Aging, Diabetes, and the Public Health System in the United States

Abstract

Diabetes (diagnosed or undiagnosed) affects 10.9 million US adults aged 65 years and older. Almost 8 in 10 have some form of dysglycemia, according to tests for fasting glucose or hemoglobin A1c. Among this age group, diagnosed diabetes is projected to reach 26.7 million by 2050, or 55% of all diabetes cases. In 2007, older adults accounted for $64.8 billion (56%) of direct diabetes medical costs, $41.1 billion for institutional care alone. Complications, comorbid conditions, and geriatric syndromes affect diabetes care, and medical guidelines for treating older adults with diabetes are limited. Broad public health programs help, but effective, targeted interventions and expanded surveillance and research and better policies are needed to address the rapidly growing diabetes burden among older adults.

Diabetes mellitus is “a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.”^1(p11) Diabetes has 2 primary forms: type 1, previously called insulin-dependent or juvenile-onset diabetes, and type 2, previously called non–insulin-dependent or adult-onset diabetes; the latter accounts for about 90% to 95% of all diagnosed cases of diabetes. In 2005 to 2008, 25.8 million Americans, or 8.3% of the US population, had diabetes, and an additional 79 million had prediabetes, according to fasting glucose or hemoglobin A1c tests.¹ As the average age of the US population rises, the prevalence of diabetes among adults is projected to increase to 14% to 33% by 2050.²

Because the anatomical and physiological changes characteristic of the normal aging process are accelerated in people with diabetes,^3,4 life expectancy is shorter. For example, among people aged 55 to 64 years, diabetes reduces life expectancy by 8 years.^5,6 A 57-year-old person with diabetes may have a biological age equivalent to that of a person aged 65 years without diabetes. Along with the importance of chronological and biological age, certain ages have social (typical retirement age), political,⁷ or programmatic significance,⁸ which should be considered in planning strategies for addressing diabetes among older adults. Older adults with diabetes present special epidemiological and public health challenges, and public health actions to prevent and control diabetes in this growing subpopulation should address these.

A GROWING PROBLEM

According to estimates for 2010, 10.9 million Americans aged 65 years or older had diabetes.¹ The prevalence of prediabetes among Americans of this age, derived from results of fasting glucose or hemoglobin A1c testing in 2005 to 2008 and applied to 2010 data, was estimated to be 50%, indicating an extremely large reservoir of older adults at high risk for type 2 diabetes.¹ Together, these results indicate that almost 8 in 10 older adults in the United States have some form of dysglycemia.

National survey data showed that the incidence of diagnosed diabetes among Americans aged 65 to 79 years increased by 65% from 1997 to 2003.⁹ For 2010, 390 000 new cases were estimated to have occurred among Americans aged 65 years and older.¹ At the same time, from 1980 to 2004, the estimated number of Medicare beneficiaries with diabetes increased from 2.3 million to 5.8 million, and diabetes accounted for 32% of all Medicare spending during that period.¹⁰ The incidence of diabetes among Medicare beneficiaries aged 67 years or older also increased by 36.9% between 1997 and 2003.¹⁰

The number of Americans aged 65 years or older who are diagnosed with diabetes is projected to increase from 6.3 million in 2005 to 26.7 million by 2050 (a 3.2-fold increase), and the percentage of diabetic persons aged 65 years or older is projected to increase from 39% to 55% (Figure 1).⁶ In 2004, 25% of US nursing home residents had diabetes,^11,12 and in 2007, 86% of all US deaths associated with diabetes were among people aged 60 years or older.¹³

FIGURE 1—

Projected number of cases of diagnosed diabetes among total population and older adults aged 65 years and older: United States, 2005–2050.

Source. Narayan et al.⁶

Most older adults with diabetes also have other major chronic diseases. A study of chronic disease prevalence among Americans aged 65 years or older during 1999 to 2004 found substantial comorbidities: prevalence of diabetes alone was 3.0% among women and 4.9% among men; diabetes with arthritis, 5.4% among women and 3.8% among men; diabetes with any combination of coronary heart disease, chronic lower respiratory tract disease, or cerebrovascular accident, 1.2% among women and 3.3% among men; and diabetes with arthritis and cardiorespiratory disease, 6.3% among women and 3.9% among men (Figure 2). Collectively, these comorbidities of diabetes and other serious diseases affected 11.7% of women and 7.7% of men (or roughly 2 288 480 women and 1 211 590 men).¹⁴

FIGURE 2—

Prevalence of major chronic diseases in adults aged 65 years and older: United States, 1999–2004.

Note. AR = arthritis; CHD = coronary heart disease; CLRT = chronic lower respiratory tract disease; CVA = cerebrovascular accident; DM = diabetes mellitus.

Source. Weiss et al.¹⁴

Diabetes and its complications also impose profound economic costs.¹⁵ In 2007, the total cost of diabetes in the United States was estimated to be $174 billion, $116 billion in direct medical costs and $58 billion in indirect costs (e.g., disability, work loss, premature death).¹ For 2007, average medical expenditures among Americans with diagnosed diabetes were estimated to be 2.3 times as high as expenditures among those without diabetes, and annual diabetes-related expenditures were even higher among older diabetic patients because of their more frequent use of medications, medical services, and home care. In all, Americans with diabetes aged 65 years or older accounted for $64.8 billion (56%) of all US health care expenditures ($9713 per person).¹³

In a study of Americans born between 1931 and 1941, researchers estimated that sick days, disability, early retirement, and premature death cost the United States almost $133.5 billion during 1992 through 2000 and that persons with diabetes lost, on average, $2800 because of early retirement, $630 because of sick days, and $22 100 because of disability.¹⁶ For this American cohort and period, total diabetes-related losses were estimated to be $58.6 billion; coupled with an estimated $60 billion in productivity losses prior to 1992, the total estimated cost of diabetes was nearly $120 billion. An analysis of 1993 data from a nationally representative survey of all adults aged 70 years or older calculated time spent in informal care (h/wk) from medication use of diabetic patients and found that patients taking no medication required 10.1 hours of informal care; for oral medication, 10.5 hours; and for insulin, 14.4 hours; in each case substantially higher than for persons without diabetes (6.1 h/wk).¹⁷ The researchers estimated the associated annual cost of informal care provided to older-adult diabetic patients to be between $3 billion and $6 billion (in 1998 dollars). More data on diabetes caregiving is available elsewhere.^18,19

PUBLIC HEALTH BURDEN

The public health significance of the rising prevalence of diabetes among older Americans goes beyond sheer numbers. The amplified complexity and challenges of aging-related health concerns produce a highly heterogeneous mix of varied duration of disease, coexisting illness and disability, exposure to many types of medication, and limited financial and social means to deal with infirmity.^20,21

Traditional Diabetes Risks and Outcomes

Cardiovascular disease.

