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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 169-176

Impact of diabetes on the risk of geriatric conditions among patients seen in a tertiary care hospital in India


1 Department of Pharmacy Practice, JSS College of Pharmacy, Mysuru, Karnataka, India
2 Department of Emergency Medicine, JSS Medical College and Hospital, Jagadguru Sri Shivarathreeshwara University, Mysuru, Karnataka, India

Date of Web Publication9-Aug-2017

Correspondence Address:
Parthasarathi Gurumurthy
Department of Pharmacy Practice, JSS College of Pharmacy, Jagadguru Sri Shivarathreeshwara University, Mysuru - 570 015, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_167_16

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  Abstract 


Context: Geriatric conditions (GCs) are associated with poor quality of life, higher morbidity and mortality among the elderly.
AIMS: To assess the risk of diabetes mellitus (DM) on GCs and the effect of gender differences on this association.
Materials And Methods: A cross-sectional, observational study was conducted in a tertiary care teaching hospital for eight months. Patients with ≥60 years of age were included. Selected GCs included cognitive impairment (CoI), falls, depression, urinary incontinence (UI), dizziness, lower body mass index (BMI), visual impairment (VI), and hearing impairment. The Short Portable Mental Status Questionnaire and Geriatric Depression Scale were used to assess CoI and depression, respectively. Other GCs, DM, and comorbidities were self-reported. Binary logistic regression analysis was used to identify the risk of GCs among DM patients.
Results: A total of 1150 patients were included; more than half (65%) were males and 60% aged between 60 and 69 years. After adjustment for basic demographics and comorbid conditions, DM was associated with increased risk of overall GCs (risk ratio [RR]: 1.41; 95% confidence interval [CI]: 1.01–1.96; P = 0.04) and specifically for UI (RR: 2.91; 95% CI: 2.09–4.04; P< 0.001) and VI (RR: 1.59; 95% CI: 1.16–2.18; P< 0.001). We found less risk of lower BMI among patients with diabetes (RR: 0.49; 95% CI: 0.32–0.77; P< 0.001). In the subgroup analysis, males were found to have significant increased risk to get GCs (RR: 1.60; 95% CI: 1.05–2.44; P = 0.02) than females (RR: 1.28; 95% CI: 0.71–2.30; P = 0.08).
Conclusions: DM was associated with excessive risk for GCs, especially for UI and VI.

Keywords: Cross-sectional study, diabetes mellitus, geriatric conditions


How to cite this article:
Varghese A, Undela K, Gurumurthy P, Gopalakrishna NM. Impact of diabetes on the risk of geriatric conditions among patients seen in a tertiary care hospital in India. Int J Health Allied Sci 2017;6:169-76

How to cite this URL:
Varghese A, Undela K, Gurumurthy P, Gopalakrishna NM. Impact of diabetes on the risk of geriatric conditions among patients seen in a tertiary care hospital in India. Int J Health Allied Sci [serial online] 2017 [cited 2019 Sep 21];6:169-76. Available from: http://www.ijhas.in/text.asp?2017/6/3/169/212592




  Introduction Top


Diabetes mellitus (DM), a syndrome affecting the metabolism and vasculature of the body, has rapidly increased to epidemic proportions with its dire relation to atherosclerosis (myocardial and cerebral infarction), nephropathy, neuropathy, and retinopathy.[1] In 2015, 415 million people were estimated currently have diabetes worldwide, which is projected to be 642 million by 2040. It is also expected that the number will be highly concentrated in the urban areas of the world. The top three countries with the highest number of adults with diabetes identified as China (109.6 million), India (69.2 million), and the United States of America (29.3 million). In India, it is projected reach 123.5 million people with diabetes by 2040.[2]

The aging population has been an important upcoming demographic phenomenon in India.[3] According to the United Nations, a country is termed as “aging,” when 7% of the individuals in that country have crossed 60 years of age.[4] With the rapid changes in demographic patterns, it can be anticipated that the Indian population will undergo “aging” in the next couple of decades. Currently, India has about 116 million elderly people. Under a medium-fertility scenario, the United Nations Population Division projects that elderly people will comprise 19% of India's total population by 2050 – more than 324 million individuals, which is more than the current populations of all but five of the world's nations.[5]

