Type 1 diabetes in older adults: Comparing treatments and chronic complications in the United States T1D Exchange and the German/Austrian DPV registries

https://doi.org/10.1016/j.diabres.2016.09.024Get rights and content

Highlights

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    Study of T1D adults ≥60 years in the US and German/Austrian.

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    Individuals in both registries were similar in BMI, percent with obesity, and gender.

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    Greater use of antihypertensives, statins and insulin pumps in the US.

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    Fewer chronic complications in the US.

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    Further research is needed to improve outcomes in older adults with T1D.

Abstract

Aims

Compare characteristics, therapies and clinical outcomes in older adults with type 1 diabetes in the United States T1D Exchange (T1DX) and German/Austrian Diabetes Patienten Verlaufsdokumentation (DPV) registries.

Methods

Cross-sectional study of adults ≥60 years old with type 1 diabetes seen in 2011–2012 in the T1DX (n = 1283) and DPV (n = 2014) registries. Wilcoxon rank-sum test was used for continuous variables and chi-square test for categorical variables. Adjusted analyses used generalized linear models.

Results

Individuals in both registries were similar in body mass index (mean 27 kg/m2), percent with obesity (25%) and gender (48% male). In T1DX there was longer diabetes duration (32.3 vs. 28.8 years), greater use of antihypertensive medications (including ACE-I and ARBs; 85% vs. 62%), statins (68% vs. 40%), aspirin (77% vs. 21%), insulin pumps (58% vs. 18%), and less smoking (7% vs. 10%); lower adjusted mean LDL-cholesterol (84 vs. 109 mg/dL), and lower adjusted mean systolic and diastolic blood pressures (128 vs. 136 and 68 vs. 74 mmHg); fewer myocardial infarctions (6% vs. 9% [99% CI of difference, 1% to 5%]), strokes (2% vs. 8% [3% to 7%]), microvascular complications including microalbuminuria (17% vs. 44% [22% to 32%]) but increased depression (16.1% vs. 8.7%). Adjusted mean HbA1c levels were similar (7.5%, 58 mmol/mol).

Conclusions

Differences between the registries included greater use of antihypertensives, statins and insulin pumps, and fewer chronic complications in the T1DX. Further research is needed to better understand the role of intensive therapy in improving outcomes in older adults with type 1 diabetes.

Introduction

Older adults with long-standing type 1 diabetes are a growing population globally due to rising incidence and increasing longevity [1], [2], [3], [4], [5], [6], but management strategies for these individuals have not been a focus of investigation. Most research in older adults has concentrated on people with type 2 diabetes, many of whom, in contrast to those with type 1 diabetes, do not need insulin therapy. The pathophysiology of type 1 diabetes and the development of cardiovascular and renal disease in type 1 diabetes differs from that observed in type 2 diabetes [7]. Reports from the United States (US) show that the incidence of chronic vascular complications of diabetes, with the exception of end stage renal disease, has declined in adults ≥65 years of age, but most of these individuals had type 2 diabetes [8].

Studies examining treatment approaches and complications in type 1 diabetes in the elderly are lacking. In Germany, patients with type 1 diabetes >60 years of age compared to those ≤60 years demonstrated greater microalbuminuria, retinopathy, myocardial infarctions, and strokes as well as lower hemoglobin A1c (HbA1c) levels, and less use of insulin pump therapy [9]. Results from the Pittsburgh Epidemiology of Diabetes Complications Study [10] suggest that in type 1 diabetes, inadequate treatment of hypertension and microalbuminuria relate to major adverse outcomes of diabetes (diabetes-related death, myocardial infarction, revascularization procedure/blockage ≥50%, stroke, end stage renal disease, blindness, amputation). Optimal blood pressure, lipid and glycemic goals (for the prevention of complications) for adults with type 1 diabetes ≥60 years of age are also unclear. These may not be the same as those recommended for younger patients with type 1 diabetes or for people with type 2 diabetes.

Generally, in the elderly with diabetes, evaluation and management strategies emphasize the prevention of complications that can adversely affect quality of life. In older adults in good health, longer-term prevention and treatment of microvascular and macrovascular diabetes-related complications remain important goals. How best to accomplish these objectives in older adults with type 1 diabetes is unclear. The primary aim of this study is to compare demographic and anthropometric characteristics, management approaches, cardiovascular risk factors, and diabetes-related complications in adults age 60 years or older with type 1 diabetes from the US and Germany/Austria.

