Prevalence of diabetes in care home residents.

OBJECTIVE: To determine the prevalence of known and undetected diabetes diagnosed either by an elevated fasting baseline sample or by a 2-h post-glucose load sample in a group of residents of care homes in an urban-district setting. RESEARCH DESIGN AND METHODS: We completed individual interviews with patients and caregivers in 30 care homes (both residential and nursing homes) in two metropolitan districts of Birmingham, West Midlands, U.K. All care homes were under the supervision of primary care physicians (general practitioners). We carried out 75-g oral glucose tolerance tests (OGTTs) in consenting residents without previous known diabetes. Criteria for diagnosis of diabetes were obtained from the World Health Organization (1998) and the American Diabetes Association (1997). RESULTS: Of 636 residents available for study, 76 residents (12.0%) were known to have diabetes; of the 560 remaining residents, 286 either refused to participate or were deemed too ill or unavailable to undergo testing. Complete data on 274 OGTTs were obtained (median age 83 years, range 45-101). A total of 46 subjects were diagnosed as having diabetes and 94 as having impaired glucose tolerance. Allowing for subjects who refused or were unable to participate, the calculated total prevalence (which includes known and newly detected diabetes) was 26.7% (95% CI 21.9-32.0). The calculated overall prevalence of impaired glucose tolerance was 30.2% (25.2-35.6). CONCLUSIONS: In a group of care home residents not known to have diabetes and able to undergo testing, a substantial proportion have undetected diabetes based on a 2-h postglucose load. These residents warrant further study as they may be at higher cardiovascular risk and require an intervention.

Mortality in older people with diabetes mellitus.

It is universally acknowledged that diabetes mellitus is a common cause of morbidity in the elderly population but it is less well established that the mortality of people with diabetes is greater at any given age. This comprehensive literature review aims to examine the evidence in order to clarify the relationship between diabetes and mortality risk in elderly diabetic patients. Information was obtained by carrying out a MEDLINE search for relevant papers published in 1980 and onwards; a key paper on mortality in non-insulin-dependent (Type 2) diabetes mellitus (NIDDM) was used as an index paper; Diabetes, Diabetologia, Diabetic Medicine, Diabete et Metabolisme, and Diabetes Care were hand searched; and, finally, other experts in the field were contacted. Two reviewers independently extracted the data from each of the studies and disagreements were discussed and resolved. The studies in elderly study populations comprised mainly NIDDM. The review demonstrated that diabetes is a significant contributor to mortality and reduced life expectancy in elderly subjects. Demographic trends in our population indicate that diabetes will continue to be a challenging health problem.

Admission plasma glucose and diabetes mellitus in elderly admissions to hospital.

Over 6 months, all admissions to three geriatric wards were studied to define an admission plasma glucose level (APG) that identified previously undiagnosed diabetes mellitus. Subjects with APG> or =7.0 mmol l(-1) had a modified oral glucose tolerance test (OGTT) when well before discharge if their dose of steroid and/or thiazide was constant, and they were neither terminally ill nor dead; excluded were 1 subject on reducing steroid doses, and 9 moribund admissions without APG. If the first 2 h OGTT result was > or =11.1 mmol l(-1), a second OGTT was performed 6 weeks later to fulfil 1985 WHO criteria. Subjects with APG<7.0 mmol l(-1) did not have OGTT. Seventy had a previous diagnosis of diabetes; scrutiny of records and OGTT refuted the diagnosis in 5, who were excluded from further analysis. Diabetes was only commonly found among those with APG> or =8.0 mmol l(-1), and the proportion was small until APG> or =13 mmol l(-1), although even then only 47% (95% CI 21-73%) had diabetes. Fourteen of 28 subjects with initial OGTT results suggesting diabetes were not diabetic on retesting. Inpatient mortality was higher if APG> or =7.0 (Odds ratio 2.82; CI 1.63-4.89) or the subject had known diabetes (Odds ratio 2.43; CI 1.15-4.97) compared to APG<7; there was no age or sex difference between these three groups. We conclude that, unless overtly diabetic, diagnosis of diabetes in elderly medical admissions needs later confirmation.

