Management of diabetes mellitus in older people with comorbiditiesBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2200 (Published 15 June 2016) Cite this as: BMJ 2016;353:i2200
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Indeed diabetes is one of the major diseases we are facing in the modern era. Unfortunately this disease requires lifestyle modifications and tight glycemic control to curb the impending long term complications. Totally agreed that a lot of research still needs to be done as obesity predisposing to diabetes is becoming a major problem for our era, and more and more people are unfortunately becoming prey to this disease.
Competing interests: No competing interests
The multidimensional contribution of Diabetic retinopathy to the comorbidity of diabetes mellitus in older people
It was with great interest that we read the paper by Prof. Huang.1 In our opinion the author does not emphasize on the relative impact of specific ocular complications, namely on Diabetic Retinopathy.
We would like to draw attention on diabetic retinopathy, as a comorbidity factor of paramount importance.
The incidence of legal blindness among diabetics is 25 fold that of non diabetics.2, 3 In the developed world, diabetic retinopathy is the leading cause of legal blindness in individuals over 40 years old, while in the US alone diabetic retinopathy is responsible for 12% of new cases of legal blindness annually.2 According to the Wisconsin Epidemiologic Study of Diabetic Retinopathy, after 20 years with the disease, nearly all the patients suffering from Diabetes Type I and 60% of patients with Diabetes Type II, present with Diabetic Retinopathy that is potentially sight threatening.4, 5 Moreover, diabetic patients often neglect the need for ophthalmologic monitoring6. In a study by Witkin et al.7, approximately 26% of the < 30 years old at onset and 36% of the >30 years old at onset diabetic population had never had an ophthalmologic examination. In the same study 11% of the < 30 years old at onset and 7% of the >30 years old at onset individuals with high-risk characteristics for severe visual loss according to Diabetic Retinopathy Study, had never been examined or were examined by an ophthalmologist for more than two years.
Visual impairment may have a multidimensional impact on patients. Conditions such as dementia or hypoglycemia, extremely common in elderly diabetic patients, are directly influenced by the diminished ability of the patient to perceive visual information, while the frequency of the development and/or progression of retinopathy increase significantly with age.8
More specifically, visual impairment due to diabetic retinopathy may:
• Contribute significantly to functional impairment and the ability to maintain an adequate level of self care 9 (receiving medication timely and correctly, self monitoring blood glucose levels, taking proper action in case of hypoglycemia).
• Impair the activities of daily living (ADLs), as well as any type of physical activity and thus being an independent morbidity factor.10
• Has an overall negative impact on Quality of Life. From the patient’s perspective, any therapy should aim to make his life longer and better. Health related Quality of life, not currently measured in the majority of clinical trials, is closely correlated to the visual function.11, 12
• Decreased vision may spark a vicious circle of depression and cognitive impairment by the loss of control over important everyday activities, loss of independence, deprivation of stimulating visual information (reading, watching a TV broadcast, socializing).13, 14
Based on the above, we strongly believe that moving towards an individualized approach to older diabetic patients, and actively involving this sensitive population in their treatment could be greatly benefited by focusing on the early detection and treatment of diabetic retinopathy, as well as the use of new therapeutic modalities, namely the anti-vascular endothelial growth factor (anti-VEGF) agents.
1. Huang ES. Management of diabetes mellitus in older people with comorbidities. BMJ (Clinical research ed.). 2016;353:i2200
2. Kahn HA, Hiller R. Blindness caused by diabetic retinopathy. American journal of ophthalmology. 1974;78:58-67
3. Palmberg PF. Diabetic retinopathy. Diabetes. 1977;26:703-709
4. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The wisconsin epidemiologic study of diabetic retinopathy. Ii. Prevalence and risk of diabetic retinopathy when age at diagnosis is less than 30 years. Archives of ophthalmology (Chicago, Ill. : 1960). 1984;102:520-526
5. Klein R, Klein BE, Moss SE, Davis MD, DeMets DL. The wisconsin epidemiologic study of diabetic retinopathy. Iii. Prevalence and risk of diabetic retinopathy when age at diagnosis is 30 or more years. Archives of ophthalmology (Chicago, Ill. : 1960). 1984;102:527-532
6. Will JC, German RR, Schuman E, Michael S, Kurth DM, Deeb L. Patient adherence to guidelines for diabetes eye care: Results from the diabetic eye disease follow-up study. American journal of public health. 1994;84:1669-1671
