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Psychology in Diabetes Care, 2nd Ed, PART 17

Edited by Frank J. Snoek and T. Chas Skinner

Diabetes in Older Adults

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Physical disability

Diabetes is also associated with greater risks of disabilities related to mobility and daily tasks among older adults.58,59

Findings from the National Health and Nutrition and Examination Surveys indicate that people with diabetes have about two to three times the prevalence of inability to walk 400 meters, do housework, prepare meals and manage money. One-quarter of diabetic women 60 years of age and older report being unable to walk 400 meters, compared with less than one-sixth of non-diabetic women of the same age. Diabetic women become disabled at approximately twice the rate of non-diabetic women and have an increased risk of falls and hip fractures.59,60….

The association of diabetes with physical disability is explained in part by classic complications of diabetes (for example, coronary heart disease and visual impairment), but a 60 per cent excess prevalence of disability remains after controlling for these factors. The mechanisms explaining the association are probably multifactorial. In NHANES III, CHD and high body mass index (BMI) were the strongest explanatory factors among women, accounting for 52 per cent of their excess risk for disability.58 Among men, CHD and stroke were the most important explanatory factors, explaining 25 and 21 per cent of the excess disability risk, respectively. These findings were supported in a number of further studies.59,61 In all of these studies, however, a significant excess risk of disability associated with diabetes remained, even after controlling for diabetes-related complications. This indicates either that diabetes has an intrinsic influence on disability or that other unmeasured or undiscovered diabetes-related complications influence the risk for disability.

4.6 Mortality in Type 2 Diabetes

Five-year mortality in type 2 diabetes is increased two-to-threefold, and age adjusted life expectancy is reduced by 5-10 years compared with the general population.62,63 Interestingly, the mortality risk does not seem particularly related to the duration of the disease;64 indeed, for type 2 patients diagnosed over the age of 75 years, mortality is similar to that of their age-matched, non-diabetic counterparts.65

4.7 Diabetes Control and Complications

The natural history of microvascular and neuropathic complications in type 2 diabetes has been difficult to define because the disease may be present for many years before it is diagnosed, and the incidence and progression of complications may be influenced by multiple confounding factors including age and hypertension. Nevertheless, hyperglycemia is clearly associated with the presence and progression of microvascular complications in type 2 diabetes.66–68

The recently reported UK Prospective Diabetes Study (UKPDS), a multicenter, prospective, randomized clinical trial, was designed to determine whether improved blood glucose control would prevent complications and reduce morbidity and mortality in patients with newly diagnosed type 2 diabetes. Endpoints included major clinical events that affect the life and well-being of patients, such as stroke, angina, heart attack, blindness, renal failure and amputations.

The trial was started in 1977 and recruited over 5000 patients. All were treated initially by diet and those who remained hyperglycemic were randomly allocated to diet, sulphonylurea or insulin. Obese patients were also randomized to metformin. Patients who failed monotherapy with sulphonylurea were further randomized to combination therapy; those who failed monotherapy with metformin also received sulphonylurea, while those who developed hyperglycemic symptoms or fasting hyperglycemia on maximal oral therapy were transferred to insulin. 69 Results indicate that lowering raised blood glucose and blood pressure levels, with intensive use of existing treatments, substantially reduces the risk of heart disease, stroke and death from diabetes-related diseases as well as diabetic eye disease and early kidney damage. However, it is important to note that intensive treatment is not without side-effects. In the UKPDS, patients in the intensive group had more hypoglycemic episodes compared with those in the conventional treatment group. In addition, weight gain was significantly higher in the intensive group and patients assigned insulin had a greater gain in weight compared with those on hypoglycemic medication.

4.8 Quality of Life

Quality of life (QoL) is increasingly recognized as an important health outcome in its own right, and has been said to represent the ultimate goal of all health interventions.70 More than 50 years ago, the World Health Organization stated that health was defined not only by the absence of disease and infirmity, but also by the presence of physical, mental and social well-being.71 Most studies report worse quality of life for people with diabetes compared with the general population, especially regarding physical functioning and well-being.72,73 Snoek74 suggests that one of the most intriguing findings from QoL research is the relatively weak association between patients’ objective health status and their subjective life quality. Apparently, health in itself does not guarantee happiness, nor does good glycemic control. Studies examining the relationship between diabetes control (HbA1c) and subjective well-being find low correlations if any,75-77 although there is evidence to suggest that patients suffering from diabetes-related complications on average report lower levels of QoL compared with patients without secondary complications.78 Specific measures, such as the Problem Areas in Diabetes (PAID) scale and the Diabetes Quality of Life (DQOL) scale, can help health care professionals to identify areas of patient concern and worry and thereby serve as aids to assessment.

