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Review

Complications and Comorbidities in Individuals >80 Years with Diabetes: A Scoping Review

by
Christian Ward-Bradley
,
Adam Erwin
,
Tunde Peto
,
Laura N. Cushley
and
Katie Curran
*
Centre for Public Health, Queen’s University Belfast, Belfast BT12 6BA, UK
*
Author to whom correspondence should be addressed.
Diabetology 2025, 6(12), 152; https://doi.org/10.3390/diabetology6120152
Submission received: 25 September 2025 / Revised: 20 October 2025 / Accepted: 14 November 2025 / Published: 1 December 2025
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Abstract

Background/Objectives: Diabetes mellitus is increasingly prevalent among adults aged over 80 years; however, this population remains substantially underrepresented in clinical research on diabetes complications. This scoping review synthesises current evidence on diabetes-related complications and comorbidities in this older age group (>80 years), reported prevalence, and key evidence gaps. Methods: A systematic search of MEDLINE, Embase, and Web of Science was conducted for studies published between 1992 and 2024 reporting diabetes-related complications in individuals aged ≥80 years. Two reviewers independently screened titles, abstracts, and full texts. Data were extracted and summarised using narrative synthesis, and descriptive statistics (SPSS v29) were conducted. Results: Fifty-one studies were included, comprising 17,630,083 individuals aged ≥80 years. Macrovascular complications were most frequently reported, followed by microvascular and peripheral outcomes. Hypertension was the most reported comorbidity. Macrovascular outcomes were assessed in over 17 million individuals, while microvascular complications were studied in fewer than 400,000. Only five studies focused exclusively on adults aged ≥80 years. Reporting was also limited by retrospective designs, heterogeneity in definitions, and frequent omission of key variables, including diabetes duration, HbA1c, frailty, and cognitive status. Conclusions: There is a critical mismatch between research focus and the complications most relevant to function and quality of life in older populations with diabetes. Easily measurable yet clinically impactful outcomes, such as retinopathy, neuropathy, nephropathy, and foot disease, remain under-investigated in this cohort. Standardised, age-stratified reporting that incorporates functional and geriatric domains is needed to inform person-centred care in this expanding population.

1. Introduction

Diabetes mellitus is a chronic metabolic disorder characterised by hyperglycaemia [1]. Its impact extends beyond clinical outcomes to substantial health and social care needs, particularly in the ≥80-year-old population, where tailored interventions are increasingly recognised as essential [2]. According to the International Diabetes Federation (IDF) Diabetes Atlas (2024), more than 540 million adults currently live with diabetes worldwide, a figure projected to exceed 780 million by 2045, with the steepest increases occurring in low- and middle-income countries (LMICs) [3,4]. The World Health Organization’s Global Report on Ageing and Health (2015) similarly identifies diabetes as a leading contributor to frailty, disability, and reduced quality of life in older adults [5].
As the global population ages, the number of individuals aged ≥80 years living with diabetes is also set to rise substantially [6,7], reflecting both improved longevity and age-related metabolic changes [7]. Nearly half of all type 2 diabetes mellitus (T2DM) diagnoses now occur in individuals aged ≥65 years [8], and this proportion is expected to grow further with continued population ageing [9]. T2DM accounts for over 90% of diabetes cases and is primarily linked to insulin resistance and ageing [10]. Its prevalence in older adults reflects both cumulative risk factor exposure and physiological decline [11]. Chronic hyperglycaemia and age-related changes contribute to oxidative stress, inflammation, and vascular dysfunction [12,13], accelerating the development of atherosclerosis and elevating cardiovascular disease risk [14,15,16].
This demographic shift presents significant clinical challenges. The physiological changes associated with ageing, combined with polypharmacy and multimorbidity, complicate glycaemic control and diabetes management [17]. The coexistence of advanced age and diabetes heightens the risk of both microvascular and macrovascular complications [18], yet the literature often aggregates all adults aged over 65 [16,17,18,19,20], obscuring the distinct risks and clinical needs of the >80 years [1].
Individuals over 80 are particularly vulnerable to acute and chronic complications, including retinopathy, neuropathy, cardiovascular events, and nephropathy due to higher frailty, impaired glucose counter-regulation, and a greater burden of comorbid conditions [21]. Managing diabetes in this age group requires nuanced, individualised care. Frailty, polypharmacy, cognitive decline, and hypoglycaemia sensitivity increase the risk of adverse outcomes and functional loss [6,8,18,22]. These complications can lead to loss of independence, institutionalisation, and higher mortality [21]. Clinical management must also account for renal impairment, fluctuating insulin needs, and geriatric syndromes such as dementia and sarcopenia [23]. Despite these complexities, many studies fail to consider frailty and cognitive function, two key determinants of treatment safety and complication risk in the oldest-old [24].
As such, evidence to guide diabetes care in this population remains limited, fragmented, and poorly generalisable. This scoping review seeks to map the landscape complications and comorbidities in individuals over 80 years with diabetes. Addressing these challenges could lead to improved disease management, enhanced quality of life, and greater awareness of this significant healthcare issue in an ageing population.

2. Materials and Methods

This scoping review adhered to the framework by Arksey and O’Malley [25], refined by Levac et al. [26], to map evidence on diabetes-related complications in adults aged >80 years and identify knowledge gaps. Methodological transparency and rigour were ensured through the PRISMA-ScR guidelines [27]. MEDLINE ALL, Embase, and Web of Science Core Collection analyses were conducted using Boolean operators, with guidance from an Information Specialist at Queen’s University Belfast (RS). Table 1 summarises the search terms used with the number of hits.

