods of abstinence.

Sitting down in a nice restaurant together and sharing a bottle of wine used to be one of his most cherished activities. “All of those entrenched, habitual ways that we are partners together have had to change, or are in a process of changing,” he said.

Their go-to date night now? “It’s going to sound really boring,” he said, “but we go on a walk.”

Connecting With Your ‘Why’

When working with couples in which one or both partners wants to moderate or stop drinking, Laura Heck, a licensed marriage and family therapist based in Bend, Ore., emphasizes the importance of each individual understanding their own reasons for making the change.

“Each person has to connect with their own ‘why’” Ms. Heck said, adding, “I never want one person to lean into another person’s goal and just tack it on.” She offered her own relationship as an example: Her husband stopped drinking years ago because of a heart condition. Lately, Ms. Heck has been abstaining as well, but not because of him. She simply wants to better understand the ways in which drinking has become a habit for her — and to improve her marathon times.

Experts also emphasize that partners cannot force each other to change.

“One thing we remind everyone is that their journey is their own,” said Andrea Pain, executive director of Moderation Management, a nonprofit that runs peer support groups for those who want to cut back on their drinking. “You can’t expect anyone to change what they’re doing because you’ve set this new intention for yourself.”

The Davidsons acknowledge that they are lucky. Their marriage was fundamentally sound before Ms. Davidson quit drinking, she said, and Mr. Davidson never felt threatened by her decision, nor did he attempt to derail her efforts, something which she has seen happen among her coaching clients.

The pair have found their rhythm: Mr. Davidson continues to drink in moderation, Ms. Davidson remains sober. “The way I think about it is: If I decided to become a vegetarian, that doesn’t mean Mike has to be a vegetarian too,” she said. “But he certainly wouldn’t take me to a steakhouse.”