Disease burden amongst elderly patients in a tertiary-care centre

Introduction

The increasing prevalence of obesity and global ageing of the population implies that the incidence and prevalence of diabetes will continue to rise. The worldwide prevalence of diabetes will double from the year 2000 to 2030, witha most significant increase in those (65 years of age).¹ Diabetes mellitus (DM) is a chronic metabolic disease characterised by hyperglycemia and high glycated haemoglobin with or without glycosuria.² Glucose metabolism disorders (GMDs) result from a defect in insulin secretion by the pancreas, insulin action on the target tissues (or insulin resistance), or both.³ Chronic hyperglycemia leads to damage and failure of various organs, especially the heart, blood vessels, eyes, kidneys, and nerves.⁴  That macro- and microangiopathies can be observed even in newly diagnosed patients and are due to GMDs of long-term duration.⁵ Diabetes is associated with premature morbidity, mortality, and is a substantial health burden on individuals, health systems, and society.^{6, 7}

However, in older people diabetes is a disabling disease due to the traditionally associated vascular complications, coexisting multiple co-morbidities, and the increased prevalence of geriatric syndromes, such as cognitive and physical dysfunction, leading to increased risk of nursing home admissions by threefold.^8,9

Because of the complexity of diabetes in old age and the heterogeneous nature of this age group, comprehensive geriatric assessment is essential on the initial examination of older people with diabetes with an individualised goal of therapy aiming to prevent loss of autonomy, and preserve independence and quality of life.¹⁰ We report the burden of diabetes mellitus and co-morbidities in elderly aged patients at a tertiary care centre.

Materials and Methods

The study involves elderly subjects aged over 65 years. During the study period from 2014 to 2017, patients visiting the Diabetes Centre, were enrolled for diabetes mellitus and associated complications, after a detailed examination.  The total number of subjects came out to be 726 with diabetes mellitus. During their visits, risk stratification, close monitoring of their symptoms, signs and laboratory values were undertaken. Anthropometric data was collected during the baseline interview. Trained interviewers measured height, weight, and waist and hip circumferences. Measurements of waist circumference were taken 2.5 cm above the umbilicus and hip circumference at the maximum width of the buttocks. Circumferences were measured to the nearest 0.1 cm. Weight was measured to the nearest 0.1 kg. BMI was calculated (kg/m2). These patients were examined for various microvascular and macrovascular complications and assessed the burden of diseases. All the variables were analysed using IBM SPSS version 20.0 (Armonk, NY, USA).

Results

A total of 726 patients attending the diabetes clinic were diagnosed and confirmed to have diabetes mellitus. Among them, 73.82% (n=536) were male and 26.17% (n=190) female. The age distribution of the patients is shown in Table 1.

The mean age of females was 69.13±4.70 (range 65 to >90 years), and in males, it was 70.41±5.49 (range 65 to > 95 years). Most of the patients were found to be in the age group of 65 to 70 years. The Waist/Hip Ratio in female was 0.99±0.04 and in male it was 0.95±0.04. Mean BMI (body mass index) in female was 28.96±3.94 kg/m2, and it was 20.04±4.98 kg/m2 in men.  Most of the male patients were observed to be lean in appearance as compared to female patients.

In this study, the fasting blood sugar (FBS) in female was 189.75±62.39 mg/dL and in male 157.66±24.00 mg/dL. Postprandial blood sugar (PPBS) in females was 355.75±94.31mg/dL, whereas in male it was 246.33±20.75 mg/dL. The mean cholesterol level in female patients was observed to be 181±17.70 mg/dL and in male it was 172.9±24.02 mg/dL. Triglycerides in female were127±36.61 mg/dL, and in the male, 83.66±22.29 mg/dL. Low-density lipoprotein (LDL) in female was 94.75±17.03 mg/dL, and in the male, 108.568.06 mg/dL. High density lipoprotein (HDL) in female was 60.75±5.67mg/dL and in male 38.2±2.34mg/ dL. In the present study, HbA1c was observed to be on the higher side in both the groups. In  ,males it was 10.6±0.79mmol/l and female 10.2±1.82 mmol/l. Most of the patients were having above HbA1c 7%. Similarly, a total of 253 (47.21%) male and 126 (66.31%) female patients had hypertension in the study group. The co-morbidities and clinical characteristics of subjects concerning the complications associated with diabetes mellitus presented in Figure 1.