Because diabetes hastens the atherosclerotic process and increases the risk of cardiovascular disease (CVD),²¹ this condition is highly prevalent among older adults with long-standing diabetes. Estimates based on self-reported survey data indicated that in 2010, 40.1% of US diabetic patients aged 65 to 74 years had CVD, 26.8% had coronary heart disease, and 9.1% had suffered a stroke; estimates for diabetic patients aged 75 years or older were 55.2%, 35.4%, and 18.0%, respectively (Table 1).²² Recent cohort studies found that incidence of CVD was significantly higher among older Americans with newly diagnosed diabetes than among their nondiabetic peers.^23–26 A 1995 to 2004 study of Medicare beneficiaries that controlled for age, gender, and race/ethnicity found that the incidence of congestive heart failure was 65% higher and the incidence of stroke was 62% higher among those with diabetes than among those without.^24,25 Although the excess CVD risk attributable to diabetes was lower for older than for younger cohorts, the findings indicate that the excess effect of diabetes on CVD persists well into old age.

TABLE 1—

Current Diabetes-Related Indicators Among Older Adults with Diabetes: United States, National Diabetes Surveillance System and National Vital Statistics System, 2003-2010

Indicator Category	Age Groups			Data Source	Year
	45–64 Years	65–74 Years	≥ 75 Years
Incidence of diagnosed diabetes
Men,a per 1000 US adults (SE)	15.6 (1.9)	13.1 (2.2)	…	NHIS	2010
Women,a per 1000 US adults (SE)	11.5 (1.6)	11.9 (1.9)	…	NHIS	2010
Prevalence of diagnosed diabetes
Men, % (SE)	13.1 (0.48)	23.2 (1.01)	23.8 (1.18)	NHIS	2010
Women, % (SE)	11.5 (0.43)	18.6 (0.83)	17.7 (0.83)	NHIS	2010
Non-Hispanic Whites, % (SE)	11.4 (0.37)	19.1 (0.77)	19.0 (0.74)	NHIS	2010
Non-Hispanic Blacks, % (SE)	18.3 (0.96)	32.4 (1.67)	30.5 (2.04)	NHIS	2010
Hispanics, % (SE)	17.9 (0.91)	30.5 (2.16)	35.7 (3.03)	NHIS	2010
Non-Hispanic White men, % (SE)	12.5 (0.54)	21.6 (1.12)	22.8 (1.31)	NHIS	2010
Non-Hispanic White women, % (SE)	10.4 (0.45)	16.9 (0.94)	16.3 (0.89)	NHIS	2010
Non-Hispanic Black men, % (SE)	17.5 (1.32)	34.1 (3.01)	33.8 (4.04)	NHIS	2010
Non-Hispanic Black women, % (SE)	18.9 (1.41)	31.1 (2.23)	28.9 (2.58)	NHIS	2010
Hispanic men, % (SE)	16.7 (1.36)	29.1 (3.33)	41.1 (4.76)	NHIS	2010
Hispanic women, % (SE)	19.0 (1.34)	31.6 (2.69)	31.4 (3.32)	NHIS	2010
Use of any diabetes medications
% of persons with diabetes (SE)b	85.5 (0.9)	88.9 (1.1)	86.4 (1.3)	NHIS	2010
Hospital discharge diagnoses (diabetes and renal)
Diabetes, first listed, per 1000 (SE)				NHDS	2009
Men	24.4 (3.1)	21.9 (3.8)	33.0 (6.6)
Women	27.5 (4.0)	30.1 (5.1)	48.0 (10.5)
Whites	18.0 (2.7)	17.7 (3.1)	32.0 (6.5)
Blacks	34.2 (6.0)	26.6 (7.0)	45.8 (12.6)
Diabetes, any listed, per 1000 (SE)				NHDS	2009
Men	194.3 (23.0)	299.2 (41.5)	415.3 (60.9)
Women	211.8 (26.0)	320.2 (42.9)	539.2 (72.6)
Whites	145.9 (19.9)	253.4 (38.5)	396.7 (59.8)
Blacks	232.6 (39.1)	277.4 (51.6)	470.4 (92.9)
Diabetic ketoacidosis,c per 1000				NHDS	2009
Men	2.2 (0.3)	…	…
Women	2.8 (0.4)	…	…
Hyperglycemic-crisis death, per 100 000 (SE)				NVSS	2009
Men	13.1 (0.5)	6.9 (0.4)	11.4 (0.8)
Women	9.1 (0.4)	6.2 (0.3)	17.5 (1.0)
Whites	10.2 (0.4)	6.7 (0.3)	14.5 (0.7)
Blacks	17.2 (1.2)	6.6 (0.6)	18.4 (1.8)
Initiate ESRD treatment, per 100 000 (SE)				USRDS	2008
Men	265.1 (9.4)	346.1 (15.2)	372.1 (19.6)
Women	212.4 (8.0)	295.1 (12.7)	274.6 (13.0)
Whites	192.7 (5.9)	272.9 (10.2)	284.5 (12.1)
Blacks	430.4 (23.2)	562.2 (37.5)	494.1 (40.2)
Hispanics	323.7 (18.8)	444.1 (38.2)	447.9 (51.5)
White men	215.3 (8.5)	306.3 (15.3)	339.3 (19.5)
White women	168.4 (7.4)	240.3 (12.1)	236.5 (12.9)
Black men	517.1 (43.2)	586.6 (62.5)	627.0 (101.5)
Black women	363.0 (23.7)	544.3 (44.4)	436.3 (37.6)
Hispanic men	369.4 (29.5)	604.4 (82.9)	401.6 (67.2)
Hispanic women	276.2 (20.8)	341.4 (36.6)	498.6 (59.4)
Hospital discharge diagnoses for CVD
Major CVD, per 1000 (SE)				NHDS	2006
Men	68.8 (5.8)	114.3 (12.8)	153.0 (18.3)
Women	57.7 (4.9)	101.9 (10.0)	164.6 (17.1)
Ischemic heart disease, per 1000 (SE)				NHDS	2006
