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Diabetes in senior population impacts all aspects of health care

AHCJ Staff

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By Liz Seegert

Chronic diseases in older adults represent an important health and economic burden to society because of associated long-term illness, diminished quality of life, and greatly increased health care costs. Although the risk of disease and disability clearly increases with advancing age, poor health is not an inevitable consequence of aging. Eighty-eight percent of people over the age of 65 have at least one chronic disease.

“The aging population is a significant driver of the diabetes epidemic”, according to a consensus report from the American Diabetes Association and American Geriatrics Society. Patients, providers, and the entire health system must grapple with the impact of the disease as more boomers enter their senior years.  When covering health trends or researching statistics, bear in mind that diabetes in older adults impacts many facets of health care, including hospitalizations, costs, population health, access, quality of life years and policy, for starters.

Facts and figures

Older adults are at greater risk of developing diabetes mellitus (type 2). 10.9 million adults, or 26.9 percent, of people age 65 and older have type 2 diabetes. Prevalence of the disease is expected to double in the next 20 years, as more of the population ages. Disease prevalence is even higher in older African Americans and in Hispanics.

Diabetes can trigger or exacerbate other serious health problems, lead to reduced functional status, increase risk of institutionalization and premature death. It also increases the risk of depression, cognitive impairment, urinary incontinence, serious falls, and chronic pain. (Brown, et. Al)

  • People with diabetes aged 60 years or older are 2–3 times more likely to report an inability to walk one-quarter of a mile, climb stairs, or do housework compared with people without diabetes in the same age group.
  • Those age 75 or older are at greater risk of complications than those at the younger end of the senior spectrum.
  • Race and ethnicity are risk factors – African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Native Hawaiians or other Pacific Islanders are at especially high risk for type 2 diabetes and complications. Among older adults, African Americans and Hispanics have worse glycemic control and higher rates of comorbid conditions and complications. The Institute of Medicine has found that disparities in quality of care contribute to poorer outcomes for these groups.
  • Alzheimer’s-type and multi-infarct dementia are approximately twice as likely to occur in those with diabetes compared with age-matched nondiabetic control subjects.

Understanding the disease

Type 2 (adult onset) and Type 1 (juvenille) diabetes are different diseases.

Type 1 (also called juvenille or insulin-dependent)  occurs when the immune system destroys pancreatic cells, known as beta cells. These are the cells that make insulin to regulate blood glucose. People with Type 1 diabetes must give themselves insulin injections or use a pump to survive. This disease usually affects children or young adults, but can occur at any age.

Type 2 diabetes accounts for 90 percent to 95 percent of all diagnosed cases of diabetes. It may begin as insulin resistance – which occurs when these beta cells do not properly process it. As insulin need increases, the pancreas slowly loses its ability to produce it.

Prediabetes is a condition in which individuals have blood glucose or A1c levels higher than normal but not high enough to be classified as diabetes. People with prediabetes have an increased risk of developing type 2 diabetes, heart disease, and stroke. (CDC)

Costs of diabetes in older adults

Diabetes complications result in more frequent hospitalizations, more visits to the emergency department, more mobility limitations, more than twice the need for help with activities of daily living among those 75 compared with the 65-74 group, more amputations among those 65 than younger adults.

The American Diabetes Association estimates $245 billion in total costs of diagnosed diabetes in the United States in 2012. This includes $176 billion for direct medical costs and $69 billion in reduced productivity.

After adjusting for population age and gender differences, average medical expenditures among all adults with diagnosed diabetes were 2.3 times higher than what expenditures in the absence of the disease. Clearly, the complications of diabetes are responsible for a major component of the total cost. Peripheral vascular disease, neuropathy, and social factors are important precursors of diabetic foot ulceration and amputation.

The most recent estimates from the ADA show that those 65 and older use a significantly larger share of health services, especially hospital in-patient days, nursing/facility days and hospice, compared with those younger than 65. These new figures represent  the increased cost and prevalence (32.8 percent) of diabetes overall. Use of prescription medications also more than doubled compared with the previous estimates from 2007.

This table shows the utilization of health services by those in the 65 age group are significantly higher than for younger adults. Elderly individuals have been reported to delay treatment as well as underreport major medical conditions, making care even more difficult for older people with diabetes.

Risk factors

Several age-related factors increase the risk of developing diabetes: including reduced physical activity, decline in pancreatic function, weight gain, loss of muscle mass and strength. Additionally, diabetes onset among older adults is more common in non-Hispanic whites and is characterized by lower mean A1C  and lower likelihood of insulin use than is middle-age–onset diabetes. Older adults are at high risk for both diabetes and pre-diabetes, with surveillance data suggesting that half of older adults have the latter.

