INVESTIGATORS AND THE ACCORD-

OBJECTIVEdSelf-management of type 2 diabetes including avoidance of hypoglycemia is complex, but the impact of cognition on safe self-management is not well understood. This study aimed to assess the effect of baseline cognitive function and cognitive decline on sub-sequent risk of severe hypoglycemia and to assess the effect of different glycemic strategies on these relationships. RESEARCH DESIGN AND METHODSdProspective cohort analysis of data from the ACCORD trial included 2,956 adults aged $55 years with type 2 diabetes and additional car-diovascular risk factors. Cognitive tests (Digit Symbol Substitution Test [DSST], Rey Auditory Verbal Learning Test, Stroop Test, and Mini Mental Status Examination) were conducted at baseline and 20 months. Study outcomes were incident confirmed severe hypoglycemia requir-ing medical assistance (HMA) and hypoglycemia requiring any assistance (HAA). RESULTSdAfter a median 3.25-year follow-up, a 5-point-poorer baseline score on the DSST was predictive of a first episode of HMA (hazard ratio 1.13 [95 % CI 1.08–1.18]). Analyses of the other cognitive tests and of HAA were consistent with the DSST results. Cognitive decline over 20 months increased the risk of subsequent hypoglycemia to a greater extent in thosewith lower baseline cognitiv