Diabetes in Older Adults

Excerpt

Diabetes in older adults is a significant and growing public health problem in the United States. About 40% (39.5%) of the adult diabetic population is age ≥65 years. Approximately 20% (21.4%) of adults age ≥65 years have a known diagnosis of diabetes, and a similar proportion (16%) is unaware that they have diabetes based on glycosylated hemoglobin (A1c), fasting plasma glucose, or oral glucose tolerance testing. From 1997 to 2010, the prevalence of diabetes in older adults increased by 62%.

The geriatric diabetic population is highly heterogeneous in regard to its race/ethnicity, duration of diabetes, comorbidity, and functional status, which complicates the development of standard guidelines for the care of this population. Diagnosed heart disease is prevalent in about one-quarter of older adults with diabetes. Geriatric conditions are also highly prevalent, including chronic pain in over half and at least one functional limitation in two-thirds of older adults with diabetes. Diabetes increases the risk of mortality and cardiovascular and microvascular complications, as well as all known geriatric conditions (cognitive impairment, frailty, unintentional weight loss, polypharmacy, and functional impairment).

The Diabetes Prevention Program showed that a lifestyle intervention may be particularly effective at reducing future diabetes in older adults. Evidence for the benefits of intensive glycemic control among older adults is mixed, and the benefits of intensive control should be weighed carefully against the risks of polypharmacy, falls, and hypoglycemia. Even less evidence is available to guide efforts to prevent the geriatric conditions associated with diabetes. Routine screening for geriatric conditions, including dementia, depression, and falls, as well as hypoglycemia, may be especially important in older adults because of the potential barrier posed by these conditions on diabetes self-management.

In the United States, the costs of diabetes in older adults are largely borne by Medicare, the federal universal health insurance program for older adults. In 2012, the direct medical costs of diabetes care for older adults were estimated to be $104 billion per year largely due to hospital inpatient stays. The additional burden on society of informal caregiving is also significant. The costs of diabetes care in older adults are expected to triple from 2009 to 2034. Future approaches to diabetes care in older adults will likely be guided by recommendations from the American Diabetes Association to provide highly individualized care.