Studies show that the prevalence of type 2 diabetes among adults aged 65 and older in the United States ranges between 20% and 25%. However, controversy has surrounded the most appropriate approaches to treating and managing diabetes in older adults, particularly with regard to identifying therapeutic targets for A1C and the control of other cardiovascular risk factors. In addition, research suggests there are disparities in risk factor control among racial and ethnic minorities with diabetes when compared with whites who have the disease.
“Diabetes continues to be a major public health problem among older racial and ethnic minorities,” says Hermes J. Florez, MD, MPH, PhD. There are important factors to consider when managing this older patient group and developing treatment targets. These include the potential for adverse effects when using pharmacologic treatment, risks for hypoglycemia, and individual comorbidities, among other factors.
A Closer Look
For a study published in Diabetes Care, investigators assessed data from the Atherosclerosis Risk in Communities (ARIC) study (2011–2013), which involved non-institutionalized, community-dwelling older adults with diabetes. The cross-sectional analysis involved more than 5,000 participants aged 67 to 90 with and without diagnosed diabetes who attended the fifth visit of the ARIC study. The authors evaluated the prevalence of glycemic, lipid, and blood pressure (BP) control overall and by race.
The study also investigated correlates of meeting treatment targets and whether or not racial differences in risk factor control could be explained by demographic and clinical characteristics. Stringent risk factor targets were defined as having an A1C of less than 7%, an LDL cholesterol (LDL-C) level of less than 100 mg/dL, and a BP level of less than 140/90 mm Hg. Less stringent risk factor targets were defined as A1C of less than 8%, LDL-C of less than 130 mg/dL, and BP less than 150/90 mm Hg.
Results of the analysis showed that most of the older adults with diabetes in the study met stringent and less stringent targets for A1C, LDL-C, and BP (Figure). “However, only about one-third of patients in the study met their targets of all three of these risk factors,” says Dr. Florez. “Regardless of how targets were defined, older white patients were more likely to meet their targets than older black patients. Importantly, black women were less likely than white women to meet targets for BP and the combination of all three risk factors.” After adjusting for demographic and clinical characteristics—including functional status and comorbidities—the study authors did not observe any appreciable changes in the association of race with meeting targets.
Findings of the study extend those from previous reports indicating that racial and socioeconomic disparities in risk factor control are prevalent in adults with diabetes. “It’s possible that there are racial differences in access to healthcare, treatment approaches, and medication adherence,” Dr. Florez says. “These factors may contribute to the observed disparities in risk factor control.”
Previous research has shown that many older adults may not reap the full benefits of having their diabetes risk factors tightly controlled. Older adults may be at particularly high risk of adverse events caused by hypoglycemia and hypotension. “The risks of tight treatment targets may outweigh the benefits,” says Dr. Florez. “As such, it’s important for clinicians to tailor their treatments for vulnerable populations, especially older racial and ethnic minorities. However, while there has been increasing emphasis on the need for individualized targets, it’s unclear how to optimize treatment in older adults to maximize health benefits and minimize risks for adverse outcomes.”
The most recent Standards of Care document from the American Diabetes Association recommends that clinicians pay special attention to racial and ethnic minorities when managing type 2 diabetes. “Healthcare providers need to look at additional risk factors when caring for these patients,” Dr. Florez says. “There is a need to improve care in ethnic minorities—especially black women—to narrow racial disparities.”
Older adults are a heterogeneous group, and it is still unknown if it is beneficial to treat older patients to very low risk factor targets. Randomized clinical trials in older racial and ethnic minorities with diabetes are needed to define appropriate treatment approaches and risk factor targets. “We also need to explore ways to optimize treatments for other racial minorities, including Latinos and Asian Americans,” says Dr. Florez. “In the meantime, data from this study can help researchers with the planning of clinical trials to address unanswered questions in this patient group.”
Parrinello CM, Rastegar I, Godino JG, Miedema MD, Matsushita K, Selvin E. Prevalence of and racial disparities in risk factor control in older adults with diabetes: the Atherosclerosis Risk in Communities Study. Diabetes Care. 2015;38:1290-1298. Available at: http://care.diabetesjournals.org/content/38/7/1290.full.
American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015;38:S1-S93.
Selvin E, Parrinello CM, Sacks DB, Coresh J. Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med. 2014;160:517-525.
Kirkman MS, Briscoe VJ, Clark N, et al. Diabetes in older adults. Diabetes Care. 2012;35:2650-2664.