title: The excess mortality risk of diabetes associated with functional decline in older adults: results from a 7-year follow-up of a nationwide cohort in Taiwan.
abstract: BACKGROUND
  Diabetes is associated with an increased risk of functional decline in older adults. Few studies have investigated the contribution of functional decline to excess mortality risk in older people with diabetes. The aim of this study was to examine how diabetes in combination with different levels of functional decline affects 7-year mortality in older adults.
  
  
  METHODS
  We analyzed data from a nationally representative sample of people aged 65 years and over, participating in the 2001 National Health Interview Survey in Taiwan. A total of 1873 participants were followed through 2002-2008, of whom 286 (15.3%) had a history of diabetes confirmed by a medical professional. Participants were divided into three functional status groups: (1) high functioning-no limitations involving activities of daily living (ADLs), instrumental activities of daily living (IADLs), or physical functioning; (2) low functioning-limitations in one or more ADLs; (3) middle functioning-all participants in between groups 1 and 2.
  
  
  RESULTS
  The crude mortality rate was 52.7 per 1,000 person-years in those with diabetes and 34.1 per 1,000 person-years in those without diabetes. After adjustment for other factors, diabetes alone was not associated with an increased mortality risk in those with high functioning. However, diabetes alone had a hazard ratio (HR) for mortality of 1.90 (95%CI = [1.02-3.53]) in those with middle functioning and 3.67 (95%CI = [1.55-8.69]) in those with low functioning. The presence of diabetes and one or more other chronic conditions was associated with a HR for mortality of 2.46 (95%CI = [1.61-3.77]) in those with middle functioning and 4.03 (95%CI = [2.31-7.03]) in those with low functioning.
  
  
  CONCLUSIONS
  Our results indicate that diabetes is not associated with increased mortality in those with high functioning. There was a gradient effect of functional decline on mortality in individuals with diabetes. Additionally, among participants with other chronic conditions, functional decline was associated with a greater burden of mortality in older adults with diabetes. These findings highlight the critical importance of the prevention of cardiovascular disease morbidity and the maintenance of functional abilities in order to reduce mortality risk in older adults with diabetes.
authors.affiliation: Department of Health Care Management, Chang Gung University, 259 Wen-Hwa 1st Road, Kwei-Shan, Tao-Yuan 333, Taiwan. clli@mail.cgu.edu.tw
authors.forename: Chia-Lin
authors.initials: CL
authors.lastname: Li
authors.forename: Hsing-Yi
authors.initials: HY
authors.lastname: Chang
authors.forename: Yea-Ing L
authors.initials: YI
authors.lastname: Shyu
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D015331:Cohort Studies; D003920:Diabetes Mellitus / Q000401:mortality* / Q000503:physiopathology; D005260:Female; D005500:Follow-Up Studies; D015577:Geriatric Assessment / Q000379:methods*; D006306:Health Surveys; D006801:Humans; D008297:Male; D018570:Risk Assessment; D013624:Taiwan / Q000453:epidemiology