Older people with diabetes are at higher risk of falling and seriously injuring themselves.  Diabetes-related causes of falls include physical disability, vision problems, nerve damage in the feet and legs, low blood sugar or drug interactions and side effects.

Older women with diabetes are at increased risk for urinary incontinence than are older men. It may be due to high blood sugar, but many other health problems can also lead to loss of urine control, so ask the family doctor to test for the cause.

Diagnosis can be delayed or missed in older people because many symptoms, such as blurred vision or fatigue, mimic signs of “normal” aging.

Prevention and care

Medicare Part B provides coverage of diabetes screening, supplies, self-management training, and medical nutrition therapy services. Screenings are covered if a person has certain risk factors mentioned above, a family history of the disease, or if a woman had gestational diabetes while pregnant.

ADA-recommended screening and interventions for diabetes complications are evidence-based and proven cost-effective in a younger population. For older people, recommendations vary. The California Healthcare Foundation/American Geriatrics Society (AGS) Panel on Improving Care for Elders with Diabetes published evidence-based guidelines in 2003 to manage those age 65 years and older.  Note: AGS is in the process of updating its guidelines and will publish modified recommendations later this year.

The U.S. Department of Veterans Affairs has varying screening criteria for people with diabetes depending on age, severity of disease, and co-morbidities.  The Institute of Diabetes for Older People (IDOP) launched The European Diabetes Working Party for Older People guidelines for treating people with diabetes aged >/= _70 years. They recommend that clinicians weigh likely benefit/risk ratio of the intervention to the individual when offering treatment.  However, a University of Michigan study says that most older people with diabetes live long enough to benefit from intervention.

The American Diabetes Association, CDC, and other organizations are working to actively educate, prevent onset, or minimize effects of diabetes in older adults. There are few studies available on older adults with diabetes and the ADA/AGS Consensus Report calls for more research into this area.

Data analysis from the National Health and Nutrition Examination Survey (NHANES) 1999-2006, which examined the relationship of diabetes and functional disability in older adults found that disability burden can be significantly reduced through aggressive management of cardiovascular risk factors and obesity.

Consequences

Studies show that people with diabetes are hospitalized more frequently and stay longer than same-aged individuals without the disease for a given admission.  Elderly people with diabetes use more health care services. Various co-morbidities may affect care and treatment of the disease, and increase the likelihood of adverse drug interactions, side effects, and poorer outcomes, – increasing the complexity of care.

Diabetes has been linked with a more rapid decline in cognitive function, as reported in this 2012 New York Times article. Failing memory and other losses of mental ability can make it harder for older people to comply with care plans, check blood sugar regularly, maintain proper nutritional status, or remember to take medication on time.

Reporting on diabetes

The American Diabetes Association has local chapters in every state and in many cities. Contact a local representative for up-to-date statistics for your area, or comments about a study or drug. You can find a list of local chapters on their website, along with more stats and information about programs which target specific minority or ethnic groups.  The US Department of Indian Health Services has programs specific to the Native American population.

This Reporting on Health blog post summarizes the 2013 AHCJ Conference session on diabetes. Many of these points carry over to the older adult population.  AHCJ reporting guides on covering Medical Research, Obesity and Hospitals can also help you make sense of studies and data.

Most primary care providers deal with the day-to-day care of patients with diabetes. However you may want to get comments from a specialist — the chief (or department head) of endocrinology at your local hospital is a good place to start. If you have a teaching hospital in the area, talk to the media relations department to see if they are working on any trials or studies.

Nutrition and diet are a huge part of the story. The local chapter of the American Dietetic Association, now known as the Academy of Nutrition and Dietetics, can put you in touch with a qualified registered dietician (RD). The Dietetic Association offers some other good online resources, including videos. Hospitals also have RDs on staff who do community outreach and education. They can help you find patients to speak with.

Ask about:

  • Disease prevalence among older adults in your community, city, or state
  • Diabetes-specific hospitalization rates
  • Diabetes-triggered or exacerbated co-morbidities
  • Estimated cost of care for diabetes-related treatment for the 65 population
  • Outreach/education programs for older adults and compliance
  • Access to care and medical supplies, adherence
  • Monitoring/preventable hospitalizations

Reference articles

1. Brown AF, MangioneCM, SalibaD, SarkisianCA; California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus. J Am GeriatrSoc.2003 May;51(5 SupplGuidelines):S265-80.

2. Kirkman, et. al, Diabetes in Older Adults. Consensus Report. Diabetes Care. Published online. October 2012

3. Gambert, S and Pinkstaff, S. Emerging Epidemic: Diabetes in Older Adults: Demography, Economic Impact, and Pathophysiology, Diabetes Spectrum 2006, 19(4). 221-228

General diabetes-related sources

Aging-specific diabetes resources

Some top hospitals for diabetes and endocrinology care

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