Original articles
Aging, Comorbidity, and Reduced Rates of Drug Treatment for Diabetes Mellitus

https://doi.org/10.1016/S0895-4356(99)00055-4Get rights and content

Abstract

Advanced age and its related comorbidity may affect both the patterns and goals of diabetes treatment. We examined the relationships of demographic variables and comorbidity with drug treatment for diabetes in the elderly. We studied both the 81,700 residents of New Jersey, aged 65–99 years, who were hospitalized between July 1, 1989 and June 30, 1991 and had prescription drug coverage either through Medicaid or the Pharmacy Assistance for the Aged and Disabled program, and a sample of 80,000 nonhospitalized elderly beneficiaries in these programs. Rates of utilization of insulin or oral hypoglycemic drugs in the 120 days before admission were substantially lower in those aged ≥85 or in nursing homes. Among patients with previously treated and diagnosed diabetes, the likelihood of treatment after discharge declined with older age (odds ratio [OR] for treatment in those aged ≥85 relative to 65–74 years: 0.57; 95% confidence interval [CI]: 0.45–0.72), nursing home residence (OR: 0.30; CI: 0.22–0.41), and higher levels of comorbidity (OR for modified Charlson index ≥5 relative to 0: 0.43; CI: 0.27–0.67). In patients who had a discharge diagnosis of diabetes but no prior treatment, those in nursing homes and those with greater comorbidity also had lower rates of diabetes treatment after discharge. Although the prevalence of diabetes increases with age and the risks of many consequences of diabetes remain high, the rate of drug treatment for diabetes declines with older age and greater comorbidity, perhaps because of concern about side effects or reduced treatment benefits due to competing risks of death. Absence of data from randomized clinical trials of diabetes treatment in the elderly appears to have resulted in considerable physician ambivalence on the benefits and risks of glycemic control in older diabetics.

Introduction

The Diabetes Control and Complications Trial has demonstrated unequivocally the value of strict glycemic control of insulin-dependent diabetes mellitus [1], but controversy remains about the appropriate intensity of treatment for patients with non–insulin-dependent diabetes mellitus 2, 3. This controversy persists even with the recent completion of the 17-year United Kingdom Prospective Diabetes Study 4, 5. Treatment guidelines acknowledge that the choice and goals of therapy are affected by such patient characteristics as advanced age, the presence of comorbid conditions, and the patient's capacity to understand [6]. Concern about the side effects of hypoglycemic drugs that occur with increasing frequency in older patients 7, 8 may also influence treatment strategies. However, the extent to which such factors have affected the actual treatment of diabetes in the elderly is unclear.

In this article, we examine the influence of age and comorbidity on patterns of drug treatment for diabetes in a large elderly population. We first evaluate the extent to which rates of treated diabetes vary by demographic variables and levels of comorbidity. Next, we identify factors associated with the decision to initiate treatment after a hospital diagnosis for diabetes or to continue prior treatment after a hospitalization.

Section snippets

Population

The primary population for this study consisted of all residents of New Jersey who, according to Medicare records, were hospitalized at least once between July 1, 1989 and June 30, 1991, were aged 65 to 99 at the time of hospitalization, and satisfied minimal requirements for participation (defined later here) in either the New Jersey Medicaid program or that state's Pharmacy Assistance for the Aged and Disabled program. We determined participation in these programs through review of pharmacy

Results

Overall, 16.4% of the 81,700 hospitalized elderly enrollees in Medicaid or the Pharmacy Assistance for the Aged and Disabled Program filled at least one prescription for a hypoglycemic agent in the 120 days before their hospitalization (Table 1). Rates of treatment declined substantially with increasing age, with 22.3% of those aged 65–74 years receiving treatment for diabetes compared with only 9.2% of those aged 85–99 years. Blacks had higher rates of treatment for diabetes than whites,

Discussion

Our data suggest that the likelihood of drug treatment for diabetes with either insulin or oral hypoglycemics declines substantially with increasing age. Although the age-related decline in treatment rates in our cross-sectional data is potentially explainable by selective survival or other patient-selection factors, our prospective results confirm these patterns and demonstrate markedly lower treatment rates after discharge in older patients with previous treatment for diabetes. While it is

Acknowledgements

Supported by grant AG12106 from the National Institute on Aging. M. Monane and J. H. Gurwitz were recipients of Clinical Investigator awards (K08 AG00642 and AG00512, respectively) from the National Institute on Aging during the period of this research.

References (49)

  • C.M. Clark et al.

    Prevention and treatment of the complications of diabetes mellitus

    N Engl J Med

    (1995)
  • UK Prospective Diabetes Study (UKPDS) Group

    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)
  • American Diabetes Association

    Standards of medical care for patients with diabetes mellitus

    Diabetes Care

    (1994)
  • R.I. Shorr et al.

    Individual sulfonylureas and serious hypoglycemia in older people

    J Am Geriatr Soc

    (1996)
  • E.A. Chrischilles et al.

    Use of medications by persons 65 and overData from the Established Populations for Epidemiologic Study of the Elderly

    J Gerontol

    (1992)
  • A. Paganini-Hill et al.

    Reliability of recall of drug usage and other health-related information

    Am J Epidemiol

    (1982)
  • T.L. Bush et al.

    Self-report and medical record report agreement of selected medical conditions in the elderly

    Am J Public Health

    (1989)
  • E.S. Fisher et al.

    The accuracy of Medicare's hospital claims dataProgress has been made, but problems remain

    Am J Public Health

    (1992)
  • J.G. Jollis et al.

    Discordance of databases designed for claims payment versus clinical information systems

    Ann Intern Med

    (1993)
  • D.W. Hosmer et al.

    Applied Logistic Regression

    (1989)
  • T. Wetle

    Age as a risk factor for inadequate treatment

    JAMA

    (1987)
  • V. Mor et al.

    Relationship between age at diagnosis and treatments received by cancer patients

    J Am Geriatr Soc

    (1985)
  • T.J. McLaughlin et al.

    Adherence to national guidelines for drug treatment of suspected acute myocardial infarction in community hospitalsEvidence for undertreatment in women and the elderly

    Arch Intern Med

    (1996)
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