7. Witkin SR, Klein R. Ophthalmologic care for persons with diabetes. Jama. 1984;251:2534-2537
8. Kato S, Takemori M, Kitano S, Hori S, Fukushima H, Numaga J, et al. Retinopathy in older patients with diabetes mellitus. Diabetes research and clinical practice. 2002;58:187-192
9. Crews JE, Chou CF, Zhang X, Zack MM, Saaddine JB. Health-related quality of life among people aged >/=65 years with self-reported visual impairment: Findings from the 2006-2010 behavioral risk factor surveillance system. Ophthalmic epidemiology. 2014;21:287-296
10. Fisher DE, Jonasson F, Klein R, Jonsson PV, Eiriksdottir G, Launer LJ, et al. Mortality in older persons with retinopathy and concomitant health conditions: The age, gene/environment susceptibility-reykjavik study. Ophthalmology. 2016
11. Hariprasad SM, Mieler WF, Grassi M, Green JL, Jager RD, Miller L. Vision-related quality of life in patients with diabetic macular oedema. The British journal of ophthalmology. 2008;92:89-92
12. Davidov E, Breitscheidel L, Clouth J, Reips M, Happich M. Diabetic retinopathy and health-related quality of life. Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie. 2009;247:267-272
13. Sturrock BA, Xie J, Holloway EE, Hegel M, Casten R, Mellor D, et al. Illness cognitions and coping self-efficacy in depression among persons with low vision. Investigative ophthalmology & visual science. 2016;57:3032-3038
14. Court H, McLean G, Guthrie B, Mercer SW, Smith DJ. Visual impairment is associated with physical and mental comorbidities in older adults: A cross-sectional study. BMC medicine. 2014;12:181
Competing interests: No competing interests
Comorbidity affects prognosis of medical conditions, and diabetes is not an exception (Mc Donald, Sharpe & Blaszczynski, 2014). Huang (2016) argues that comorbidities in diabetes are highly prevalent and may alter the effectiveness and treatment for diabetes. This is particularly concerning as diabetes has been described by the World Health Organization (WHO) as a "growing epidemic “with 346 million cases estimated worldwide. The Americas has over 33,000 people living with diabetes while Jamaica has over 81,000 (WHO, 2012). In Barbados, all-cause mortality after diabetes-related amputation are the highest reported worldwide (Hambleton, Jonnalagadda, Davis, Fraser, Chaturvedi, & Hennis, 2009).
Diabetes is one of the most demanding chronic illnesses on a person's psychological and behavioral well being. The diagnosis, symptomatology and rigorous management regime can be a source of great distress (Maharaj, 2013). The prevalence of clinical depression in diabetic patients is approximately twice that in the general population (Egede & Ellis, 2010; Li, Ford, Zhao, Balluz, Berry & Mokdad, 2010)). It can however be argued that the diabetes-depression association is bidirectional (Pan, Lucas, Sun, van Dam, Franco & Manson, 2010).
In recognition of the importance of detection and treatment of depression in primary health care, the Mental Health Department in the Ministry of Health (MOH), Jamaica conducted training sessions for health care practitioners in primary care. The aims of the sessions were to: 1). Facilitate the continued integration of mental health care into primary care. 2). Equip practitioners working in primary care to identify depression in patients, treat promptly and or refer appropriately. A depression screening tool was recommended for use and was laminated for display in health centers to guide the early detection and prompt treatment. (C. Baker-Burke, personal communication, November 29, 2012).
Depressive symptoms in patients with Type 2 Diabetes Mellitus adversely affects their physical, psychological and socio-economical functioning, and increasing awareness of and screening for these symptoms will optimize outcomes.
Egede, L. E. & Ellis, C., (2010). Diabetes and depression: Global perspectives. Diabetes Research and Clinical Practice, 87, 302-312. doi:10.1016/j.diabres.2010.01.024.
Hambleton, I. R., Jonnalagadda, R., Davis, C. R., Fraser, H. S.,Chaturvedi, N. & Hennis, A. J. (2009). All-Cause Mortality after Diabetes-Related Amputation in Barbados. Diabetes Care, 32 (2) 306-307; DOI: 10.2337/dc08-1504
Huang, E. S. (2016). Management of diabetes mellitus in older people with comorbidities. British Medical Journal. 2016; 353 doi: http://dx.doi.org/10.1136/bmj.i2200
Li, C., Ford, E. S., Zhao, G., Balluz, L. S., Berry, J. T., Mokdad, A. H. (2010). Prevalence and Correlates of undiagnosed depression among U.S. adults 46 46 with diabetes: the Behavioral Risk Factor Surveillance System. Diabetes Care, 33(5), 1061–1064. doi: 10.2337/dc09-1515
Maharaj, F. T. (2013). Prevalence of depression in type 2 diabetic patients in Trinidad and Tobago. West Indian Medical Journal, 62(7).
Mc Donald, S., Sharpe, L. & Blaszczynski A. (2014). The psychosocial impact associated with diabetes-related amputation. Diabetic Medicine, 31(11),1424–30.
Pan, A., Lucas, M., Sun, Q., van Dam, R. M., Franco, O. H., Manson, J. E., ... & Hu, F. B. (2010). Bidirectional association between depression and type 2 diabetes mellitus in women. Archives of Internal Medicine, 170(21), 1884-1891.
Competing interests: No competing interests