Men	31.5 (2.9)	45.1 (6.5)	41.6 (5.5)
Women	21.4 (2.5)	29.2 (3.9)	34.5 (4.0)
Congestive heart failure, per 1000 (SE)				NHDS	2006
Men	…	23.1 (3.7)	42.9 (6.2)
Women	…	25.3 (3.0)	55.7 (7.5)
Stroke, per 1000 (SE)				NHDS	2006
Men	…	16.1 (2.4)	22.4 (3.8)
Women	…	15.4 (1.9)	25.6 (3.6)
Self-report of CVD
CHD or stroke (any), % (SE)	…	40.1 (1.7)	55.2 (1.9)	NHIS	2010
Coronary heart disease, % (SE)	…	26.8 (1.7)	35.4 (1.9)	NHIS	2010
Stroke, % (SE)	…	9.1 (0.9)	18.0 (1.5)	NHIS	2010
Hospital discharge diagnoses (other complications)
Lower extremity condition (any), per 1000 (SE)	13.9 (0.8)	15.6 (1.2)	21.6 (1.9)	NHDS	2007
Peripheral arterial disease, per 1000 (SE)	3.7 (0.3)	6.9 (0.6)	8.5 (0.9)	NHDS	2007
Ulcer/inflammation/infection, per 1000 (SE)	6.3 (0.5)	6.2 (0.7)	8.7 (1.0)	NHDS	2007
Neuropathy, per 1000 (SE)	3.9 (0.3)	2.6 (0.4)	4.5 (0.9)	NHDS	2007
Nontraumatic LEA, per 1000 (SE)					2009
Nontraumatic LEA (any)	…	3.5 (0.9)	3.7 (1.0)	NIS-HCUP
Toe	…	2.1 (0.14)	2.3 (0.16)	NIS-HCUP
Foot	…	0.6 (0.05)	0.7 (0.06)	NIS-HCUP
Below knee	…	1.2 (0.09)	1.4 (0.10)	NIS-HCUP
Above knee	…	0.8 (0.06)	1.4 (0.10)	NIS-HCUP
Limitations
Visual, % (SE)				NHIS	2010
Men	17.1 (1.4)	16.5 (1.8)	17.6 (2.2)
Women	22.9 (1.5)	19.0 (1.7)	21.2 (2.0)
Mobility, any, % (SE)	59.1 (1.4)	68.6 (1.8)	78.7 (1.7)	NHIS	2010
Stoop, bend, kneel, % (SE)	52.2 (1.4)	61.5 (1.7)	68.9 (1.7)	NHIS	2010
Stand for 2 h, % (SE)	45.1 (1.4)	52.3 (1.8)	65.5 (1.8)	NHIS	2010
Walk quarter mile, % (SE)	42.4 (1.4)	49.5 (1.9)	63.1 (1.8)	NHIS	2010
Climb up 10 steps, % (SE)	33.9 (1.3)	39.9 (1.6)	52.1 (2.0)	NHIS	2010
Physical or mental, % (SE)	66.9 (0.6)	57.3 (0.7)	57.5 (0.8)	BRFSS	2010
Physical only, % (SE)	56.8 (0.6)	49.9 (0.7)	52.0 (0.8)	BRFSS	2010
Mental only, % (SE)	41.3 (0.6)	26.2 (0.6)	22.1 (0.6)	BRFSS	2010
Physical and mental, % (SE)	31.2 (0.6)	18.8 (0.5)	16.7 (0.6)	BRFSS	2010
Unable to perform usual actions, % (SE)	38.0 (0.6)	28.7 (0.6)	26.0 (0.7)	BRFSS	2010
Fair or poor general health, % (SE)	47.6 (0.6)	45.0 ( 0.7)	46.2 (0.7)	BRFSS	2010
ADL problemsd				NHIS	2008
Whites	…	7.2 (1.03)	14.6 (1.74)
Blacks	…	9.1 (1.83)	21.0 (3.82)
Instrumental ADL problemsd				NHIS	2008
Whites	…	13.0 (1.25)	24.0 (2.19)
Blacks	…	21.6 (2.82)	33.6 (4.15)
Preventive care received
≥ 1 doctor visit/y,e % (SE)	89.2 (0.5)	89.4 (0.5)	86.2 (0.7)	BRFSS	2010
≥ 2 A1c tests in past year,e % (SE)	72.4 (0.7)	78.2 (0.8)	75.7 (0.9)	BRFSS	2010
Daily self-monitoring,e % (SE)	62.2 (0.7)	65.2 (0.9)	65.7 (0.9)	BRFSS	2010
DSM class,e % (SE)	56.0 (0.8)	55.0 (0.9)	46.8 (1.0)	BRFSS	2010
Pneumonia vaccine,f % (SE)	47.0 (0.6)	69.1 (0.7)	79.5 (0.6)	BRFSS	2010
Influenza vaccine,f % (SE)	54.6 (0.6)	67.7 (0.7)	74.4 (0.7)	BRFSS	2010
Daily feet self-examination,e % (SE)	66.8 (0.7)	66.7 (0.9)	62.6 (1.0)	BRFSS	2010
Annual feet examination,e % (SE)	72.8 (0.7)	74.9 (0.8)	72.1 (0.9)	BRFSS	2010
Annual dilated eye examination,e % (SE)	65.7 (0.7)	74.8 (0.8)	80.3 (0.8)	BRFSS	2010
Risk factors for complications
Physical inactivity, % (SE)	37.2 (0.6)	38.0 (0.7)	45.2 (0.7)	BRFSS	2010
Smoking, % (SE)	18.8 (0.5)	10.4 (0.4)	4.1 (0.3)	BRFSS	2010
Overweight (with obese), % (SE)	89.3 (0.4)	85.5 (0.5)	74.2 (0.7)	BRFSS	2010
Obese, % (SE)	59.9 (0.6)	49.0 (0.7)	33.1 (0.7)	BRFSS	2010
High blood cholesterol, % (SE)	66.7 (0.6)	66.4 (0.7)	59.8 (0.8)	BRFSS	2010
Hypertension, % (SE)	69.0 (0.6)	75.9 (0.7)	73.5 (0.7)	BRFSS	2010
Hemoglobin A1c,g % (SE)				NHANES	2003–2006
< 7%	49.9 (3.8)	67.2 (3.3)	…
< 8%	70.6 (2.9)	89.8 (1.4)	…
> 9%	16.6 (2.1)	4.1 (1.1)	…
Blood pressure,g mm Hg, % (SE)				NHANES	2003–2006
< 130/80	50.0 (3.7)	33.2 (3.0)	…
< 140/90	74.9 (2.8)	55.8 (2.9)	…

Note. A1c = hemoglobin A1c; ADL = activities of daily living; BRFSS = Behavioral Risk Factor Surveillance System; CHD = coronary heart disease; CVD = cardiovascular disease; DSM = diabetes self-management; ESRD = end-stage renal disease; LEA = lower-extremity amputation; NHDS = National Hospital Discharge Survey; NHIS = National Health Interview Survey; NIS-HCUP = Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project; NVSS = National Vital Statistics System; USRDS = United States Renal Data System.