As the aging population is rising, the greatest relative risk of diabetes is estimated to occur in the older population. It is estimated that there will be 200.5 million individuals aged 65 years or older with diabetes worldwide by 2040, more than double the number estimated in 2015 (94.2 million).[2] In addition to the classical cardiovascular diseases (CVDs) and microvascular complications associated with diabetes, conditions referred to as “geriatric syndromes” occur in higher proportions in elderly individuals with diabetes, leading to functional impairment and more complex health status.[3] The common geriatric conditions (GCs) are identified as cognitive impairment (CoI), depression, falls, urinary incontinence (UI), low body mass index (BMI), dizziness, visual impairment (VI), and hearing impairment (HI).[6] Even though effective medical interventions are available, GCs still remain underdiagnosed recognized to a great extent and hence left untreated in most cases.

Considering other related studies on this topic, it was observed that the present study was the first ever to be carried out in India. Previous studies have included relatively few of the GCs and the gender variations in the various GCs were not addressed in detail.[6],[7],[8] Taking into consideration all the limitations of the previous studies, this study has been conducted to assess the propensity for diabetes to be associated with GCs in both the genders.


  Materials and Methods Top


A cross-sectional study was carried out in a tertiary care teaching hospital over a period of eight months from June 2013 to February 2014. The study was approved by the Institutional Human Ethics Committee.

Patients aged ≥60 years, of either gender, admitted to the hospital as in-patients, or seeking consultation on an outpatient basis, and who gave their consent to be involved were included in the study. Patients were excluded if they were mentally disabled or admitted to the critical care or emergency units of the study hospital. Information was retrieved from the patient's prescriptions, medical records, and interview with the patient and/or carers and documented in a specially designed data collection form. Data collection form contains the components such as patient demographic details, reason for admission, medical history, diagnosis, status of DM, medication history, and GCs. A proxy respondent answered the questions if the eligible older adults could not be interviewed or could not complete the interview because of medical or communication problems.

The presence of diabetes was assessed by asking respondents whether they were diagnosed with diabetes by a physician and the same were confirmed by verifying the medical records. If the subject had diabetes, enquiry was made on the duration of the disease and medications with which the subject was treated at the time of hospital presentation. All patients irrespective of diabetes status were interviewed to assess the presence or absence of any of the GCs including CoI, falls, low BMI, VI, depression, dizziness, UI, and HI. The presence of GCs was taken into consideration only if it occurred after the diagnosis of diabetes or at any time in patients without diabetes.

CoI was assessed using the Short Portable Mental Status Questionnaire (SPMSQ). The SPMSQ scale is an observer-rated 10-item questionnaire used to evaluate the orientation and memory of the subjects involved. Accordingly, four levels of mental health were categorized. 0–2 errors represented normal mental functioning; 3–4 errors was mild CoI, 5–7 errors depicted moderate cognitive function, and errors above 8 represented severely impaired cognition. One more error was allowed if a patient had lower grade schooling whereas one less error if the education was beyond the high school level.

The Geriatric Depression Scale (GDS) was used for the determination of depression in the elderly subjects. The GDS is a 15-item questionnaire in which the basic attitude of the subject to things around them is assessed, including interaction with society or the general outlook between the patient and their environment. Each depressive answer accounted for 1 error. If the subject scored a value of 5 or above, it is likely that the patient suffers from depression.

A fall was regarded as any self-reported unintentional fall to the ground, regardless of injury, during the past 12 months. UI involved self-reported unintentional urine leakage during the past 12 months including urge, frequency, incontinence, or even nocturia. HI was defined as self-reported poor hearing despite using hearing aids. VI was defined as self-reported poor eyesight despite using corrective lenses. Low BMI (<18 kg/m 2) was calculated from self-reported and/or measured height and weight. Dizziness represented a true vertigo episode, light-headedness, weakness, unsteadiness, or even a feeling of fainting, with or without the involvement of visual disturbances during the past 12 months.