Diabetes and cognitive impairment: a community-based study of elderly subjects.

To ascertain whether diabetes in elderly people is associated with cognitive impairment, we offered all residents of Melton Mowbray aged 75, 80 and 85 years both a modified glucose tolerance test (1985 WHO criteria) and Folstein mental state examination (MMSE, 23/24 cut-off). Analysis of the results, stratified by age, revealed that subjects with known diabetes were more likely than normal subjects to have low MMSE [odds ratio 3.30 (95% CI 1.3 to 8.5)], whilst newly found diabetic subjects were less likely to have low MMSE [odds ratio 5(-14) (95% CI 9(-25) to 0.003)]. The difference between known and newly found diabetic subjects might relate to duration of diabetes. The increased frequency of cognitive impairment in known diabetic subjects may be pertinent to the safe use of hypoglycaemic agents.

The mortality of elderly people with diabetes.

To assess the full effect of diabetes on survival in elderly subjects, residents of Melton Mowbray aged 65, 70, 75, 80, and 85 years were screened by glucose tolerance test and followed up for 4.5 years. Death occurred in 56 of 520 normal subjects, 9 of 44 subjects with impaired glucose tolerance, 7 of 19 newly diagnosed diabetic subjects, and 27 of 52 known diabetic subjects. Diabetic subjects were 4.5 times (95% confidence interval 2.9-7.0) more likely to die than subjects with normal glucose tolerance. Thus elderly diabetic subjects have a substantially increased risk of death compared to their normal glucose tolerant peers.

Fructosamine in diabetes screening of the elderly.

The use of serum fructosamine in diabetes detection was investigated during a diabetes survey performed with a modified oral glucose tolerance test (MOGTT) on 742 residents of the Melton Mowbray area aged between 65 and 85 years. Subjects were tested in the morning and remained at rest. MOGTT results were classified by WHO criteria. The fructosamine concentration was measured in a random sub-group of 264 normal subjects and had a Gaussian distribution (mean = 1.67 mmol/L, SD = 0.126 mmol/L). In the survey as a whole 25 new diabetics were found of which 23 had fructosamine measured; 17 had values above the 95th percentile and four more had values above the 90th percentile. We have found fructosamine concentration to be a useful screen for diabetes but this may be dependent upon the standardized sampling procedure used, and the population studied.

The prevalence of diabetes in elderly people.

The prevalence of diabetes mellitus was investigated in a sample of people aged 65 to 85 years, using a modified oral glucose tolerance test and 1985 WHO criteria. Of the sample of 861, 52 had previously been diagnosed diabetic; 583 consented to be tested and 19 were diabetic. The prevalence of previously diagnosed diabetes was 6.0 (95% CI 4.3 to 8.1) %, and the prevalence of previously undiagnosed diabetes was 3.3 (95% CI 2.0 to 5.0) %. The high prevalence of previously diagnosed diabetes might be due to the longstanding community diabetes care in the area studied.

Care of the elderly person with diabetes: a questionnaire study comparing geriatricians with diabetic specialists.

The management of elderly diabetic patients by 100 geriatricians and 100 diabetologists was assessed by a postal questionnaire. Replies were initially received from 54 geriatricians and 81 diabetologists (p less than 0.001); geriatricians were re-contacted increasing replies to 71. The geriatricians were less likely to check the visual acuities (p less than 0.001), less likely to dilate the pupils for fundoscopy (p less than 0.025), less likely to refer a patient with maculopathy to an ophthalmologist (p less than 0.001), more likely to discharge a stable diabetic to general-practitioner care (p less than 0.05), less likely to use insulin (p less than 0.01) or antidepressants (p less than 0.01) in treating painful peripheral neuropathy, and more likely to use glibenclamide instead of a shorter-acting sulphonylurea (p less than 0.001).