Optimal management of diabetes requires adherence to medication therapy and multiple other aspects of the treatment plan. Many barriers to treatment adherence exist, including complexity of the medication regimen, patients' perception of the benefits and risks of medication therapy, and multiple psychosocial-related factors. Diabetes management in older adults may be particularly complex depending on the presence of comorbidities, multiple medications, and cognitive and functional status. This article provides an introdudion to these major considerations in the management of adult patients with diabetes.
Patients with diabetes mellitus need a comprehensive and patient-centered treatment plan. Adherence is an important consideration in the management of managing this condition, as are the impact of diabetes-related distress and comorbid depression. Older patients with diabetes pose a particular challenge because they may have even more comorbidities than their younger counterparts, be more at risk for drug interactions and side effects due to multiple medications, and may also have functional and cognitive deficits. A brief overview of these considerations is provided herein.
Adherence to the treatment plan is often a challenge for patients living with any chronic medical condition but it can be particularly difficult for diabetes patients. All patients with type 1 diabetes and the majority of those with type 2 diabetes require drug therapy as part of their treatment plan. Successful achievement of diabetes control requires the patient not only to adhere to drug therapy but also to juggle a multitude of other tasks, including medical nutrition therapy and physical activity prescriptions, self-monitoring of blood glucose, frequent medical and laboratory appointments, and other selfcare activities such as daily foot exams.
MEDICATION ADHERENCE. A systematic review of the literature on medication adherence in diabetes reported that adherence rates range from 31% to 87% in retrospective studies and from 53% to 98% in prospective studies.1 Another systematic review reported that treatment persistence ranged from 16% to 80% in patients remaining on treatment for 6 to 24 months and insulin adherence in patients with type 2 diabetes was only 62% to 64%.2 Nonadherence to insulin therapy can be especially problematic. Fear of insulin therapy is common among those with type 2 diabetes and many factors contribute to "psychological insulin resistance" (Table I).35 Demographic variations to the acceptance of insulin therapy may also exist. A study of 178 adult patients with type 2 diabetes using validated interview measures found that women, Hispanics, Asians, Pacific Islanders, and Native Americans had significantly higher fear of injections than men or Caucasian patients.6
Medication nonadherence has been correlated with worse glycemic control and health outcomes. A retrospective study found that a 10% increase in nonadherence to metformin was associated with an increase of 0.14% in glycosylated hemoglobin (AlC) level.7 Medication nonadherence to oral diabetes medications, antihypertensives, and statin medications was correlated with higher AlC, systolic and diastolic blood pressure, and low-density lipoprotein cholesterol levels as well as increased risks for all-cause hospitalization and all-cause mortality.8
A variety of patient and prescriber-related barriers to medication adherence exist. Patient-related adherence barriers include fears (such as of worsening disease and side effects), lack of understanding about the rationale for the medication regimen, lack of skills and self-efficacy to manage the medication regimen, personal health beliefs, depression and/or presence of other concurrent medical conditions, poor health literacy, poor patient-prescriber relationship, adverse family dynamics, and lack of confidence in the immediate or future benefits of the medication.1,1011 Medication-related adherence barriers include complex regimen, frequency of dosing (2 or more times daily), cost, and adverse effects. …