^aOldest age range was 65–79 years.

^bWhen it was not possible to supply indicator data for age by sex, age by race, or age by sex by race, data for age only has been listed.

^cFor diabetic ketoacidosis by sex, the age group is ≥ 45 years.

^dMiddle age range was 60–74 years.

^eData from 46 states/territories.

^fData from 52 states/territories.

^gOldest age range was ≥ 65 years.

Hospital discharge data from 2009 showed that circulatory diseases accounted for 501 000 first-listed diagnoses among US hospital patients with diabetes aged 45 to 64 years, 380 000 among those aged 65 to 74 years, and 493 000 among those aged 75 years or older, constituting 25% to 31.5% of all hospital discharges for these age groups.²⁷ In 2006, rates of hospitalization among diabetic Americans for whom major CVD was the first-listed diagnosis were 68.8 per 1000 patients for men aged 45 to 64 years, 114.3 for those aged 65 to 74 years, and 153.0 for those aged 75 years or older, and 57.7, 101.9, and 164.6, respectively, for women (Table 1).

Chronic kidney disease.

Major microvascular complications of diabetes affecting the kidneys and eyes impose a considerable burden on individuals and society.^28–31 Older adults with diabetes are at increased risk for chronic kidney disease (CKD).^32–34 During 1999 to 2006, the estimated prevalence of CKD among Americans aged 60 years or older was significantly higher among those with diabetes (58%) than among those without (41%).^35,36 It is encouraging, however, that recent trials found that diabetic patients who received treatment for glucose and high blood pressure enjoyed a significant reduction in negative renal outcomes.^37,38

Early stages of CKD can lead to frailty, disability, decreased physical and cognitive function, and end-stage renal disease (ESRD, or kidney failure).^39–41 Risk factors for ESRD, which is treatable only by dialysis or transplantation, are protein in urine, high blood pressure, diabetes, and race/ethnicity.³⁸ Of all new cases of ESRD in 2006, 45% were estimated to have been caused by diabetes.^3,41–43 The estimated incidence of ESRD treatment initiation among all Americans with diagnosed diabetes increased by an average of 5.8% per year from 1990 through 1996 but decreased by an average of 2.9% per year from 1996 through 2006; among those aged 65 to 74 years, incidence rates rose about 6% per year through 1998 and declined by 3.4% per year through 2006; and among those aged 75 or older, rates rose more than 10% per year through 1999 and declined by 2.1% per year thereafter.⁴⁴ Overall, age-adjusted incidence rates over the entire study period were lower among women than men and were highest among Blacks and lowest among Whites. The average annual decrease in ESRD treatment initiation rates after 1996 was higher among women (4.3%) than men and higher among Whites (5.0%) than other racial/ethnic groups.⁴⁴ Estimates for gender and racial/ethnic differences among older diabetic patients are shown in Table 1 and detailed in Goldfarb-Rumyantzev and Rout.⁴⁵

Diabetic retinopathy.

During 2005 to 2008, the estimated prevalence of diabetic retinopathy among diabetic Americans aged 65 years or older was 29.5%, and the estimated prevalence of vision-threatening diabetic retinopathy was 5.1%.²⁸ Neither estimate differed significantly from those for diabetic Americans aged 40 to 64 years. Age-standardized prevalence estimates for diabetic retinopathy and for vision-threatening diabetic retinopathy have increased since 1998, and prevalence rates are projected to triple among Americans aged 40 years or older and to quadruple among those aged 65 years or older between 2005 and 2050.⁴⁶ Diabetes also increases older adults’ risk of cataracts, which affects 15 million Americans aged 65 years or older,⁴⁷ and it may increase the risk of primary open-angle glaucoma among women.⁴⁸

Neuropathies.

Peripheral neuropathies are a large group of disabling sensory and motor nerve abnormalities that are common among older adults and persons with diabetes.^49,50 Peripheral sensory neuropathy is a type of peripheral neuropathy that is widely recognized as a complication of diabetes. In older persons with diabetes, peripheral sensory neuropathy is associated with impairments in balance, gait, performance of activities of daily living, increased incidence of recurrent falls and fractures,^49,51 and the presence of lower-extremity peripheral arterial disease. Peripheral sensory neuropathy contributes to lower-extremity ulceration, deformity, and nontraumatic amputations.^1,49 In 2009, the rate of lower-extremity amputations in diabetic patients aged 65 to 74 years was 3.5 per 1000 and for those aged 75 years and older, 3.7 (Table 1 shows the disease's anatomical sites).⁵² In a representative sample of US adults aged 40 years and older in 1999 to 2000, peripheral sensory neuropathy was almost twice as prevalent among persons with diabetes (28.5%) as among those without (13.3%), and was 2- to 4-fold higher for persons aged 60 years and older (17.5%–34.7%) as for those aged 40 to 49 years (8.1%).⁵⁰

In older adults with diabetes, autonomic neuropathy, another type of peripheral neuropathy, may affect many organ systems, including the cardiovascular system, upper and lower gastrointestinal tract, genitourinary tract, and skin.⁵³ The most commonly reported manifestation is cardiovascular autonomic neuropathy; however, its epidemiology has not been fully investigated. Prevalence estimates range from 7% to as high as 90%, derived from a variety of diagnostic criteria, populations, and settings.⁵³

Sensory impairment.

Some evidence associates diabetes with hearing loss, although the mechanisms underlying such an association are unclear.^54–57 People with diabetes have been found to have a lower age-, gender-, and race-standardized prevalence of normal hearing than those without diabetes.⁵⁸ Although the overall prevalence of hearing impairment in the United States declined from 1971 through 2004, it did not decline among people with diabetes. Although age is a strong predictor of hearing impairment,⁵⁸ scant evidence has been found that diabetes increases the risk of hearing impairment among older people. Dual sensory impairment (hearing impairment coupled with visual impairment) is particularly prevalent among older adults and may lead to physical limitations.⁵⁹

Less Traditional Risks and Outcomes

Geriatric syndromes.

