Comorbidity in the elderly with diabetes: Identification of areas of potential treatment conflicts

https://doi.org/10.1016/j.diabres.2009.10.019Get rights and content

Abstract

Aims

To investigate the prevalence of comorbid conditions in the elderly with diabetes and the prescribing of potentially inappropriate medicines or treatment conflicts.

Methods

A cross-sectional study of diabetics aged ≥65 years, using prescription dispensing data from the Australian Department of Veterans’ Affairs. Comorbidities were determined using the comorbidity index Rx-Risk-V. Potentially inappropriate prescribing or treatment conflicts specific for the elderly were determined from guidelines or reference compendia, in addition to the 2003 updated Beers criteria.

Results

Of 18,968 diabetics, the median number of comorbidities was 5 (IQR 3–8). Diabetes and associated cardiovascular medicines accounted for 41.9% of all medicine use. Associated cardiovascular diseases were highly prevalent comorbidities. 46% had gastro-oesophageal reflux disease, 25% depression, 20% chronic airways disease or chronic pain and 15% also had heart failure or inflammation-pain. At least 16% were dispensed a medicine associated with adverse effects in patients with diabetes and 22.7% were dispensed at least one potentially inappropriate medicine.

Conclusion

Significant comorbid conditions in elderly diabetic patients with potential for inappropriate prescribing or treatment conflicts include arthritis, heart failure, chronic airways diseases and diseases treatable with systemic corticosteroids. Appropriate management of comorbidity should be included in guidelines for the elderly with diabetes.

Introduction

Diabetes is one of the major challenges for health care systems worldwide. The prevalence of type 2 diabetes is predicted to increase from 171 million in 2000 to 366 million in 2030, with the greatest increase in prevalence in those aged ≥65 years [1]. Multimorbidity, that is the presence of multiple chronic diseases, is common in the elderly population (65–80%) [2], [3], [4], further adding to the complexity of treating the elderly patient with diabetes. According to recent studies almost 75% of adults with diabetes have 2 or more comorbid conditions and these account for much of the morbidity and mortality that these patients experience [5], [6], [7].

Some comorbid diseases such as cardiovascular disease (CVD) and retinopathy, are known to be associated with diabetes due to their shared pathophysiological profile and as such are incorporated into diabetes management programs and clinical guidelines. However, there is limited guidance to facilitate the care of concomitant non-related diseases in the diabetic patient [8], and failure to adequately do so may result in ineffective control of diabetes-specific risk factors and may lead to decreased patient quality of life, functioning and potentially increased mortality risk. The major challenge for both the physician and patients is how to best integrate, coordinate and prioritise treatment strategies for all comorbidities, in addition to patient specific diabetes treatment goals [5], [9], [10].

Previous studies examining diabetes and comorbidity have looked at the effects of individual comorbid conditions [11], [12] or provided a count of numbers of conditions related to diabetes and number of independent conditions [5], [6]. Increased numbers of comorbid conditions are associated with a decreased prioritisation of diabetes and ability of patients to self-manage their disease [5], [6]. Use of diabetes-specific health services does not appear to be affected by the number of comorbid diseases [5], [6]. The prevalence of specific comorbid conditions in the elderly with diabetes is less well studied, particularly for those conditions that are not associated with diabetes. Implicit with comorbidity is the use of multiple medicines. Polypharmacy is associated with an increased risk of inappropriate prescribing and adverse drug reactions, resulting in an increase in adverse outcomes, such as falls, hospital admission and mortality [13], [14]. Importantly, the characteristics of specific comorbid conditions can potentially impact on how physicians and patients approach their care relative to their diabetes management.

The aims of this study were to investigate the prevalence of specific comorbid conditions in elderly diabetic patients and to examine the prescribing of potentially inappropriate medicines or areas of potential treatment conflicts that physicians commonly encounter in caring for elderly multimorbid diabetic patient.

Section snippets

Study sample and design

A retrospective cross-sectional study was undertaken from 1st April to 31 July 2007, which included all veterans aged 65 years and over on 1 April 2007, who had an eligible gold card (entitles veterans to full access to health services) and who had been dispensed at least one medicine for the treatment of diabetes (A10). Data were sourced from prescription dispensing records from the Department of Veterans’ Affairs (DVA), Australia. This database contains details of all prescription medicines,

Results

A total of 18,968 subjects were included in the diabetic cohort, of which 55.9% were men and 44.1% women, with a median age of 82 years (IQR 79–85) (Table 1). The median number of comorbid conditions was 5 (IQR 3–8) and the median number of unique medicines dispensed was 10 (IQR 7–14). Over 70% of the diabetic cohort were dispensed 5 or more unique medicines (Table 1).

Table 2 provides an overview of the prevalence of the number and types of anti-diabetic and cardiovascular medicines dispensed

Discussion

This large population based study show a high level of comorbidity and associated polypharmacy in elderly Australian diabetic patients. This includes both those cardiovascular comorbidities of known association with diabetes and non-related comorbid diseases. Overall 40% of the comorbidity could be attributed to associated cardiovascular conditions and 40% of all medicine use was attributed to the dispensing of diabetes guideline treatments, which includes the management of both diabetes and

Conflicts of interest

The authors declare no conflict of interest.

Acknowledgements

This work was funded by the Australian Research Council/National Health and Medical Research Council of Australia from an Ageing Well Ageing Productively Program Grant.

We thank all the Chief Investigators who collaborated with us on this project: Prof Philip Ryan, Prof Adrian Esterman and Prof Mary Luszcz.

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