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References

58. Gregg EW, Beckles GL,Williamson DF, Leveille SG, Langlois JA, Engelgau MM. Diabetes and physical disability among US adults. Diabetes Care 2000; 23: 1272–1277.

59. Gregg EW, Mangione CM, Cauley JA, Thompson TJ, Schwartz AV, Ensrud KE et al. Diabetes and incidence of functional disability in older women. Diabetes Care 2002; 25: 61–67.

60. Schwartz AV, Sellmeyer DE, Ensrud KE, Cauley JA, Tabor HK, Schreiner PJ et al. Older women with diabetes have an increased risk of fracture: a prospective study. J Clin Endocrinol Metab 2001; 86: 32–38.

61. Volpato S, Blaum C, Resnick H, Ferrucci L, Fried LP, Guralnik JM. Comorbidities and impairments explaining the association between diabetes and lower extremity disability. Diabetes Care 2002; 25: 678–683.

62. Panzram G. Mortality and survival in Type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 1987; 30: 123–131.

63. Goodkin G. Mortality factors in diabetes. J Occupational Med 1975; 17: 716–721.

64. Nathan DM, Singer DE, Godine JE, Perlmutter LC. Non-insulin-dependent diabetes in older patients. Complications and risk factors. Am J Med 1986; 81: 837–842.

65. Williams G. Management of non-insulin-dependent diabetes mellitus. Lancet 1994; 343: 95–100.

66. Klein R, Klein BEK, Moss SE, David MD, DeMets DL. Glycosylated hemoglobin predicts the incidence and progression of diabetic retinopathy. JAMA 1988; 260: 2864–2871.

67. Liu QZ, Knowler WC, Nelson RG et al. Insulin treatment, endogenous insulin concentration, and ECG abnormalities in diabetic Pima Indians. Cross-sectional and prospective analyses. Diabetes 1992; 41: 1141–1150.

68. Klein R. Hyperglycaemia and microvascular and macrovascular disease in diabetes. Diabetes Care 1995; 18: 258–271.

69. UKPDS Group. United Kingdom Prospective Diabetes Study. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352: 837–853.

70. Rubin RR. Diabetes and quality of life. Diabetes Spectrum 2000; 13: 21–23.

71. World Health Organization. Constitution of the World Health Organization. Basic Documents. Geneva: World Health Organization, 1948.

72. Rubin RR, Peyrot M. Quality of life and diabetes. Diabetes Metab Res Rev 1999; 15: 205–218.

73. Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997; 20: 585–590.

74. Snoek FJ. Quality of life: a closer look at measuring patients’ well-being. Diabetes Spectrum 2000; 13: 24–28.

75. Nerenz DR, Repasky D, Whitehouse FW, Kahkonen DM. Ongoing assessment of health status in patients with diabetes mellitus. Med Care 1992; 5 (Suppl.): MS112–MS124.

76. Sonnaville JJ, Snoek FJ, Colly LP, Deville W, Wijkel D, Heine RJ. Well-being and symptoms in relation to insulin therapy in type 2 diabetes. Diabetes Care 1998; 6: 919–924.

77. Weinberger M, Kirkman S, Samsa GP, Cowper PA, Shortliffe EA, Simel DL, Freussner JR. The relationship between glycemic control and health-related quality of life in patients with non-insulin dependent diabetes mellitus. Medical Care 1994; 12: 1173–1181.

78. Klein BEK, Klein R, Moss SE. Self-rated health and diabetes of long duration: theWisconsin 74. Snoek FJ. Quality of life: a closer look at measuring patients’ well-being. Diabetes Spectrum 2000; 13: 24–28.

75. Nerenz DR, Repasky D, Whitehouse FW, Kahkonen DM. Ongoing assessment of health status in patients with diabetes mellitus. Med Care 1992; 5 (Suppl.): MS112–MS124.

76. Sonnaville JJ, Snoek FJ, Colly LP, Deville W, Wijkel D, Heine RJ. Well-being and symptoms in relation to insulin therapy in type 2 diabetes. Diabetes Care 1998; 6: 919–924.

77. Weinberger M, Kirkman S, Samsa GP, Cowper PA, Shortliffe EA, Simel DL, Freussner JR. The relationship between glycemic control and health-related quality of life in patients with non-insulin dependent diabetes mellitus. Medical Care 1994; 12: 1173–1181.

78. Klein BEK, Klein R, Moss SE. Self-rated health and diabetes of long duration: the Wisconsin Epidemiologic Study of Diabetic Retinopathy. Diabetes Care 1998; 21: 236–240. Epidemiologic Study of Diabetic Retinopathy. Diabetes Care 1998; 21: 236–240.

For more information on this book and how to get a copy, just follow this link to Amazon.com, Psychology in Diabetes Care (Practical Diabetes).

Copyright © 2005 by John Wiley & Sons, Ltd.