Original articlesAging, Comorbidity, and Reduced Rates of Drug Treatment for Diabetes Mellitus
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)
Some answers, more controversy, from UKPDS
Lancet
(1998)Drug-induced hypoglycemiaa review of 1418 cases
Endocrinol Metab Clin North Am
(1989)- et al.
A new method of classifying prognostic comorbidity in longitudinal studiesDevelopment and validation
J Chron Dis
(1987) - et al.
Adapting a clinical comorbidity index for use with ICD-9-CM administrative data
J Clin Epidemiol
(1992) - et al.
Demographics and prevalence, incidence, and management of coronary heart disease in the elderly and women
Ann Epidemiol
(1992) - et al.
Do coronary heart disease risk factors measured in the elderly have the same predictive roles as in the middle agedComparisons of relative and attributable risks
Ann Epidemiol
(1992) - et al.
Tracking of glycated homoglobin in the original cohort of the Framingham Heart Study
J Clin Epidemiol
(1996) - et al.
Risk of functional decline among well elders
J Clin Epidemiol
(1989) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus
N Engl J Med
(1993)- Clark CM Jr, Vinicor F, Editors. Risks and benefits of intensive management in non–insulin-dependent diabetes mellitus:...
Prevention and treatment of the complications of diabetes mellitus
N Engl J Med
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
Standards of medical care for patients with diabetes mellitus
Diabetes Care
Individual sulfonylureas and serious hypoglycemia in older people
J Am Geriatr Soc
Use of medications by persons 65 and overData from the Established Populations for Epidemiologic Study of the Elderly
J Gerontol
Reliability of recall of drug usage and other health-related information
Am J Epidemiol
Self-report and medical record report agreement of selected medical conditions in the elderly
Am J Public Health
The accuracy of Medicare's hospital claims dataProgress has been made, but problems remain
Am J Public Health
Discordance of databases designed for claims payment versus clinical information systems
Ann Intern Med
Applied Logistic Regression
Age as a risk factor for inadequate treatment
JAMA
Relationship between age at diagnosis and treatments received by cancer patients
J Am Geriatr Soc
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
Cited by (50)
Effects of hypertension, diabetes, and/or cardiovascular disease on health-related quality of life in elderly Korean individuals: A population-based cross-sectional survey
2014, Asian Nursing ResearchCitation Excerpt :The most common comorbid chronic diseases among diabetic patients were hypertension, chronic lung diseases, and osteoarthritis of the hip/knee (Schellevis, Velden, Lisdonk, Eijk, & Weel, 1993). Those with more comorbid conditions used significantly more hypoglycemic medications and injectable insulin (Glynn, Monane, Gurwitz, Choodnovskiy, & Avorn, 1999). A longitudinal study in Amsterdam found that diabetes plus arthritis resulted in a noticeable decline in physical functioning (Kriegsman, Deeg, & Stalman, 2004).
Prescription medication burden in patients with newly diagnosed diabetes: A SUrveillance, PREvention, and ManagEment of diabetes mellitus (SUPREME-DM) study
2014, Journal of the American Pharmacists AssociationGood news and bad news: Depressive symptoms decline and undertreatment increases with age in home care and institutional settings
2012, American Journal of Geriatric PsychiatryCitation Excerpt :The present results point to systematic age differences in treatment choices for the oldest old who are experiencing depressive symptoms. The phenomenon of undertreatment among very old persons has already been discussed in the context of pain treatment,46,52 treatment of asthma,53 diabetes mellitus,54 osteoporosis,55 and secondary prevention after myocardial infarct.56 The undertreatment of depression among older patients was reported by Wang et al.57 and Kessler et al.35 and observed in palliative care in a representative survey in Germany.58
Prospective Comparison of 6 Comorbidity Indices as Predictors of 1-Year Post-Hospital Discharge Institutionalization, Readmission, and Mortality in Elderly Individuals
2012, Journal of the American Medical Directors AssociationGeriatrics index of comorbidity was the most accurate predictor of death in geriatric hospital among six comorbidity scores
2010, Journal of Clinical EpidemiologyCitation Excerpt :Such patients are likely to fare better than patients whose primary diagnosis has a poor short-term prognosis that may deter treatment of secondary conditions. This is consistent with earlier findings that sicker patients are less likely to be treated for comorbid conditions [20], particularly if these conditions are not immediately life threatening; additionally, medication for treating these conditions has preventive effects, for example, oral antidiabetic agents [21] or lipid-lowering drugs [22]. Users are thus often healthier than would be suggested by their medication-based scores.
Medication adherence in low income elderly type-2 diabetes patients: A retrospective cohort study
2010, International Journal of Diabetes MellitusCitation Excerpt :Also, if patients were obese then metformin might be favorable since research has shown that it works best in obese patients aged below 60 years. Also, metformin is a comparatively cheaper drug, and might lead to weight loss [8,9]. The majority of patients in all age groups were African Americans.
- †
Current address: Director of Geriatrics, Department of Medical Affairs, Merck-Medco Managed Care, Montvale, NJ.
- ‡
Current address: The Meyers Primary Care Institute, University of Massachusetts Medical School and the Fallon Healthcare System, Worcester, MA.