Nearly 12 million patients living with diabetes in the United States are more than 60 years old, and those numbers are expected to double in the next two decades. The disease is undoubtedly an epidemic, and as people age and live longer with diabetes they are at greater risk for cardiovascular complications, kidney disease, eye disease and severe hypoglycemia.
Yet the fact that so many older people are living with diabetes presents a conundrum, said Elbert Huang, MD, associate professor of general internal medicine at the University of Chicago.
“We’re doing such a great job of keeping people basically healthy and alive, but the longer people live, the more likely they are to start developing other problems. So it’s a problem of success,” he said. And solving that problem could take the form of shifting the focus of physicians to managing different conditions as a patient ages.
Huang and his colleagues from the Department of Medicine recently published a study in JAMA Internal Medicine that looked at the rates of diabetes complications in an aging population, including how these problems evolve the longer a patient has lived with the disease. Using data from more than 70,000 patients with type 2 diabetes over the age of 60 from the Kaiser Permanente health care system in Northern California, they found that cardiovascular issues and hypoglycemia were the most common, nonfatal complications overall.
However, as patients live longer with the disease, the picture becomes more complicated. For any given age group (60-69, 70-79, and over 80), rates of complications increased dramatically the longer they had the disease. For a given duration of diabetes (0-9 years or more than 10) though, rates of hypoglycemia, cardiovascular complications and mortality increased with age.The study better reflects current clinical practice for treating diabetes because the Kaiser data are fairly recent, from 2004 to 2010. Previous studies of its kind were based on data from the 1990s, before many landmark clinical trials on chronic conditions like diabetes, high cholesterol and hypertension were published. Better medications and treatment regimens have been developed since that time, and the Kaiser data from the past decade reflect the typical course of diabetes in the current medical context.
Huang said understanding how diabetes affects patients both as they age in absolute terms, and the longer they’ve had the disease, adds a crucial variable that could lead to better, individualized care. For instance, hypoglycemia appears to be a significant risk for the oldest patients. When people are first diagnosed with diabetes, physicians usually focus on helping them maintain tight blood glucose control. But as they age, extreme low blood sugars can be dangerous, and perhaps the treatment focus should shift to preventing eye disease or circulatory issues in the lower extremities that could lead to amputation.
“Most patients have had a whole lifetime of other stuff that’s happened to them by the time they arrive in an internist’s office. They’ve already had diabetes for 10-20 years, and right now for most doctors, I don’t think they make any distinction for that,” Huang said. “But now as we learn more about how complications change, you could use a combination of age, how long someone’s had diabetes along with how sick they are with other diseases, as a guide to treating them.”
Huang E.S., Laiteerapong N., Liu J.Y., John P.M., Moffet H.H. & Karter A.J. Rates of Complications and Mortality in Older Patients With Diabetes Mellitus, JAMA Internal Medicine, DOI: 10.1001/jamainternmed.2013.12956