Evidence suggests that diabetes is independently associated with increased risk of multisystem geriatric syndromes.^60–62 Geriatric syndromes, whose manifestations include falls and fear of falling, urinary or fecal incontinence, functional decline, and delirium, are common among older adults, share multiple risk factors, and often contribute to substantial disability and a lower health-related quality of life (HRQOL).^61,62 Disability risk has been estimated to be 100% to 200% greater among people with diabetes than without,^63–66 in part because of the many co-occurring health problems among people with diabetes, including cardiorespiratory problems, arthritis, and poor muscle strength and quality.^67,68 Diabetes is also associated with an increased risk of falls among older adults.^69–72 A prospective study showed that women with diabetes had a significantly greater risk of falling more than once in a year than did women without diabetes, indicated by age-adjusted odds ratios of 1.68 for women who were not using insulin and 2.78 for those who were.⁵¹

Geriatric syndromes appear to be more common among older women than older men, illuminating the specific burden women with diabetes bear.⁶⁰ They also call into question the traditional approach of targeting treatment to each system separately,⁷³ because needs among older adults with diabetes may be heterogeneous. No hard evidence shows that currently recommended diabetes care is efficacious or cost-effective for these syndromic outcomes; more research, leading to evidence-based approaches to prevent or delay such outcomes, is needed. Much is still unknown about the natural history of the development and progression of diabetes in persons with geriatric syndromes.

Infectious diseases.

Aging and increased levels of glycated hemoglobin and advanced glycation end products are associated with decreased immunological function and may account for enhanced susceptibility to infections among older adults, some of which lead to death.⁷⁴ For example, regardless of study design, population, or geographic region, diabetes has been associated with increased incidence of pulmonary tuberculosis⁷⁵ and higher significant multivariate-adjusted relative risks of tuberculosis, ranging from 1.23 to 2.69 across racial/ethnic groups among US adults.⁷⁶

Transmission of blood-borne pathogens is linked to blood glucose monitoring, a recommended part of diabetic self-care.⁷⁷ Older adults with diabetes in nursing homes and assisted-living facilities have a pronounced risk of person-to-person transmission of hepatitis B and C viruses.⁷⁸ From 1998 to 2008 in the United States, 33 outbreaks of hepatitis B and C occurred among 448 adults (5 deaths); 15 (45.5%) occurred in long-term care facilities and were attributed to sharing of finger-stick and blood glucose–monitoring devices.⁷⁹

Older adults also experience high levels of morbidity and mortality from several other vaccine-preventable diseases.⁸⁰ Adults aged 65 years and older account for almost 90% of influenza-related deaths: 56 per 10 000 influenza-related hospitalizations for patients with comorbidities and 19 for patients without.⁸¹ In response, by 2010 the percentage of US diabetic patients who received an influenza vaccine in the previous year had risen to 54.6% for persons aged 45 to 64 years, 67.7% for persons aged 65 to 74 years, and 74.4% for those aged 75 years or older (Table 1).⁸² In addition, older adults account for 20% of deaths related to invasive pneumococcal disease and nearly half (47%) of all cases of tetanus.⁸⁰ Among unvaccinated enrollees in a large managed care organization aged 60 years and older, the incidence of herpes zoster was 13 per 1000.⁸³ Although people with diabetes are considered a high-risk group for vaccine-preventable diseases, we did not find specific epidemiological evidence that diabetes increases the risk of any vaccine-preventable diseases.

Periodontal disease.

Periodontal disease (also called gingivitis or periodontitis) is a chronic inflammatory disease that is a common cause of tooth loss among older adults in the United States.^84–87 Diabetes is a significant risk factor for periodontal disease.^88–90 Results of a national survey showed that 15.1% of Americans aged 45 years or older with poorly controlled diabetes had severe periodontitis; only 6.0% of those whose diabetes was under better control and 4.3% of those without diabetes reported this condition. Results also showed that 20% of Americans aged 65 years or older needed a referral for periodontal disease treatment; 2.0% required an urgent referral.^91,92 The causal relationship between periodontal disease and diabetes was found to be bidirectional, with periodontal disease associated with impaired glycemic control and a risk of diabetes complications, notably cardiovascular problems, nephropathy, and ESRD.⁹³ No age-specific estimates were reported for participants with diabetes.

Urinary incontinence.

Estimates of the prevalence of urinary incontinence among US women aged 60 years or older range from 17% to 49%, and estimates of the direct medical costs of the condition range from $19.5 to $26 billion annually.^94,95 Population-based studies have shown that women with diabetes are at significantly higher risk for urinary incontinence than are those without diabetes.^94–97 These studies also showed increased risk with duration of diagnosed diabetes and indicators of severity of diabetes assessed via insulin use and evidence of existing microvascular disease.

Cognitive impairment.

Diabetes is a significant risk factor for cognitive impairment and the acceleration of cognitive decline.^60,98,99 The extent of cognitive decline among people with diabetes has been positively associated with the duration of their diabetes. Meta-analyses of studies among people with mean ages of about 70 to 80 years found that those with diabetes had a relative risk of 1.47 for dementia, 1.39 for Alzheimer's disease, and 2.38 for vascular dementia, with nondiabetic persons as the reference group.⁶⁰

Depression.

Health outcomes among diabetic patients tend to be worse among those who are depressed. For example, a study of US patients with newly diagnosed type 2 diabetes found that participants who were depressed had more physician office visits, emergency room visits and inpatient admissions, and prescriptions filled than did those who were not depressed, along with 65% higher overall health care costs.¹⁰⁰ Depression among older women with diabetes is linked to poor HRQOL and to negative effects on diabetes and other self-care regimens.¹⁰¹

Polypharmacy.

Older adults frequently take multiple prescription and nonprescription medications to reduce or prevent the complications associated with multiple medical conditions.^102,103 Paradoxically, however, such polypharmacy may also increase their risk of adverse events such as the onset or worsening of geriatric syndromes, drug interactions, and even death.^72,102,104 One review found that 50% to 60% of noninstitutionalized adults aged 65 years and older use 5 or more prescription medications and 2 to 4 nonprescription medications daily.¹⁰² A study of US nursing home residents found that 45% of those aged 65 to 84 years and 34.9% of those aged 85 years or older used at least 9 medications.¹⁰³ A 1994 to 1997 US study found that adult managed care enrollees with type 2 diabetes were prescribed an average of 4.2 medications.⁷² We found no national data on the use of multiple medications among older Americans by diabetes status.

Health-related quality of life.

