Tip Sheets

A look at the wide-ranging complications of diabetes among older adults

By Liz Seegert

The prevalence of Type 2 diabetes is projected to skyrocket among older adults in the next two decades. This trends places millions of older people at risk for serious and life-threatening complications, such as renal disease, retinopathy, heart disease and amputations. That can lead to reduced functioning, the need to enter an institution and higher mortality – with resulting higher costs to the health system.

By 2034, diabetes is expected to affect around 14.6 million Medicare-eligible individuals. Spending related to the disease among the Medicare-eligible population is projected to increase to $14.6 million by 2034, with associated spending nearly quadrupling from $45 billion in 2009 to $171 billion, according to the American Diabetes Association (ADA). (Note: Among the total U.S. population, 44.1 million people are expected to have either diagnosed and undiagnosed diabetes by then.)

The ADA now estimates that more than one quarter (25.9 percent), or 11,8 million seniors live with diagnosed or undiagnosed diabetes. Driving much of this growth is the aging baby boomer demographic, compounded by increasing obesity in the overall population.

The U.S. Centers for Disease Control (CDC) put diabetes prevalence among older adults even higher than the ADA’s figures.  Depending on the diagnostic criteria, it may be as high as 33 percent, according to 2012 data. Even if rates level off, CDC predicts that the rate among the aging population will double.

One major challenge in countering this trend is that adults older than 65 tend not to be enrolled in clinical trials, which makes it harder to determine effective interventions. Also, many in this group suffer from other chronic conditions. “Heterogeneity of health status of older adults (even within an age range) and the dearth of evidence from clinical trials present challenges to determining standard intervention strategies that fit all older adults,” according to conclusions of an ADA Consensus conference.

Older-age–onset diabetes is more common among non-Hispanic whites and characterized by lower mean A1C and less likelihood of insulin use than in middle-age-onset diabetes. Although a history of retinopathy is significantly more common in older adults with middle-age-onset diabetes than those with older-age -onset diabetes, there is interestingly no difference in prevalence of cardiovascular disease (CVD) or peripheral neuropathy by the age of onset, according to this article in Diabetes Journal.

In addition:

  • Older adults with diabetes have the highest rates of major lower-extremity amputation, myocardial infarction, visual impairment, and end-stage renal disease of any age-group.

  • Those 75 years and older have higher rates than those age 65-74 years for most complications.

  • Deaths from hyperglycemic crises also are significantly greater in older adults, although rates have declined markedly in the past two decades.

  • Those 75 years and older also have double the rate of emergency department visits for hypoglycemia than the general population with diabetes.

  • Older adults are at high risk for the development of Type 2 diabetes, due to the combined effects of increasing insulin resistance and impaired pancreatic islet function as aging progresses. Age-related insulin resistance appears to be primarily associated with adiposity, sarcopenia and physical inactivity

  • Half of older adults have pre-diabetes.

  • African American and Hispanic older adults have a higher incidence and prevalence of Type 2 diabetes than non-Hispanic whites, and those with diagnosed diabetes have worse glycemic control and higher rates of comorbid conditions and complications.

  • The Institute of Medicine found that although health care access and demographic variables account for some racial and ethnic disparities, there are persistent, residual gaps in outcomes. That is attributed to differences in the quality of care they receive.

  • African-American adults were twice as likely as non-Hispanic white adults to have been diagnosed with diabetes by a physician, according to the Office of Minority Health.

  • American Indian/Alaska Native adults were more than twice as likely as white adults to be diagnosed with diabetes.

  • Hispanic adults were 1.7 times more likely than non-Hispanic white adults to have been diagnosed with diabetes by a physician.

  • Native Hawaiians/Pacific Islanders are twice as likely to be diagnosed with diabetes.

Individualizing treatment

The ADA recommends that older adults who are functional, cognitively intact and have significant life expectancy should receive diabetes care using goals developed for younger adults.

However, other cardiovascular risk factors should be treated in older adults with consideration of the time frame of benefit and the individual patient. Treatment of hypertension is indicated in virtually all older adults, and lipid and aspirin therapy may benefit those with life expectancy at least equal to the time frame of primary or secondary prevention trials. Screening for diabetes complications should be individualized in older adults, but particular attention should be paid to complications that would lead to functional impairment.

Diabetes is associated with increased risk of multiple coexisting medical conditions in older adults. In addition to the classic cardiovascular and microvascular diseases, a group of conditions called geriatric syndromes, also occur at higher frequency in older adults with diabetes, and may affect self-care abilities and health outcomes including quality of life.

Research indicates that Alzheimer’s and other dementias are approximately twice as likely to occur in those with diabetes compared with age-matched nondiabetic control subjects. Signs of cognitive dysfunction can vary from subtle executive dysfunction to overt dementia and memory loss. Both aging and diabetes are risk factors for functional impairment. Lack of physical activity and functional impairment from comorbid conditions impact peripheral neuropathy, vision and hearing, gait and balance. That can lead to higher risk of falls and fractures. Women with the disease have a greater risk of hip and leg fractures.

There also is the likelihood of greater polypharmacy, which increases the risk of dangerous side effects or interactions, as well as costs. Diabetes also is associated with a high prevalence of depression. Untreated depression can make self-care, especially healthier lifestyle choices, more difficult. And that can increase the risk dementia in patients with diabetes and also greater mortality.

Other considerations

Nutrition is an integral part of diabetes care for all ages, but there are additional considerations for older adults with the disease. As AHCJ member Melinda Hemmelgarn, R.D., wrote in this tip sheet, meeting nutritional needs among older adults already is challenging due to loss of taste and smell sensations, difficulty swallowing, oral/dental issues and functional impairment. A restricted diet due to diabetes can exacerbate these problems.

To better assist with self-care, education strategies require some adaptation for aging. Learning new diabetes self-management skills may be difficult for older people, increasing the need a simple, step-like approach to educating them. Cognitive dysfunction, depression and functional disabilities (such as poor eyesight, hearing deficit, and a decline in dexterity) are important issues to consider when assessing the older adult’s ability for self-care. Involvement of family members or friends may be required to assure appropriate self-care and adherence to treatment programs, according to the Joslin Diabetes Center in Boston, Massachusetts.

Medicare currently pays for diabetes management, including education, testing, supplies, shoes, foot exams, eye exams and meal planning.  While those benefits should remain in place, changes to the Affordable Care Act now under consideration may increase out-of-pocket costs down the road.

Resources

Experts

  • Thomas W Donner, M.D., associate professor of medicine and director of Johns Hopkins Diabetes Center: 410-464-6641.

  • John B. Buse, M.D., Ph.D., professor of medicine, chief of the division of endocrinology and director of the Diabetes Care Center at University of North Carolina School of Medicine: 984-974-1140 (Media relations); 919-966-0134 (office).

  • Jane Jeffrie Seley, D.N.P., M.P.H., G.N.P., C.D.E., B.C.-A.D.M., C.D.T.C., diabetes nurse practitioner in the Division of Endocrinology at NewYork-Presbyterian Hospital Weill Cornell: 646-962-9564 (office of external affairs); 646-962-8690 (division office).