Discussion:

Ageing is a global issue, the number of elderly individuals in developing countries has increased rapidly in the past few decades.¹¹ A country like India is experiencing the quadruple burden of disease, consisting of chronic diseases. Due to prolonged life expectancy and changing lifestyle among the population, incidence of diabetes mellitus is a growing health problem worldwide.¹² In old age (≥60 years old), DM is becoming an alarming public health concern in both developed and in developing countries as for some clinicians one from two elderly persons are diabetic or pre-diabetic, and for others,eight from 10 elderly persons have some dysglycemia.¹³ DM complications and comorbidities are more frequent in elderly diabetics compared to their young counterparts. Among the associated complications the most frequent are  cardiovascular diseases due to old age and to advanced atherosclerosis specific to DM and the most bothersome are visual and cognitive impairments, chronic kidney diseases and other disorders. The present research validates the morbidity patterns among the diabetic population in both genders from a single tertiary care centre.

Based on the analysis, older adults with chronic diseases may suffer from various illnesses that lead to poor control of movement and limit the performance of multiple activities. The lack of physical activity added to eating disorders characterising modern lifestyle is the most incriminated factors. In this study, we assessed the individuals of both the gender for their clinical characteristics, which has shown significant variations among the complications associated with the diabetics. The overall mean age of men was 70.41±5.49 years and in females 69.13±4.70 years. Among these individuals, 70.52 % of female and 56.52 % of males were between 65 to 70 years of age group. Our results were similar to the previous studies conducted at different centres with a varying number of subjects studied.¹⁵

Similarly, the anthropometric measurements in this study found that a more substantial hip circumference to be associated with a reduced type 2 diabetes risk after accounting for overall and central obesity and also found that this relationship was more significant in lean individuals16. Although a more substantial hip circumference, associated with a lower risk, waist circumference and BMI remained definite risk factors for type 2 diabetes.

The increased risk of type 2 diabetes associated with increased BMI and abdominal adiposity, has been well established.¹⁷ Consistent with this, we found that all three of the commonly used anthropometric risk markers, i.e. BMI, waist circumference, and the waist-to-hip ratio, similarly predicted type 2 diabetes in our subjects. The occurrence of hypertension, diabetes, and the metabolic syndrome intensified with age, and ageing per se closely linked to increased prevalence of most of the abnormalities contributing to the metabolic syndrome.¹¹ The incidence of the metabolic syndrome rose with increasing BMI, and broader waist circumference was more common in men older than 65 years than in younger agegroups. The occurrence of the metabolic syndrome reached peak levels in the 6th decade for men and the 7th decade for women, and a decline was noted only in the 8th decade for men and women in the study group.

Hypoglycemia is a condition of reduced blood glucose levels below the normal range18. According to the latest recommendations of the American Diabetes Association hypoglycemia is recognised with a decrease in blood glucose below 70 mg/dL (3.9 mmol/L).¹³ In the present study, 38.56% of the male had 157.66±24.00 mg/ dL FBS,and 61.43 % of the female had 189.75±62.39 mg/dL.PPBS was measured in 12.5% (n=67) in males and 56.31% (n=108) in females. The results of the present study indicate that hypoglycemia is one of the most common acute complications of diabetes therapy and is concordance with the study published previously. Hypoglycemia may associate with other diseases such as adrenal insufficiency, hepatic parenchymal illness, or ethanol intoxication, post-resection syndrome.¹³ Hypoglycemia also has a negative impact on the cardiovascular system. Hypoglycemia may exacerbate myocardial ischemia.

Clinical manifestation of hypoglycemia depends not only on current blood glucose levels but also include the rate of decrease of blood glucose, the duration and degree of metabolic control of diabetes, the age of the patient, concomitant complications, previous episodes of severe hypoglycemia and the type of medication.¹⁴ Hypoglycemia, associated with such manifestations as sweating, tremor, hunger, palpitations. These symptoms depend on the increased secretion of catecholamines, activation of the autonomic nervous system. There may be other manifestations such as mood changes or a headache. Moderate hypoglycemia, associated with dysfunction of the central nervous system. It may include dizziness, anxiety, confusion, ataxia, blurred vision15. Blood glucose levels below 45 mg/dL (2.5 mmol/L) may cause profound disturbances of Central Nervous System (CNS) with loss of consciousness and generalised convulsions. Hypoglycemic coma is a medical emergency usually associated with blood glucose level around 20 mg/dL (1.1 mmol/L) 16.

