Treating older diabetics in the USA - not good news

Summarized by Robert W. Griffith, MD
May 25, 2000 (Reviewed: December 8, 2002)

Introduction

The benefits of treating diabetes vigorously are becoming better known. Tight control of blood glucose levels reduces the frequency of complications, effective control of blood pressure in diabetics lowers the risk of cardiovascular events, and the morbidity of the disease is reduced by early use of statins.

However, before treatment can even be considered, the diagnosis must be made. Dr Halter's editorial makes it clear that the situation in respect to both recognition and treatment of diabetes in older US citizens is not good.

Diagnosis

The new American Diabetes Association (ADA) diagnostic criteria concentrate on the fasting blood glucose level, as being easier to use for screening purposes. It is recognized that this test will not specifically detect postprandial hyperglycemia, or so-called isolated postchallenge hyperglycemia, which is particularly common among older persons. This condition is associated with the same degree of risk of cardiovascular events as the glucose intolerance detected by a raised fasting blood glucose.

The magnitude of the problem is revealed by the recent NHANES III survey, which suggests that 30% to 50% of people in the USA who meet the full criteria for diabetes do not know they have the disease.¹

Treatment

Equally important, many older diabetics are not receiving adequate treatment. The same NHANES III survey shows that, among diabetics 65 and above, 71% of those receiving no drug treatment have adequate control of their blood sugar levels, whereas only 44% of those taking oral antidiabetics and 27% of those on insulin are well controlled.² The situation is similar to that with regard to the control of hypertension in the community, where results are also rather disheartening.

This is particularly disappointing at a time when there is a growing list of highly effective therapeutic agents designed to address various mechanisms contributing to the diabetic state (e.g. impaired insulin secretion, increased gluconeogenesis, impaired insulin-mediated glucose uptake), as well as those that can interfere with gastrointestinal glucose absorption.

What can be done?

While physicians are probably aware of the problems involved, they have pressures that often limit their time-per-patient for an office visit to 15 minutes. Diagnostic tests that go further than a fasting blood glucose level become mandatory if isolated postprandial hyperglycemia is to be detected.

Once the diagnosis is made, more time needs to be made available for patient education in matters of diet, glucose monitoring, treatment dosing, and awareness of possible complications. Furthermore, there must be effective follow-up to ensure that blood glucose control is being maintained, and that no complications have developed. Patients often receive inadequate advice on the importance of efficient lifetime treatment for a condition that may not have many symptoms, initially. The rewards of successful control of type 2 diabetes in older persons are expressed in reduced mortality and morbidity, surely a result that is worth striving for.

Source

• Diabetes mellitus in older adults: underdiagnosis and undertreatment JB. Halter, Editorial. J Am Geriatr Soc, 2000, vol. 48, pp. 340--341

Footnotes
1. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. The Third National Health and Nutrition Examination Survey, 1988-1994. MI. Harris, KM. Flegal, CC. Cowie,  et al., Diabetes Care, 1998, vol. 21, pp. 518--524
2. Glycemic control of older adults with type 2 diabetes: findings from the Third National Health and Nutrition Examination Survey, 1999-1994. RI. Shorr, LV. Franse, HE. Resnick,  et al., J Am Geriatr Soc, 2000, vol. 48, pp. 264--267

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