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Quality of life in older people with diabetes

Key learning points:

 - The burden of diabetes in the older population

 - Using tools to assess quality of life in older people with diabetes

 - Identifying the factors important to quality of life in older people

Healthcare aims to reduce or eliminate the impact of disease morbidity and mortality. In addition, it should also improve or maintain the quality of life (QOL) for each patient. This is a particular challenge in older people with diabetes. QOL can be organised into different life domains which can all be assessed as part of a QOL assessment tool. Various assessment tools have been developed and evaluated, including the Audit of Diabetes-Dependent Quality of Life (ADDQOL) that has demonstrated validity, reliability and responsiveness. 

The highest aim of any healthcare system is to deliver optimal health care and to have a broader impact on the true quality of life of the patient. This is especially true in older people with diabetes as diabetes is a chronic disease with an additional negative impact on other aspects of aging including visual loss, mobility, frailty and dementia. The high prevalence of diabetes in older people, estimated to affect 6-9% of people aged 65 years and over in the UK,1 makes it all the more important that all aspects of the disease impact should be well managed. It has been shown in a survey in France in those aged >65 years with diabetes rated themselves as feeling worse than others and worried more about their health status.2 The accurate and broad assessment of healthcare outcomes and needs are essential to measure the true impact of disease on any patient. A broad range of health issues, including symptomatic impact and functional disability as well as emotional and social wellbeing, are all important factors that contribute to the overall quality of life of the patient. 

Assessment of quality of life

Several self-assessment tools or instruments have been developed in order to allow patients to report on their health-related QOL in varies areas. The different assessment instruments aim to include aspects of QOL that are important to patients as well as the general population. The optimal assessment tool should demonstrate validity, reliability and responsiveness. Assessment tools with a specific focus on diabetes have been developed to measure the impact of diabetes on the QOL of the patient with diabetes. The ADDQOL is individualised and aims to measure the perceived impact of diabetes on the quality of life in people with diabetes. The ADDQOL has demonstrated validity, reliability3-7 and responsiveness.8-10 In addition to a focus on diabetes, a special focus on the older person with diabetes is needed in order to assess the true QOL in this population group. For this purpose the ADDQOL Senior11 has been developed as a modification of the ADDQOL to assess the QOL for older people with diabetes. 

In the ADDQOL Senior, applicable life domains (the areas of QOL being measured, for example physical or emotional functioning) are determined by introducing a preliminary question for each one, resulting in a simplified assessment. The number of response options for the positive end of the impact scale was reduced from three to one, and as a result the impact score ranges from -3 to +1 instead of from -3 to +3, as scored in the original ADDQOL. There are two overview life domains at the beginning of the ADDQOL Senior that are scored separately from one another and from the main questionnaire. These overview life domains are the 'present quality of life' [scored from 'excellent' (+3) to 'extremely bad' (-3)] and 'diabetes-dependent quality of life' [scored from 'very much better' (-3) to 'worse' (+1)]. Patients are asked to rate the impact of diabetes and then its importance in their quality of life, for each domain-specific item. Usual scoring procedures are followed to calculate the weighted impact score for each applicable life domain by multiplying the impact rating by the importance rating. With the impact rating ranging from -3 to +1 and the importance rating ranging from 0 to 3, the weighted impact score will range from -9 negative to +3 positive. An average weighted impact (AWI) score is derived by adding together the weighted impact scores for all applicable domain-specific items and dividing by the number of applicable domains. 

Easy-to-use formats are very important for the older or visually impaired patient and enlarged fonts and vertical response formats with dot leaders are more user-friendly. Additional important life domains could be included in future assessments by making additions from an open-ended item option. An open-ended item to ask whether an assessment includes all the relevant life domains could improve assessments in the future. 

Managing and improving quality of life

In the management of diabetes in older people it is important to focus on the management of glucose control, the management of complications, assessment of functional status as well as the overall quality of life of the patient. 

The first important aspect to manage the QOL for older people with diabetes is to assess each patient using a validated assessment tool that has demonstrated validity, reliability and responsiveness. This will assess QOL for the older person with diabetes as well as the QOL in specific life domains. A targeted approach is needed to improve the QOL in the relevant life domains should help to improve the QOL aspects in these domains. Regular follow-up assessments to measure the improvement or deterioration in QOL in key areas will distinguish the most successful improvement strategies from less impactful ones. Additional important life domains could be included in future assessments by making additions from the open-ended item option. Practical aspects should also be considered including the font size, format, total length of the assessment tool and possible support from a carer or health care worker if needed. 

Conclusion

The assessment, management and improvement of the quality of life for older patients with diabetes remain an important challenge for the health care system and we have summarised some of the key issues in Box 1. The increase of diabetes in an ageing population will make this all the more important for the future. Focusing on symptomatic impact of disease as well as the emotional and social wellbeing of the patient can improve management decisions and outcomes. Improving the quality of life will result in improved overall care for older people with diabetes.

 

References

1. Sinclair AJ, Gadsby R, Penfold S, Croxson SCM, Bayer AJ. Prevalence of diabetes in care home residents. Diabetes Care 2001;24:1066-1068.

2. Bourdel-Marchasson I, Dubroca B, Manciet G, Decamps A, Emeriau JP, Dartigues JF. Prevalence of diabetes and effect on quality of life in older French living in the community: the PAQUID Epidemiological Survey. J Am Geriatr Soc 1997;45(3):295-301.

3. Bradley C, Todd C, Gorton T, Symonds E, Martin A, Plowright R. The development of an individualized questionnaire measure of perceived impact of diabetes on quality of life: the ADDQOL. Qual Life Res 1999;8:79-91.

4. Bradley C, Speight J. Patient perceptions of diabetes and diabetes therapy: assessing quality of life. Diabetes Metab Res Rev 2002;18:S64-S69.

5. Wee HL, Tan CE, Goh SY, Li SC. Usefulness of the Audit of Diabetes-Dependent Quality-of-Life (ADDQOL) questionnaire in patients with diabetes in a multi-ethnic Asian country. Pharmacoeconomics 2006;24:673-682.

6. Sundaram M, Kavookjian J, Patrick JH, Miller L-A, Suresh Madhavan S, Scott V. Quality of life, health status and clinical outcomes in Type 2 diabetes patients. Qual Life Res 2007;16:165-177.

7. Singh H, Bradley C. Quality of life in diabetes. Int J Diabetes Dev Ctries 2006;26:7.

8. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: Dose Adjustment for Normal Eating (DAFNE) randomised controlled trial. Br Med J 2002;325:746-749.

9. Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice: impact on current wellbeing and future disease risk. Br Med J 1998;317:1202-1208.

10. Ashwell SG, Bradley C, Stephens JW, Witthaus E, Home PD. Treatment satisfaction and quality of life with insulin glargine plus insulin lispro compared with NPH insulin plus unmodified human insulin in individuals with type 1diabetes. Diabetes Care 2008;31:1112-1117.

11. Speight J, Sinclair AJ, Browne JL, Woodcock A, Bradley C. Assessing the impact of diabetes on the quality of life of older adults living in a care home: validation of the ADDQOL Senior. Diabet Med 2013;30(1):74-80. doi: 10.1111/j.1464-5491.2012.03748.x.