How to eliminate the link between diabetes and disability in late life?

Due to the growing aging population, non-pharmacological interventions to prevent diabetes-related disability is critical to potentially reduce the costly healthcare and excess mortality. Reviewing existing preventive interventions, there are two things that one needs to be aware of. First, currently, limited interventions have been developed to prevent disability for older adults with diabetes.^6-8 Several systematic reviews have shown that interventions are mostly focusing on lifestyle interventions (physical activity and a healthy diet) and self-management interventions to promote metabolic control.^9-10 However, poor glycemic control was not necessarily associated with disability in older adults with diabetes.^1,3 Second, even lifestyle interventions are widely acknowledged to promote muscle strength, physical function, and reduce premature disability for older adults,¹¹ little evidence have supported the claim that lifestyle interventions may prevent disability. Keysor, Lorig, and Simonsick et al. all found that the benefits of physical activities in preventing disability is rarely understood in late life.^4,11,12 This fact may be explained by three limitations in current lifestyle interventions. First, disability is less chosen as a primary outcome in lifestyle interventions.⁵ Second, there is a widely believed that managing physical activities, healthy diets, and medication can transfer and generalize to promote other daily activities to prevent disability.⁹ However, we need more evidence to confirm: does the improved physical function actually prevent or delay disability in late life? One may suggest that physical activity interventions can prevent mobility disability in late life. However, disability has been considered as an umbrella concept that includes mobility disability (walking, climbing, or standing), ADL disability (eating and dressing), and IADL disability (shopping, driving, or preparing meals).^2,13-15 We need to further understand whether physical activity programs not only prevent mobility disability but also prevent ADL and IADL disability. Third, some lifestyle interventions have been successfully engaged older adults in exercises and healthy diets. How to support continued engagement in physical activities and healthy diets are critical to prevent disability long-term.

After discussing current gaps in the interventions for preventing disability for older adults with diabetes, one may think: what are the next steps for future research to prevent disability for older adults with diabetes? In fact, there are three steps when one considers preventing disability for older adults with diabetes:

• Define and decide what kind of disability you want to prevent. Older adults with diabetes reported different types of disability (mobility; ADL; IADL) in daily lives.^1,2,16,17 For example, Maty et al. found that among 3570 non-institutionalized female older adults with diabetes, 51% of them have difficulties walking 2-3 blocks, 31% of them had difficulties shopping, and 30% of them had difficulties bathing and showing.¹⁷ If one wants to prevent disability for older adults with diabetes, strategies should target on preventing mobility, ADL, and IADL disability.
• Consider the type of prevention you are going to apply. Since older adults with diabetes are at high risk of developing risk factors of disability (depressive symptoms; cognitive impairment), one should apply the concept of indicative prevention: older adults who are experiencing early signs of disability or other risk factors associated with disability and treat them with special programs to reduce the risk factors.
• Identify specific active ingredients to maintain the effects of interventions. A systematic review of active ingredients in interventions had found that non-pharmacological interventions focused on behavioral changes rarely specified techniques to maintain the effects of interventions. Research has found that older adults with diabetes who maintained engagement in social activities had a better survival rate over a 2 year period.¹⁸ When one is developing interventions to prevent disability, there is a need to identify active ingredients for both initiating and continuing engagement of daily activities for older adults with diabetes.¹⁹

Diabetes-related disability is a problem that reduces older adults’ quality of life and health. Preventing disability for older adults with diabetes is important to potentially reduce the substantial healthcare costs in late life. With all the medical, psychological, and social factors that increase the risk of disability in older adults with diabetes, interventions that focus on diabetes diagnoses alone are not sufficient to explain the heterogeneity of disability in late life.²⁰ Medical management itself is not sufficient to prevent disability. Future interventions that aim to prevent disability should be individualized and tailored to older adults’ unique medical, psychological, and social situation. Indicated prevention Interventions should include strategies to address the interactions between risk factors (depressive symptoms. and cognitive impairment) and disability in older adults with diabetes. Without considering the active ingredients that address social and environmental factors, preventing disability in late life is less likely to happen.

References

1. Kalyani RR, Saudek CD, Brancati FL, Selvin E. Association of diabetes, comorbidities, and A1C with functional disability in older adults: Results from the National Health and Nutrition Examination Survey (NHANES), 1999-2006. Diabetes Care. 2010;33(5):1055-1060.
2. Wong E, Backholer K, Gearon E, et al. Diabetes and risk of physical disability in adults: A systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2013;1(2):106-114Bruce DG, Davis WA, Davis TME. Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes. Diabetes Care. 2005;28(10).
3. Bruce DG, Davis WA, Davis TME. Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes. Diabetes Care. 2005;28(10).
4. Simonsick EM, Guralnik JM, Volpato S, Balfour J, Fried LP. Just get out the door! Importance of walking outside the home for maintaining mobility: Findings from the women’s health and aging study. J Am Geriatr Soc. 2005;53(2):198-203.
5. Stewart A, Guralnik JM, Balfour J, Fried LP, deLateur BJ, Schwartz RS. Conceptual challenges in linking physical activity and disability research. Am J Prev Med. 2003;25(3):137-140.
6. Gregg EW, Caspersen CJ. Review: Physical disability and the cumulative impact of diabetes in older adults. Br J Diabetes Vasc Dis. 2005;5(1):13-17.
7. Gregg EW, Boyle JP, Thompson TJ, Barker LE, Albright AL, Williamson DF. Modeling the impact of prevention policies on future diabetes prevalence in the United States: 2010–2030. Popul Health Metr. 2013;11.
8. Gregg EW, Brown A. Cognitive and physical disabilities and aging-related complications of diabetes. Clin Diabetes. 2003;21(3).
9. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care. 2001;24(3):561-587.
10. Schellenberg ES, Dryden DM, Vandermeer B, Ha C, Korownyk C. Lifestyle interventions for patients with and at risk for type 2 diabetes. Ann Intern Med. 2013;159(8):543.
11. Keysor JJ, Jette AM. Have We oversold the benefit of late-life exercise? Journals Gerontol Ser A Biol Sci Med Sci. 2001;56(7):M412-M423.
12. Lorig KR, Holman HR. Self-management education: History, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26(1):1-7.
13. Cigolle CT, Langa KM, Kabeto MU, Tian Z, Blaum CS. Geriatric conditions and disability: The health and retirement study. Ann Intern Med. 2007;147(3):156.
14. Murtagh KN, Hubert HB. Gender differences in physical disability among an elderly cohort. Am J Public Health. 2004;94(8):1406-1411.
15. Wray LA, Blaum CS. Explaining the role of sex on disability: A population-based study. Gerontologist. 2001;41(4):499-510.
16. Wu JH, Haan MN, Liang J, Ghosh D, Gonzalez HM, Herman WH. Diabetes as a predictor of change in functional status among older Mexican Americans: A population-based cohort study. Diabetes Care. 2003;26(2):314-319.
17. Maty SC, Fried LP, Volpato S, Williamson J, Brancati FL, Blaum CS. Patterns of disability related to diabetes mellitus in older women. J Gerontol A Biol Sci Med Sci. 2004;59(2):148-153.
18. Kuo Y-F, Raji MA, Peek MK, Goodwin JS. Health-related social disengagement in elderly diabetic patients. Diabetes Care. 2004;27(7).
19. Greaves CJ, Sheppard KE, Abraham C, et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011;11(1):119.
20. Leveille SG, Fried L, Guralnik JM. Disabling symptoms: What do older women report?. J Gen Intern Med. 2002;17(10):766-773.