Continuous variables such as age and BMI were represented as “mean (standard deviation [SD])” and categorical variables as “number (%).” Independent sample t-test and Chi-square test were used for continuous and categorical variables, respectively, to identify the significant difference between variables among diabetics and nondiabetics. Prevalence of GCs among patients with or without diabetes was analyzed by considering the eight GCs collectively and individually. Binary logistic regression analysis was used to examine the association between diabetes and GCs. Analysis was done using four models to identify the influence of confounders on the above association: Model 1 unadjusted relative risk; Model 2 adjusted for basic demographics such as age, gender, BMI, marital status, education, living area, smoking and alcohol status; Model 3 adjusted for variables in Model 2 plus co-morbid conditions like hypertension, CVD, chronic kidney disease (CKD), cerebrovascular accidents (CVAs), chronic obstructive pulmonary disease, asthma, arthritis, tuberculosis and cancer and medications received; Model 4 adjusted for variables in Model 3 plus seven other GCs. As this study not aimed for proving an association between specific antidiabetic drug exposure among elderly and specific GC, no formal sample size calculation was performed and recruited 90% of the eligible patients during the study period. The results were considered statistically significant at a standard of P< 0.05. All the analyses were carried out using Statistical Package for Social Sciences (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp).


  Results Top


A total of 1150 patients were enrolled in the study. The prevalence of diabetes was 35.3% among the study population (34.4% among males and 36.9% among females). Mean (SD) age of the patients was found to be 68.4 (7.5) years and did not differ significantly between diabetics and nondiabetics. About 60% of patients were aged between 60 and 69 years. [Table 1] and [Table 2] represent the demographic details of patients by diabetes status and both gender and diabetes status, respectively. BMI was found to be significantly higher among elderly diabetics. Gender, marital status, smoking, and alcohol status of patients did not differ significantly between the groups. More nondiabetics were found to be illiterate and living in rural areas. Significantly, more men in rural areas were nondiabetic than diabetic, but there was no significant difference observed among females. Prevalence of comorbidities such as hypertension, CVD, and CKD was significantly higher in elderly diabetics (P ≤ 0.001). Upon subgroup analysis, CVD was found to be higher only among male diabetics and CVA only among female diabetics. Prevalence of cancer was found to be significantly higher among nondiabetics than diabetics (P = 0.001), specifically among females.
Table 1: Demographic details by diabetes status

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Table 2: Demographic details by gender and diabetes status

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The overall prevalence of GCs among included subjects was found to be 73.9% (77.1% among diabetics and 72.2% among nondiabetics). The prevalence of GCs among diabetic men was found to be 73.9% and 82.6% in diabetic women. The prevalence of UI, VI, and HI were found to be significantly higher among diabetics. Low BMI was found to be significantly higher only for nondiabetic males. UI and VI were found to be significantly higher among both diabetic males and females, but HI was significantly higher only among diabetic males. Upon subgroup analysis, low BMI was found to be significantly higher only among nondiabetic males and HI was found to be significantly higher only among diabetic males [Table 3] and [Table 4].
Table 3: Prevalence of geriatric conditions by diabetes status

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Table 4: Prevalence of geriatric conditions by gender and diabetes status

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[Table 5] depicts risk of GCs among diabetes patients in four bivariate adjusted models. Before adjusting for confounders, diabetes was associated with significant increased risk for UI, VI, and HI (risk ratio [RR]: 3.31, 95% confidence interval [CI]: 2.49–4.39; RR: 1.89, 95% CI: 1.45–2.45; and RR: 1.50, 95% CI: 1.07–2.11, respectively), but not for any GC (RR: 1.30, 95% CI: 0.98–1.72). After adjustment for demographic variables in Model 2, there was no change in the association for UI, VI and HI (RR: 3.30, 95% CI: 2.44–4.45; RR: 1.95, 95% CI: 1.47–2.58; and RR: 1.80, 95% CI: 1.23–2.63, respectively), but it became significant for any GC (RR: 1.62, 95% CI: 1.19–2.21). After further adjustment in Model 3, the RR for UI, VI, HI, and any GC among diabetics, as compared with nondiabetics, were 3.04 (95% CI: 2.20–4.21); 1.80 (95% CI: 1.33–2.43); 1.58 (95% CI: 1.05–2.38); and 1.41 (95% CI: 1.01–1.96), respectively. Final adjustment for other GCs in Model 4 revealed significantly increased risk for UI and VI (RR: 2.91, 95% CI: 2.09–4.04; and RR: 1.59, 95% CI: 1.16–2.18, respectively), but not for HI (RR: 1.30, 95% CI: 0.83–2.04). Patients with diabetes was observed to have significant decreased risk for low BMI, and the association became consistent throughout all the four models (RR: 0.34, 95% CI: 0.23–0.50; RR: 0.41, 95% CI: 0.28–0.62; RR: 0.49, 95% CI: 0.32–0.75; and RR: 0.49, 95% CI: 0.32–0.77, respectively).
Table 5: Bivariate adjusted risk ratios for diabetes and selected geriatric conditions among elderly