Diabetes has been consistently associated with a reduced HRQOL^105–111 Factors contributing to this association include diabetes-specific complications, greater risk of other chronic conditions, and the effects of polypharmacy. A systematic review of persons with diabetes undergoing interventions to treat complications and comorbidities revealed significant improvement of HRQOL.¹¹² Unfortunately, this review did not specifically note the effectiveness of such interventions for older adults with diabetes.

Social circumstances.

Despite improvement in the social circumstances of older adults since the 1960s, many remain socioeconomically disadvantaged.¹¹³ The Federal Interagency Forum estimated that in 2007, 9.7% of Americans aged 65 years or older had annual incomes below the federal poverty level, including 8.8% of those aged 65 to 74 years and 13.0% among those aged 85 years or older.¹¹³ Among all Americans aged 65 years or older, women were about twice as likely as men to have annual incomes below the federal poverty level (12.0% vs 6.6%). The Interagency Forum also estimated that in the United States, 18.5% of men and 39.5% of women aged 65 years or older lived alone in 2008; almost 1 in 5 men and half of women aged 75 years and older lived alone. In both genders and all racial/ethnic groups, older Americans’ likelihood of having an annual income below the federal poverty level was greater among those who lived alone.

Although national data on the social circumstances of older adults with diabetes are sparse,¹¹⁴ several epidemiological studies have shown that among Americans in late middle age, those with diabetes were significantly more likely than their nondiabetic peers to be poorly educated and to live in low-income households.^115,116 These results suggest that the capacity of many older Americans to deal with diabetes and its consequences may be compromised by their social circumstances and that the likelihood of living in adverse circumstances is especially high among women, members of some minority racial/ethnic groups, and those who live alone. Smedley calls for comprehensive strategies that address inequality in many sectors, such as housing, education, and employment, as well as inequalities in health care.¹¹⁷

PUBLIC HEALTH INTERVENTIONS

Studies of adults (not specifically older adults) have demonstrated that tight control of blood glucose in patients with type 1 diabetes and control of both blood glucose and blood pressure in those with type 2 diabetes significantly reduced the risk of microvascular complications.^118–120 In general, a percentage point drop in the hemoglobin A1c concentration of a person with diabetes is associated with a 40% reduction in the risk of microvascular complications. Research has also shown the value of controlling lipids in adults with or at risk for diabetes.¹²¹ Partly as a result of these findings, diabetic patients are advised to “know their ABCS” (i.e., their A1c level, blood pressure, cholesterol level, and the importance of smoking cessation).^122–125

Guidelines

The Task Force on Community Preventive Services^126,127 and the US Preventive Services Task Force¹²⁸ have recommended evidence-based strategies for diabetes detection and management. In a systematic review of selected community-based interventions, the task force found strong evidence for the usefulness of case- and disease-management programs; for adults with type 2 diabetes, the review found sufficient evidence for the usefulness of diabetes self-management education in community gathering places, but insufficient evidence for the usefulness of in-home diabetes education.^129,130

Recent evidence indicates that screening for diabetes is not cost-effective among people aged 45 years or older.^131,132 The Preventive Services Task Force, however, recommends screening for type 2 diabetes among asymptomatic adults with sustained high blood pressure (> 135/80 mm Hg).¹³³ In 2005 to 2006, the estimated prevalence of undetected diabetes among Americans aged 65 years or older was 13.0%, and undetected cases accounted for more than 40% of all diabetes cases among older Americans.¹³⁴ Like uncontrolled diabetes, undetected diabetes among older adults is associated with an increased prevalence of CVD risk factors and an increased risk of cognitive impairment.^135–137

In 2003, the American Geriatrics Society established diabetes treatment guidelines for older adults.⁷³ These guidelines, based primarily on expert opinion, promote individualized patient care and education, prevention and control of cardiovascular risk factors, and screening to identify and treat patients with manifestations of geriatric syndromes. They recommend regulating glycemia to prevent and control microvascular complications, but also consideration of a higher glycemic target, as needed, according to diabetes severity, life expectancy, functional status, and patient preference.¹³⁸

The American Diabetes Association now has guidelines to address the needs of older adults, which recognize that when interventions cannot reach a lower glycemic target, a higher value for older adults might be acceptable and even might be further increased over time when the medical status and capacity of the patient decline with increasing age. These guidelines also encourage lifestyle modification, with the selection of anithyperglycemic medication that focuses on drug safety, and acknowledge that any increase in physical activity is advantageous in older patients or those with mobility limitations, if tolerated by an individual's cardiovascular system.⁷⁷ A recent systematic review of the effectiveness of interventions congruent with the association's guidelines showed that for older adults, interventions for hypertension were cost saving and for smoking cessation were cost-effective.¹³¹

Initiatives

In 1997, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health, and more than 200 partnering organizations launched the National Diabetes Education Program¹³⁹ to develop and disseminate diabetes education materials for a variety of audiences. These materials are not copyrighted, and some are aimed at older adults. More recent diabetes-related collaborative efforts include the Chronic Kidney Disease Initiative,¹⁴⁰ the Vision Health Initiative,¹⁴¹ the National Public Health Initiative on Diabetes and Women's Health,¹⁴² and state and territorial diabetes prevention and control programs.¹⁴³

The Chronic Kidney Disease Initiative is piloting a national surveillance system and developing a program to prevent and control CKD risk factors (especially hypertension), raise public awareness about CKD, promote early CKD diagnosis, and improve HRQOL and other health outcomes among people with CKD. The Vision Health Initiative works to promote vision health, which is closely related to mental and physical health, in all populations. Because diabetes is the leading cause of new cases of blindness among people aged 20 to 74 years, CDC chose to house the vision project in its Division of Diabetes Translation. The mission of the National Public Health Initiative on Diabetes and Women's Health is to prevent or delay diabetes, promote family and community support, promote appropriate diabetes care across the life stages, and prevent, delay, or minimize diabetes complications.¹⁴²

CDC funds 59 state and territorial diabetes prevention and control programs that promote the chronic care model and use a health systems approach¹⁴⁴ to address the needs of all adults with diabetes.¹⁴⁵ These programs work with local diabetes coalitions whose membership often includes organizations concerned with aging. Recently these programs and coalitions have been able to secure funding to use policy as a broad-based intervention.¹⁴⁶ CDC has developed tools to facilitate prevention and control efforts. For example, a seasonal campaign encourages older adults to receive annual influenza vaccinations,^147,148 although vaccine efficacy varies widely by age.^149,150 Another tool, the Physical Activity Reference Guide for Older Adults,¹⁵¹ helps groups choose and implement physical activity programs for older diabetic adults that are appropriate for their functional status.

