Improving Outcomes of Older Persons with Diabetes

Specific aims of this program are:

1. To improve overall health-related quality of life of older persons with diabetes
2. To determine older patients’ preferences regarding their care
3. To model cost-effectiveness of different treatment approaches to older persons with diabetes
4. To develop and evaluate computer-based tools to improve diabetes care for older persons

Diabetes mellitus afflicts over 10% (over 3 million) people age 65 years or older. In fact, approximately 40% of the patients with diabetes in the United States are 65 years or older. Older patients with diabetes are a particularly vulnerable population. Clinically, they are complicated to care for because they often have multiple comorbid conditions, numerous cardiovascular, renal, ophthalmological, and neurological complications, limited social support, and constrained economic resources. Too often, the end result of the disease process is decreased functional status and high Medicare expenditures.

Despite the prevalence and importance of older diabetic patients as a vulnerable population, few studies exist to guide physicians and older diabetic patients in the management of their care. Major studies such as the DCCT and UKPDS studied younger patients, and few translational studies seeking to improve care have been performed in the elderly population. Reflecting in part the dearth of concrete scientific evidence in older populations, the clinical practice recommendations of the American Diabetes Association give limited attention to aging issues and diabetes.

It is controversial what the optimal management strategy should be for older persons. In younger populations, tight glycemic control has been demonstrated to prevent microvascular complications such as retinopathy, nephropathy, and neuropathy. If these results can be extrapolated to older populations, then less intensive care of elders, such as potentially from age bias, would be problematic. Compared to younger patients, however, older persons with diabetes are at higher risk for dying from competing causes before developing complications from diabetes (Welch et al., 1996). Therefore, evidence demonstrating the efficacy of tight glucose control in young diabetic patients may not apply to many older patients (UK Prospective Diabetes Study Group, 1998; Diabetes Control and Complications Trial Research Group, 1993). Given that the treatment of diabetes can adversely affect quality of life through dietary restrictions, the burden of taking medications, hypoglycemia, and the discomfor t of insulin injections, treatment should have more benefit than harm. Especially given the limited scientific evidence that is available, it is crucial to inform patients about the relative benefits and costs of tight glucose control and dietary therapy, and understand patient preferences regarding the aggressiveness of treatment. The issues apply to other aspects of cardiovascular risk factor modification including blood pressure and lipid control.

In addition, some studies such as the DPP have shown the efficacy of preventive strategies in older diabetic patients. However, translational effectiveness studies in older persons are greatly needed. Moreover, older persons with diabetes are a complex, heterogeneous group. Some have newly diagnosed diabetes, are asymptomatic, and are unlikely to develop complications from their disease. Others may have had diabetes for several years with moderate glucose control, and are at risk for diabetic complications. Still others may have had longstanding disease with severe complications. Some may have significant comorbidities or dementia. Especially since no definitive studies identifying the optimal treatment approach for older persons with diabetes have been performed, the physician must individualize treatment approaches to his or her patients.

In summary, older persons with diabetes have particularly complex problems for which little research has been done. The University of Chicago team has the requisite expertise in geriatrics, gerontology, and diabetes outcomes research to explore these important areas.