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As shown in [Table 6], diabetic men had a significantly increased risk for any GC (RR: 1.60, 95% CI: 1.05–2.44) after adjustment according to Model 3. However, the association became nonsignificant for females (RR: 1.28, 95% CI: 0.71–2.30). After further adjustment in Model 4, risk of UI was found to be significantly higher among diabetic males (RR: 2.85, 95% CI: 1.84–4.42) and females (RR: 2.79, 95% CI: 1.64–4.73), and VI only among female diabetics (RR: 1.76, 95% CI: 1.04–3.00). Decreased risk of low BMI was observed among male diabetics (RR: 0.46, 95% CI: 0.27–0.79), but not among female diabetic patients (RR: 0.53, 95% CI: 0.22–1.27).
Table 6: Bivariate adjusted risk ratios for diabetes and selected geriatric conditions among elderly based on gender

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In a subgroup analysis, we found that the patients diagnosed with diabetes 6–15 years back were found to have significantly increased risk for GCs (RR: 2.57, 95% CI: 1.16–5.73, P = 0.034) than newly detected diabetes [Table 7]. Patients with diabetes aged more than median age (66 years) had significant increased risk for any GC (RR: 1.35, 95% CI: 1.02–1.79) than patients with diabetes aged less than median age (RR: 1.22, 95% CI: 0.67–2.50).
Table 7: Effect of duration of diabetes on risk of geriatric conditions

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  Discussion Top


We observed that diabetic individuals had a higher risk of being affected with hypertension, CVD and CKD. Elderly diabetic women were more prone to hypertension, CVD, and CVA and diabetic men to CKD. Similar findings were observed in a study conducted among elderly diabetic patients in Taiwan.[6]

In our study, we observed that diabetes in the elderly leads to a 41% increased risk for the occurrence of GCs. Cross-sectional studies of elderly patients in Taiwan and the USA have also suggested that there is a higher incidence of GCs in the diabetic population.[6] This association was more profoundly observed among elderly diabetic men with a 60% increased risk of developing any GC compared to elderly diabetic females. In contrast to our results, a Taiwan-based study reported that elderly diabetic women had 1.08 times higher incidence of GCs than older men.[6]

For individual GCs, we observed that diabetes increases the risk of UI by 1.91 times with no significant difference in terms of gender. In one study, UI was not significantly associated with geriatric male or female population who had diabetes.[6] Other studies have found that in elderly diabetic women there was a significant association between diabetes and UI.[7] A possible explanation for this may be relatively low levels of estrogen following menopause, obesity, and childbirth in females, while in males, UI usually develops due to prostate abnormalities.

Diabetes was observed to increase the risk of VI by 59% in the geriatric population with 76% higher risk in elderly women. A population-based study carried out in Britain suggested that VI was more pronounced in older adults with a rapid increase with advancing age, especially in elderly women.[9]

Our study showed no significant association of diabetes with the occurrence of falls. A study in Malaysia suggested an 18.8% prevalence of diabetes associated falls among the elderly.[10] Two studies also suggested a significant association of diabetes with occurrence of falls in elderly women.[11],[12] Diabetes-related falls could possibly be related to medication-induced hypoglycemia or peripheral neuropathy.[13]