There are few data explicitly addressing optimal glycemic goals in medication-treated older patients.¹⁷ Goals for glycemic control, as well as risk factor management, should be based onthe individual’s overall health and projected period of survival since the risk of complications is duration dependent.glycated haemoglobin (HbA1c) was measured in 73.15% (n=139) female patients and 52.23% (n=280) in male subjects. Patient-specific dangers for hypoglycemia should identify the appropriate target for glycated haemoglobin in fit, older patients who have a life expectancy of over ten years, and on the ability of the patients to adopt and adhere to specific treatment regimens.^15,17 This phenomenon is particularly disadvantageous to patients with diabetes. Hypoglycemia can lead to injuries, falls with fractures, traffic accidents. Severe hypoglycemia is a complication with psychological and social consequences to the patients and their families.¹⁷

In the present study, cholesterol level in male was 63.99% (n=343) and in female was 34.2% (n=65). Triglycerides was 16.63% (n=85) in male and 33.68% (n=64). Type 2 diabetes, is associated with a cluster of interrelated plasma lipid and lipoprotein abnormalities, including reduced High-density lipoprotein (HDL) cholesterol, a predominance of small dense Low-density lipoprotein (LDL) particles, and elevated triglycerides. In our study HDL in male was 28.67% (n=152) and in female was 33.68% (n=64). The LDL levels in male was 27.35% (n=145) and in female was 32.63% (n=62). These abnormalities occur in many patients despite normal LDL cholesterol levels.

These changes are also a feature of the insulin resistance syndrome (also known as the metabolic syndrome), which underlies many cases of type 2 diabetes.Chronic conditions are common among older people with diabetes. Patients have at least one comorbid chronic disease in addition to diabetes, and as many as 40% of patients have at least three conditions.¹⁹ Among the total number of subjects, the co-morbidities observed in patients are a Chronic obstructive pulmonary disease (COPD) in female 9.42 % (n=18), in male 6.0 % (n=28). Neuropathy in female 12.04 % (n=23), in male (n=61) 13.09 %. Nephropathy in female (n=44)23.03% and male (n=59)12.66%. Hypertension in female (n=126) 65.96% and male (n=253)54.29%. Cardiovascular disease (CVD) in female (n=47)24.60 % and male (n=74)15.87%. Chronic kidney disease (CKD) in female (n=15)7.85% and male (n=29)6.22 %.Bronchial Asthma in female (n=17)8.90% and male (n=32)6.86%. Hypothyroidism in female (n=28)14.65 and male (n=68) 14.59%. Peripheral vascular disease (PVD) in female (n=39) 20.41% and male (n=54)11.58%. The results indicate that older people with diabetes tend to have multiple comorbidities and develop geriatric syndromes in addition to the traditional cardiovascular complications.²⁰

Among all the significant co-morbidities associated with diabetes, hypertension was noted more frequently among the older adults as compared to the other complications associated with diabetes.²¹ The present study recommends the good quality of life should be maintained without imperilling frail older people to pointless therapeutic interventions. Tight glycemic control, including dietary restriction, frequent blood testing, insulin injections, and polypharmacy, may be a burden leading to additional complications.²² Dietary restriction may also cause weight loss, frequent finger sticks and insulin injections may lead to anxiety particularly in patients with dementia, and polypharmacy is increasing the risk of falls. The outcome of the study reveals a high prevalence of morbidity among elderly highlights the urgent need to provide geriatric health care services in the developing country like India. Elderly persons should be motivated to undergo regular health checkups to identify these common problems at earliest.

Conclusions:

The study revealed that in the elderly subjects, patients with diabetes and hypertension are at high risk of increased macrovascular and microvascular complications. However, in this study, we also observed that targeting multiple risk factors is essential to preventing and slowing the progression of these complications. Optimization of glycemic, lipid, and blood pressure control has been demonstrated to improve patient outcomes. The benefits of optimal treatment of dyslipidemia with statin drugs can become evident within months in high-risk patients, whereas significant CVD risk reduction from the control of hyperglycemia and hypertension evolves overtake several years. Initial assessment of diagnosis should be comprehensive and include screening for these syndromes, mainly cognitive and physical dysfunction. It is therefore imperative to implement a dedicated approach thatemphasisesprimary and secondary preventive practices and sustained control of multiple risk factors in patients with hypertension and diabetes. In particular, all patients to be educated on the importance of lifestyle habits, dietary modification, and regular physical activity to lead a quality life.