Older adults, 80% of whom have 1 or more chronic conditions or cognitive or physical limitations, are especially vulnerable during emergencies,¹⁵² which often involve physical displacement and shortages of food, water, and medical supplies (e.g., glucose monitors and insulin) that diabetic patients need.¹⁵³ Governmental and nongovernmental organizations urge the public to be prepared and have produced numerous resources for use before, during, and after emergencies.^154–158

National Diabetes Prevention Program

In 2002, the Diabetes Prevention Program completed a research trial aimed at primary prevention of diabetes.^159,160 Participants either enrolled in an intensive lifestyle program with one-on-one counseling or took the drug Metformin.^159,160 Among those aged 60 years or older, participation in the lifestyle program was associated with a 71% reduction in risk of diabetes; use of Metformin was associated with little if any reduction in diabetes risk (Figure 3).^159,160 These results suggest that a lifestyle intervention is the only viable option for older adults who demonstrated a greater commitment to making healthful lifestyle changes than did younger participants, and that older adults drove the impressive findings found thus far in the Diabetes Prevention Program trial.¹⁶¹ Follow-up studies have shown that some degree of risk reduction can continue for 10 years or more.^162,163 More recently, research has shown that intensive lifestyle programs, delivered in group settings, can be effective as well as cost-effective or cost saving^164–170; results of one study suggested that lowering the Medicare eligibility age from 65 to 60 years could be of benefit.¹⁷⁰

FIGURE 3—

Reductions in diabetes incidence, by intervention and age group, in 1043 men and 2191 women, with mean age 51 years, with IGT and IFG: Diabetes Prevention Program, 1997–2001.

Note. IFG = impaired fasting glucose; IGT = impaired glucose tolerance.

Source. Knowler et al.¹⁵⁹

In response to a provision in the Patient Protection and Affordable Care Act,¹⁷¹ which authorized CDC to establish a national prevention program for adults at high risk for diabetes, CDC's Division of Diabetes Translation launched the National Diabetes Prevention Program.¹⁷² This program encompasses 4 components:

1. Train a work force to deliver the structured lifestyle program cost-effectively.

2. Implement a recognition program to ensure quality, and establish a registry of program sites.

3. Prepare sites to deliver the lifestyle program.

4. Market the program.

As of April 2012, more than 90 organizations participate by administering lifestyle programs.¹⁷³ These include inaugural partners such as the Y (also known as YMCA of the USA) and UnitedHealth Group.¹⁷²

Governmental Policy

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 expanded diabetic services covered by Medicare to include diabetes screening for beneficiaries at risk for the disease.^174,175 For beneficiaries with diabetes who meet eligibility requirements, Medicare covers diabetes self-management training. In certain circumstances, Medicare also covers other diabetes services, as well as diabetes supplies and care.

Healthy People 2020 offers a strategic framework for health coordinated by the Department of Health and Human Services in conjunction with other federal agencies, public stakeholders, and the department's Secretary's Advisory Committee on Health Promotion and Disease Prevention Objectives.¹⁷⁶ The chapter on diabetes proposes 16 diabetes-related objectives for adults in 6 areas: burden of disease; macrovascular, microvascular, and metabolic complications; laboratory services; health provider services; diabetes education; and patient protection behaviors.¹⁷⁷ A chapter on older adults calls for increasing by 10% the proportion of Medicare beneficiaries who receive diabetes self-management benefits.¹⁷⁸

The Diabetes Mellitus Interagency Coordinating Committee, led by the National Institute of Diabetes and Digestive and Kidney Diseases and incorporating representatives from many federal agencies, was established in 1974 to coordinate federal efforts to prevent and control diabetes. The committee has coordinated the Diabetes Prevention Program and other research efforts targeting older adults. At least 1 committee meeting was devoted to the treatment of older adults with diabetes.¹⁷⁹ The committee recently called for a clinical trial of optimized diabetes care for older diabetic patients to assess the value of such care in reducing diabetic complications and manifestations of geriatric syndromes, in particular impairment, activity limitations, disability, and falls.¹⁸⁰

OPTIONS FOR PUBLIC HEALTH ACTION

Efforts to elucidate and reduce the diabetes burden among older adults occur within a public health system that interfaces with medical care settings, state and local health departments, and a large array of partners with interests in or impacts on the diabetes and aging fields. Options for public health action can be categorized into 4 contexts: surveillance, programs, applied research, and policy.

Surveillance

Surveillance findings and projections based on those findings have helped define the burden of diabetes among older Americans and can help to evaluate progress in diabetes prevention and control.^15,181 Summaries of surveillance data for 10 groups of diabetes-related indicators¹⁸¹ and for diabetes-related mortality¹⁸² are shown in Tables 1 and 2, respectively, with data current for 2003 to 2010 at the time of compilation. Although these data begin for adults aged 45 years and older, few diabetes-related indicators were stratified for Americans aged 85 years or older or for institutionalized older adults; only rates for mortality, diabetes prevalence, and initiation of ESRD treatment produced estimates by gender, race/ethnicity, and age.

TABLE 2—

Diabetes Mortality by Race/Ethnicity, Age, and Gender Among Older Adults: United States, 2006

Racial/Ethnic Group	Age Group
	45–54 Years, No./100 000	55–64 Years, No./100 000	65–74 Years, No./100 000	75–84 Years, No./100 000	≥ 85 Years, No./100 000
Non-Hispanic Whites
Men	14.2	179.6	37.6	83.9	179.6
Women	7.9	23.3	33.6	127.8	244.3
Non-Hispanic Blacks
Men	34.3	92.6	191.3	334.2	468.2
Women	22.6	68.6	154.7	479.1	306.2
Hispanics
Men	16.2	49.9	14.7	257.7	381.2
Women	10.1	35.8	103.7	208.7	363.7

Source. National Vital Statistics System.¹⁸²

Table A (available as a supplement to the online version of this article at http://www.ajph.org) shows that among 58 indicators for percentages and rates, demographic coverage extended to age groupings for persons 45 years and older for all of the indicators, with only about 21% for gender by age, 9% for race by age, and about 3% for race by gender by age. None were available by socioeconomic and social circumstances,^113-116 for example, education, income, living alone, and so forth, which are important to characterize the current and future face of diabetes, especially among women.^114,142

An expanded and more systematic surveillance structure is needed for all adults aged 45 years and older at national, state, and local levels to routinely describe the prevalence of diabetes and its complications, the prevalence of comorbidities among diabetic patients, and the relationship between diabetes and health outcomes or factors such as geriatric syndromes, HRQOL, injuries, health-related behaviors, and preventive care practices. Such surveillance data should be broken down by major sociodemographic categories, such as gender, race/ethnicity, age, income, and education. Surveillance data should also be collected on the range and adequacy of diabetes-related services, the extent to which various groups use these services, and the views of older adults regarding the adequacy and accessibility of existing services. The need for an integrated surveillance system to collect such data can be expected to increase with the projected increase in the number of older Americans with diabetes.