Diabetes was observed to have no significant association with the occurrence of CoI in our study. A population-based study observed increased cognitive dysfunction in the diabetic elderly.[14] Another study also suggested that diabetes is associated with a rapid decline in cognitive function amongst elderly individuals.[15] Epidemiological studies suggest that subjects with diabetes have 1.6–3-fold increased risk of producing Alzheimer's type dementia and vascular dementia.[16] It was observed that CoI was more prevalent in elderly diabetic women and no association was observed with elderly diabetic men.[6] In our study, we also observed that individuals with a previous existence of stroke have a 3.79 times higher risk of developing CoI. Again, it can be noted that diabetic women are more prone to develop stroke than diabetic males. Such a finding suggests a possible interrelationship between diabetes, stroke and the occurrence of GCs.

In our study, the simultaneous presence of depression with diabetes was not found to be significant. Reports from other studies suggest that elderly diabetics have an increased risk of depressive episodes, with a significant correlation with postprandial blood sugar values.[17] A study on older diabetic Mexican Americans suggested that 30% of subjects with diabetes had a higher incidence of depressive symptoms.[18] A study in Spanish community-dwelling elderly suggested that diabetes could not be considered an independent risk factor in the occurrence of depression.[8] Diabetes-related depression may be attributed to the complications associated with this metabolic disease that leads to individuals becoming dependent on others, as well as psychological isolation from society.

In our study, it was observed that elderly diabetic men may possibly have a risk of HI. However, the fully adjusted model did not give a significant association. A population-based study suggested that HI was more prevalent among the diabetic elderly.[19] HI was observed to be 1.85 times more prevalent in the age group of 60–69 years. A population-based study of adults suggested that there was an increased chance of HI with increasing age, with 3.42 times higher risk in elderly males.[20] Diabetes-associated damage of the neural structures in the inner ear could be the possible explanation for the occurrence of HI in the diabetic population.

Our study did not report any significance association between diabetes and dizziness in the elderly subjects. A cross-sectional study observed that diabetes could be a risk factor for the occurrence of dizziness.[21] The likelihood of diabetes-related dizziness may be supported by the hypoglycemic episodes accompanying the disease.

We observed that diabetic subjects had a 51% lower risk of developing low BMI and similar findings were observed among males after subgroup analysis. In a study by Hillier and Pedula an inverse linear relation was found between BMI and age at diabetes onset.[22] Adults with early diagnosed diabetes were more obese than were adults with a later onset of type 2 diabetes.[23]

Our study faced certain limitations. Being a cross-sectional study, the patients were not followed up, so that correlation between intensity of GCs and glycemic control could not be established by observing blood glucose estimations or glycated hemoglobin levels. Not all the geriatric patients coming for consultation to the outpatient department could be taken into the study. Most of the patients were not informed or aware about the medications used to treat their disease conditions. Hence, an association between their medications use pattern and GCs could not be established.


  Conclusions Top


Diabetic individuals aged 60 years and above are at a higher risk of developing GCs, especially UI and VI. At the same time, diabetic subjects are at lower risk for having low BMI. It has been well documented that diabetes is associated with geriatric syndrome including falls, CoI, depression, dizziness, and HI among elderly people in different races and countries; limited association of these components of geriatric syndrome with diabetes was found in this study may be due to a geographical variation. Since there is a significant association between diabetes and GCs, effective measures should be taken to manage diabetes through diet, exercise and medications; treatment of specific GC individually, thereby optimizing the overall quality of life for geriatric patients. Future studies are required to prospectively investigate the relationship between diabetes and the duration of the disease required to develop a GC by considering other comorbidities and also to analyze the risk of occurrence of GCs in early life (below 60 years).

