Older Diabetes Patients Benefit From Group Education

Miriam E. Tucker

January 18, 2013

The benefits of group behavioral interventions for people with diabetes are not limited to the young, a new randomized trial demonstrates.

"Compared with younger adults, older adults receive equal glycemic benefit from participating in self-management interventions," Elizabeth A. Beverly, PhD, from the Joslin Diabetes Center, Boston, Massachusetts, and colleagues write in their article, which was published online January 11 in Diabetes Care.

Many clinicians are reluctant to refer older patients to group education, feeling that older people may require individual attention in order to benefit, study coauthor Katie Weinger, EdD, from the Joslin Diabetes Center, told Medscape Medical News.

The new study answers research questions posed in a recent consensus statement from the American Diabetes Association and the American Geriatrics Society regarding which diabetes-education approaches work best for older people with diabetes. "Our paper addresses these issues by including both middle-aged and older adults," Dr. Weinger told Medscape Medical News.

The study randomized a total of 222 adults aged 18 to 75, with diabetes for at least 2 years. All were in relatively good health but in poor diabetes control, defined as having a hemoglobin A1c of 7.5% or higher. They were divided into a younger group of 151 (mean age 53 years, mean A1c 9.0%) and 71 who were older (mean 67 years, A1c 8.7%).

Half of the younger group and nearly a third of the older group had type 1 diabetes, and the rest had type 2.

All 3 Subgroups Focused on Self-management

Patients in each group were randomly assigned to 1 of 3 interventions focusing on self-management. In the "highly structured" experimental arm, delivered in 5 group sessions over 6 weeks, diabetes educators taught patients how food, medication, and exercise affected their glucose levels and possible actions they could take when levels were out of range. Between classes, patients set daily goals and practiced problem solving.

An "attention control" intervention arm, also given in 5 group sessions over 6 weeks by diabetes educators, was a manual-based standard diabetes-education program. In the other study control group, educators delivered one-on-one sessions for 6 months, during which the patients could receive any type of information they requested. All group interventions were delivered separately to type 1 and type 2 diabetes patients.

Overall, hemoglobin A1c levels improved equally in the older and younger groups at 3, 6, and 12 months with all the interventions and for with both diabetes types.

At 12 months, compared with baseline, hemoglobin A1c levels were reduced from baseline among the older patients by 0.72 percentage points in the highly structured behavior group and by 0.65 percentage points in the attention control group. For the younger group, A1c reductions in the 2 group settings were 0.55 and 0.43 percentage points, respectively.

Differences between improvements for the older and younger patients in the highly structured group were not significant (P = .64), but for the attention group, the older patients' improvement was significantly greater than that of the younger ones (P < .001).

Both older and younger patients also improved in frequency of self-reported self-care, daily blood glucose monitoring, and in measures of depressive symptoms, diabetes-related quality of life, diabetes-related distress, frustration with self-care, diabetes-specific self-efficacy, and emotional coping following the interventions.

Group settings can be beneficial by allowing people to hear the questions asked by others and learn from others' approaches, Dr. Weinger told Medscape Medical News, adding that older adults "may also make a commitment to the group about attendance, and they may enjoy the company."

Older Patients Are "Highly Motivated" to Perform Self-care

Sandra D. Burke, PhD, CDE, immediate past president of the American Association of Diabetes Educators and clinical associate professor and director of the Urbana Regional Program at the University of Illinois College of Nursing, Urbana, agrees with the study's overall findings. "Anecdotal evidence suggests that cognitively intact community-dwelling elders, particularly the 'young old,' are highly motivated to perform self-care," she told Medscape Medical News.

"Very little research has been focused on the older adult population. This study examined the community-dwelling older adult with diabetes. Even though the study excluded individuals with major complications and serious comorbid conditions, this research adds to the body of literature of the impact of structured diabetes education in a growing population," added Dr. Burke.

Dr. Burke noted that diabetes-education interventions are available in most parts of the country and in diverse settings such as inpatient, outpatient, community, and home health, among others. The number of hours used in the study for the interventions are consistent with the initial Medicare benefit (10 hours of initial education followed by 2 hours annually thereafter), she said.

"There are data, however, that point out that the Medicare benefit for diabetes education is woefully underutilized. This study demonstrates there is a clear benefit to structured diabetes education in the older adult population. I would suggest there is an opportunity for primary-care providers to improve the health of their older adult patients with diabetes by partnering with diabetes educators," Dr. Burke told Medscape Medical News.

The study was funded by the National Institute of Diabetes, Digestive and Kidney Diseases. Meters and strips were donated for the study by Abbott Laboratories, LifeScan, and Roche Diagnostics. Neither Dr. Weinger nor Dr. Beverly has any other disclosures; two of the coauthors consult for several manufacturers of diabetes-related products. Dr. Burke is a consultant for Janssen Pharmaceuticals and Genentech Pharmaceuticals.

Diabetes Care. 2013. Published online January 11, 2013. Abstract