Objective To investigate the occurrence of hypoglycemia and its awareness status in elderly patients with type 2 diabetes mellitus (T2DM), and to explore the risk factors of hypoglycemia. Methods Clinical data of 197 elderly T2DM patients hospitalized in our hospital from May 2021 to May 2022 were collected and retrospectively analyzed. The clinical data and incidence of hypoglycemia were compared between the patients with hypoglycemia (hypoglycemia group, n=82) and those without (non-hypoglycemia group, n=115). SPSS statistics 22.0 was used for data analysis. Student′s t test or Chi-square test was employed for intergroup comparison depending on data type. The value of body mass index (BMI), awareness score of hypoglycemia, serum creatinine (SCr) and serum urea nitrogen (BUN) in predicting hypoglycemia in elderly patients with T2DM was analyzed by receiver operating characteristics (ROC) curve. Multivariate logistic regression analysis was applied to analyze the risk factors of hypoglycemia in elderly patients with T2DM. Results Of the 197 patients, 82 developed hypoglycemia during hospitalization. The hypoglycemic group had significantly lower BMI and cognitive score of hypoglycemia, higher BUN and SCr levels, and larger proportions of duration of disease≥10 years, fasting exercise, and self-use of hypoglycemic health care agents when compared with the non-hypoglycemic group (P<0.05). ROC curve analysis showed that BMI, awareness score of hypoglycemia, and SCr and BUN levels had good predictive value for the occurrence of hypoglycemia in elderly T2DM patients, and the area under the curve (AUC) was 0.708,0.689,0.966 and 0.909, respectively. Multivariate logistic regression analysis confirmed that BMI≤18.930 kg/m² (95%CI 1.134-9.109), disease course≥10 years (95%CI 1.270-10.047), fasting exercise (95%CI 1.039-2.068), self-use of hypoglycemic health care agents (95%CI 1.106-1.450), awareness score of hypoglycemia≤68 points (95%CI 1.380-2.852), SCr≥99.930 μmol/L (95%CI 1.370-8.713) and BUN≥7.035 mmol/L (95%CI 1.505-4.130) were the risk factors for hypoglycemia in elderly T2DM patients. Conclusion Elderly T2DM patients have a higher incidence of hypoglycemia, and lower awareness of hypoglycemia. The occurrence of hypoglycemia is affected by many factors.