Acknowledgment

We thank Jagadguru Sri Shivarathreeshwara University, Mysuru, Karnataka, India, for constant support and encouragement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Indian Council of Medical Research. Guidelines for Management of Type 2 Diabetes; 2005. Available from: http://www.icmr.nic.in/guidelines_diabetes/prelim.pdf. [Last updated on 2005; Last cited on 2013 Aug 12].  Back to cited text no. 1
    
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International Diabetes Federation. Diabetes Atlas Seventh Edition. Available from: http://www.diabetesatlas.org/. [Last updated 2015; Last cited on 2017 Feb 09].  Back to cited text no. 2
    
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Laiteerapong N, Karter AJ, Liu JY, Moffet HH, Sudore R, Schillinger D, et al. Correlates of quality of life in older adults with diabetes: The diabetes & aging study. Diabetes Care 2011;34:1749-53.  Back to cited text no. 3
    
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United Nations Population Fund. Building a Knowledge Base on Population Ageing in India: Report on the Status of Elderly in Selected States of India 2011. Available from: http://www.isec.ac.in/AgeingReport_28Nov2012_LowRes-1.pdf. [Last updated on 2012; Last cited on 2014 Jan 20].  Back to cited text no. 4
    
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The Institute for the Study of Labor (IZA). Population Aging in India: Facts, Issues, and Options. Available from: http://www.ftp.iza.org/dp10162.pdf. [Last updated on 2016 Aug; Last cited on 2017 Feb 09].  Back to cited text no. 5
    
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de Jonge P, Roy JF, Saz P, Marcos G, Lobo A; ZARADEMP Investigators. Prevalent and incident depression in community-dwelling elderly persons with diabetes mellitus: Results from the ZARADEMP project. Diabetologia 2006;49:2627-33.  Back to cited text no. 8
    
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Evans JR, Fletcher AE, Wormald RP, Ng ES, Stirling S, Smeeth L, et al. Prevalence of visual impairment in people aged 75 years and older in Britain: Results from the MRC trial of assessment and management of older people in the community. Br J Ophthalmol 2002;86:795-800.  Back to cited text no. 9
    
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Schwartz AV, Hillier TA, Sellmeyer DE, Resnick HE, Gregg E, Ensrud KE, et al. Older women with diabetes have a higher risk of falls: A prospective study. Diabetes Care 2002;25:1749-54.  Back to cited text no. 11
    
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14.
Saczynski JS, Jónsdóttir MK, Garcia ME, Jonsson PV, Peila R, Eiriksdottir G, et al. Cognitive impairment: An increasingly important complication of type 2 diabetes: The age, gene/environment susceptibility – Reykjavik study. Am J Epidemiol 2008;168:1132-9.  Back to cited text no. 14
    
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Gregg EW, Yaffe K, Cauley JA, Rolka DB, Blackwell TL, Narayan KM, et al. Is diabetes associated with cognitive impairment and cognitive decline among older women? Study of Osteoporotic Fractures Research Group. Arch Intern Med 2000;160:174-80.  Back to cited text no. 15
    
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Kaulgud RS, Nekar MS, Sumanth KJ. Study of depression in patients with diabetes compared to non diabetics among elderly population and its association with blood sugar, HbA1c values. Int J Biomed Res 2013;4:55-61.  Back to cited text no. 17
    
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Black SA. Increased health burden associated with comorbid depression in older diabetic Mexican Americans. Results from the Hispanic Established Population for the Epidemiologic Study of the Elderly survey. Diabetes Care 1999;22:56-64.  Back to cited text no. 18
    
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Kakarlapudi V, Sawyer R, Staecker H. The effect of diabetes on sensorineural hearing loss. Otol Neurotol 2003;24:382-6.  Back to cited text no. 19
    
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Cruickshanks KJ, Wichmann MA. Hearing impairment and other health conditions in older adults: Chance associations or opportunities for prevention? Semin Hear 2012;33:217-24.  Back to cited text no. 20
    
21.
Kao AC, Nanda A, Williams CS, Tinetti ME. Validation of dizziness as a possible geriatric syndrome. J Am Geriatr Soc 2001;49:72-5.  Back to cited text no. 21
    
22.
Hillier TA, Pedula KL. Characteristics of an adult population with newly diagnosed type 2 diabetes: The relation of obesity and age of onset. Diabetes Care 2001;24:1522-7.  Back to cited text no. 22
    
23.
Abdul-Ghani MA, Kher J, Abbas N, Najami T. Association of high body mass index with low age of disease onset among Arab women with type 2 diabetes in a primary care clinic. Isr Med Assoc J 2005;7:360-3.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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