One method of generating a sufficient quantity of relevant data is to aggregate (even by statistical smoothing techniques) multiple years of data on National Diabetes Surveillance System indicators, as Canada has done, to achieve finer age groupings for diabetes prevalence across the entire age span.¹⁸³ Another method is to establish a multisite regional surveillance system to monitor diabetes and diabetes-related conditions among older Americans, an approach already taken with youths.¹⁸⁴ Information about the institutionalized US diabetic population, which is currently scarce, could be gathered through surveys of residential care facilities and nursing homes.¹⁸⁵ In addition to collecting administrative information, such surveys should also collect data on biological measures for establishing the prevalence of prediabetes and diabetes, the rate of progression from prediabetes to diabetes, and the prevalence of various diabetes-related impairments and complications among the residents of these facilities.

Diabetes surveillance in the United States is Web based,¹⁸¹ which allows for frequent updating of indicators. As part of updating, it will be necessary to increase consistency in the use of standard age groupings for displaying data, to improve demographic coverage across combinations of age, gender, and racial/ethnic groups, and to introduce richer sociodemographic contrasts such as poverty, living in social isolation, and others (Table A, available as an online supplement). Laboratory hemogloblin A1c testing has been used to create registries of diabetic patients; reports are sent to both patients and physicians.^186,187 This has potential as a way to reach older adults with diabetes. Although such efforts have increased the ordering of A1c tests,¹⁸⁶ improvement of glycemic control in patients has not yet been shown.

Programs

Governmental agencies at all levels as well as various private organizations are engaged in the delivery of programs, services, and care for older Americans with diabetes. CDC's Division of Diabetes Translation works with state health departments and many partners to enhance these efforts. The 10 Essential Public Health Services provides a framework to formulate goals.^188,189

• Educate agencies and scientific and professional organizations about diabetes, aging issues, and the added impact of aging on older adults with diabetes, to ensure that those who direct and implement programs and deliver health care to older Americans with diabetes are competent, person oriented, and able to effect change at multiple levels.

• Mobilize and expand existing diabetes-related partnerships^140–142 to develop joint efforts that specifically address older adults.

• Link older adults with diabetes to needed health services, and foster the provision of quality health care, when otherwise unavailable, by training health professionals and community health workers to offer such services.

• Help reduce barriers to diabetes care and services for older adults with diabetes. This might involve teaching, health situation analyses, and ongoing assessments of diabetic adults to identify changes in physical, emotional, and social functioning.

Applied Public Health Research

Research conducted in real-world contexts is important to the advancement of public health.¹⁹⁰ Such research can help fill gaps in knowledge, stimulate public health programs, and inform policy change and development. It can also identify risk factors for diseases and conditions as well as protective factors that may lead to longer life, better HRQOL, and reductions in functional limitations.

Research can clarify how social determinants of health, family support, governmental policies, sociodemographic characteristics, and other factors are associated with various health outcomes and identify effective multilevel health-promotion strategies.^117,191,192 Applied research is especially important in exploring the public health implications of factors such as income insecurity and social isolation that are common among older people with diabetes.

Public Policy

Appropriate public policies can increase the availability and accessibility of services for older adults with diabetes. The following 5 public policy efforts can help improve health care services for older diabetic Americans:

• Facilitate coordination of services to older diabetic patients to eliminate service redundancy and increase patients’ use of existing services. The coordination of services is particularly important for noninstitutionalized patients, especially women, who often live alone and in poverty.

• Expand the delivery of in-home health care by using combinations of health professionals and lay people to provide services.

• Expand diabetes education to include people serving as caregivers for older adults with diabetes, including training on how to interface with health professionals in providing care.

• Ensure that standard medical care provided to older adults with diabetes includes formal systematic assessments of their physical, emotional, and social functioning so that any barriers to appropriate self-care can be identified and, if possible, overcome.

• Promote analytic modeling of the efficacy and cost-effectiveness of interventions specifically designed to help older Americans with diabetes. An area to consider is assessing the interventions to address geriatric syndromes by estimating constructs such as disability-free life expectancy, an approach similar to the concepts of compression of morbidity and active aging.^193,194

Public policies can also help increase the number of adequately trained health care providers, who are currently unable to meet the needs of the aging US population. Shortages of geriatricians, endocrinologists, and certified diabetes educators are particularly problematic for older adults with diabetes.^195–197 An Institute of Medicine report recommends easing workforce shortages by training informal caregivers to assist in health care.¹⁹⁸

CONCLUSIONS

The United States faces an urgent need to address diabetes among older Americans because indicators already reveal considerable mortality, morbidity, medical, and societal burdens, which are expected to continue growing. Because diabetes accelerates biological aging, many members of the baby boom generation can be expected to age prematurely: almost 8 in 10 older Americans already have diabetes or a less severe form of dysglycemia. Within only 40 years, clinicians who treat adult diabetes will likely see a preponderance of older patients. Complicating diabetes care in older adults are frequent comorbidities with microvascular and macrovascular disease and many debilitating manifestations of geriatric syndromes. Physicians have no clinical consensus on how best to treat older diabetic patients with these associated conditions.

Existing public health programs instituted to reach older diabetic patients may need to be modified to fully address their complex, specific needs and functional statuses, while remaining relevant to their interests and to the social and economic contexts in which they live. Possible modifications to these programs include greater use of lifestyle interventions, which have shown impressive early results. In addition, some creative revision of existing surveillance systems and applied public health research may lead to a better understanding of how diabetes affects HRQOL, its risks for other chronic conditions and geriatric syndromes, and the association of socioeconomic factors with diabetes and its related conditions.

If diabetes is to be prevented among older adults, or controlled to halt or slow the progression to otherwise inevitable complications, the public health community needs to develop, evaluate, and expand the reach of effective, targeted interventions that address the specific needs of older adults with or at risk for diabetes.