Our study found that geriatric syndromes and hypoglycemia affect HRQL as much as, or more so, than diabetes complications in older adults with diabetes. Nearly all geriatric syndromes, diabetes complications, and hypoglycemia were associated with lower HRQL, suggesting that all of these conditions should be addressed in the care of older adults with diabetes. Many of these conditions were uniquely associated with lower HRQL; specifically, amputation, CHF, falls, chronic pain, MI, depression, underweight, and hypoglycemia were most strongly associated with lower HRQL. These conditions were more strongly associated with lower HRQL than diabetes-related characteristics, including duration of diabetes and insulin use.
Geriatric syndromes may be associated with HRQL to a comparable or greater degree than diabetes complications because they cause high morbidity, disability, are difficult to treat, and are less recognized (13
). For example, unlike many complications that can be treated with pharmacotherapy, reducing falls requires a multifactorial approach (21
). Also, because we have become more successful at preventing diabetes complications (22
), more patients are living longer with age-associated syndromes that interfere with HRQL. Because several geriatric syndromes were associated with substantively worse HRQL in older patients with diabetes, more research is needed on how to effectively screen and manage these conditions, especially depression and falls. There are likely complex interactions between geriatric syndromes, diabetes complications, and hypoglycemia that deserve further study.
We found that hypoglycemia was associated with lower mental HRQL, which provides additional support for relaxing glycemic targets in certain older adults with diabetes at high risk for hypoglycemia (1
). Older frail adults are at high risk for severe sequelae of hypoglycemia, including falls (2
), dementia (23
), and even death (24
). Results from the recent Action to Control Cardiovascular Risk in Diabetes (ACCORD) Trial (25
), which evaluated very intensive glycemic control in older adults, have heightened concerns about the harms associated with intensive glycemic control.
Our main analysis and sensitivity analysis showed some noteworthy differences. Chronic pain, depression, and incontinence were associated with lower HRQL in survey data compared with administrative data. The HRQL instrument included questions on emotional health and bodily pain, which likely caused some overestimation of the associations between HRQL and the survey-defined conditions. However, the overall findings that lower HRQL was associated with geriatric syndromes and hypoglycemia to at least the same, or greater, degree as diabetes complications was also observed in the sensitivity analysis.
Our study has several important strengths and limitations. This study included a large, ethnically diverse cohort of older adults with diabetes with detailed information on multiple comorbidities from both administrative and survey data. One important consideration in interpreting our results is that the study design was cross-sectional. Because HRQL was captured using survey data, there is likely a selection bias that would favor higher HRQL scores in respondents of the HRQL instrument than in nonrespondents. Characteristics of this managed care population may make some findings less generalizable. These limitations will likely affect absolute HRQL scores; however, relative differences in scores due to certain conditions are less likely to be affected. Also, we were not powered to study differences in HRQL by type of diabetes, and we could not study dementia because patients with dementia were under-represented in the survey.
In summary, we find that geriatric syndromes, diabetes complications, and hypoglycemia are associated with lower HRQL to a comparable degree in older adults with diabetes. In our efforts to maximize quality of life of older adults with diabetes, screening for and managing geriatric syndromes, and avoiding hypoglycemia, should be considered as high a priority as preventing diabetes complications.