Section snippets

Study design and participants

Analyses are based on multi-center cross-sectional observational data of participants from the T1D Exchange (T1DX) registry (US) and the German/Austrian Diabetes Patienten Verlaufsdokumentation (DPV) registry who were ≥60 years of age at enrollment and seen in 2011 to 2012. A 1% error margin (i.e. expressed as 99% confidence intervals of difference) was used due to the large number of participants.

There were 32 T1DX adult centers that contributed 1283 participants for these analyses; median

Participant characteristics

Participant characteristics are shown in Table 1. Overall, there were 3297 participants (T1DX n = 1283; DPV n = 2014) with an age range of 60.0–93.6 years. Participants in the two registries were similar in gender (48% male), BMI (mean 27 kg/m2), and prevalence of obesity (25% with BMI >30 kg/m2). T1DX participants were slightly younger at time of enrollment compared with DPV (mean age 67.3 vs. 70.8 years; 99% CI of difference, 2.8 to 4.1 years); 73% (n = 935) vs. 47% (n = 937) were between the ages of 60

Conclusion

Individuals with type 1 diabetes have a shortened life expectancy, even with excellent glycemic control, with cardiovascular disease being a major contributor [14], [15], [16]. We report fewer myocardial infarctions and strokes in adults ages ≥60 years of age in the T1DX (US) clinic registry compared to the German/Austrian DPV, despite similar mean BMI and prevalence of obesity. In the T1DX, there was also higher statin, antihypertensive, and asprin use, lower blood pressures and LDL levels

Funding

The T1D Exchange is supported through the Leona M. and Harry B. Helmsley Charitable Trust. The DPV is supported through the German BMBF competence network Diabetes mellitus (FKZ 01GI1106), which was integrated into the German Center for Diabetes Research (DZD) as of January 2015.

Role of funder statement

The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Acknowledgments

RSW and CGC researched data and wrote/edied the manuscript. JMH performed statistical analyses. ISF, DMM, MS, SA, SHE, RWB, and RWH research data and reviewed/edited the manuscript.

RSW’s non-profit employer is the site for multicenter clinical trials sponsored by Eli Lilly, Medtronic Inc, Astra-Zeneca, GlaxoSmithKline, Mylan and Calibra. ISF, CGC, JMH, MS, and SA have no disclosures. DMM is on the advisory board for Insulet and his non-profit employer has received research funding from

References (21)

  • S. Ioacara et al.

    Improvements in life expectancy in type 1 diabetes patients in the last six decades

    Diabetes Res Clin Pract

    (2009)
  • D.M. Maahs et al.

    Epidemiology of type 1 diabetes

    Endocrinol Metab Clin North Am

    (2010)
  • J.M. Lawrence et al.

    Trends in incidence of type 1 diabetes among non-Hispanic white youth in the United States, 2002–2009

    Diabetes

    (2014)
  • E. Selvin et al.

    Trends in prevalence and control of diabetes in the United States, 1988–1994 and 1999–2010

    Ann Intern Med

    (2014)
  • C. Abi Khalil et al.

    Cause-specific mortality in diabetes: recent changes in trend mortality

    Eur J Prev Cardiol

    (2012)
  • C. Gong et al.

    Trends in childhood type 1 diabetes mellitus incidence in Beijing from 1995 to 2010: a retrospective multicenter study based on hospitalization data

    Diabetes Technol Ther

    (2015)
  • S.D. de Ferranti et al.

    Type 1 diabetes mellitus and cardiovascular disease: a scientific statement from the American Heart Association and American Diabetes Association

    Diabetes Care

    (2014)
  • E.W. Gregg et al.

    Changes in diabetes-related complications in the United States, 1990–2010

    N Engl J Med

    (2014)
  • M. Schutt et al.

    Multiple complications and frequent severe hypoglycaemia in ’elderly’ and ’old’ patients with Type 1 diabetes

    Diabet Med

    (2012)
  • R.G. Miller et al.

    Changing impact of modifiable risk factors on the incidence of major outcomes of type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications Study

    Diabetes Care

    (2013)
There are more references available in the full text version of this article.

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