2.1. Types of Studies and Eligibility Criteria

Given the limited research on diabetes in individuals aged over 80 years, this scoping review used broad inclusion criteria to capture research on the epidemiology, complications, and management of diabetes mellitus in this population. To ensure a comprehensive overview, no restrictions were imposed on publication type or study design. Eligibility criteria were defined according to the Population–Concept–Context (PCC) framework and predefined inclusion and exclusion criteria. The inclusion and exclusion criteria can be seen in Table 2. Studies were included if they investigated diabetes-related complications or comorbidities in individuals aged >80 with diabetes as the primary exposure of interest. To further address the paucity of published literature, grey literature was searched using Google Scholar, yielding seven eligible studies included in the review.

2.2. Process of Study Selection

All records retrieved from database searches were imported into Covidence for screening and data management. Duplicates were automatically removed. Titles and abstracts were independently screened by two reviewers (CWB and AE). Full texts were then retrieved and assessed in duplicate. Discrepancies were resolved through discussion or adjudicated by a third reviewer (KC). Studies meeting the inclusion criteria proceeded to data extraction within Covidence, using a standardised, piloted extraction form to ensure consistency. All decisions were documented, and a PRISMA flow diagram was generated to depict the screening and selection process.

2.3. Data Extraction

Data regarding study design, population and sample characteristics, and comorbidity type were extracted using a predefined, structured data extraction template developed in Covidence. This template facilitated a standardised methodology, with extraction conducted independently by two reviewers (CWB and AE). Discrepancies were resolved through discussion, involving a third reviewer when necessary (KC).

2.4. Data Synthesis

A narrative synthesis approach was adopted to integrate findings across the included studies. Key study characteristics, including design, population demographics, and outcomes were extracted and mapped to enable comparison across sources. Reported diabetes-related outcomes were categorised into three complication domains: macrovascular (cardiovascular disease (CVD), peripheral arterial disease (PAD), and stroke), microvascular (retinopathy, nephropathy, neuropathy), and peripheral (foot ulcers, amputations). CVD was consistently classified as a macrovascular complication rather than a comorbidity, due to heterogeneity in how studies reported conditions, with many cardiovascular outcomes falling under the same umbrella.
Comorbidities were analysed separately and included hypertension (HTN), obesity, and chronic kidney disease (CKD)/end-stage renal disease (ESRD). Diabetic nephropathy (DN) was treated as a microvascular complication, whereas CKD and ESRD were categorised as comorbidities unless explicitly defined as diabetic nephropathy in the source study. Where studies reported complications in pooled diabetes populations without stratification by diabetes type, data were still included if the population comprised individuals aged ≥80 years.
Descriptive statistical analysis was conducted using SPSS, with results summarised as absolute counts and proportions. Meta-analysis and inferential statistics were not performed due to heterogeneity in study design, definitions, and outcome reporting. All findings were presented in tables and supplemented with descriptive commentary to illustrate the breadth of evidence and highlight existing research gaps.

3. Results

3.1. Study Selection

The search strategy yielded 1773 records across MEDLINE (n = 758), Embase (n = 589), Web of Science (n = 426), and Grey Literature (n = 7). After the removal of 31 papers identified as duplicates or ineligible, 1749 unique titles and abstracts were screened. A total of 105 full-text articles were assessed for eligibility, resulting in the inclusion of 51 studies in the review. The selection process is outlined in Figure 1.

3.2. Characteristics of Included Studies

The 51 included studies were published between 1992 and 2024. A total of 25 countries were represented overall. Most studies (82.3%) were conducted in high-income settings, with the remainder from upper-middle-income countries, namely Malaysia (n = 3), Thailand, Romania, China (n = 2), Mexico and Ecuador. The United States was the most frequent study location (24.3%), followed by the United Kingdom (10%) and Spain (8.6%). Retrospective cohort studies were the most common study type overall, representing 20 of the 51 papers (39.2%). The remaining studies consisted of eight population-based studies, seven cross-sectional studies, and seven prospective cohort studies. In addition, three longitudinal, three case–control studies and two observational cohort studies were identified. No randomised controlled trials or survey-only designs were reported among the included literature. The total sample size across all papers encompassed 88,346,088 participants, 17,628,973 of which were over the age of 80. The average age across all the included studies was 72.2 years. Only five studies (9.8%) exclusively focused on individuals aged ≥80 years. The remaining studies featured older adults as a subgroup within broader populations but did not consistently stratify findings by age.
Ethnic, socioeconomic, and frailty-related variables were inconsistently reported across the dataset. Where such data were included, subgroup analysis was infrequent and often not specific to the population aged ≥80 years. With respect to diabetes type, 16 studies (31.7%) focused exclusively on T2DM, and two studies (3.9%) focused on type 1 diabetes mellitus (T1DM). The remaining 33 studies (64.7%) either did not distinguish between diabetes types or included both T1DM and T2DM populations. The full characteristics of all included studies, encompassing study title, country, design, sample size, diabetes type, and reported prevalence of diabetes-related complications and comorbidities are presented in Appendix A. A detailed breakdown of outcomes is provided in Table 3. As several of the 51 included papers investigated more than one outcome, the table presents the total number of times each complication or comorbidity was studied across all papers.

3.3. Macrovascular Complications

Macrovascular complications including stroke, CVD, and PAD constituted a major focus in the reviewed literature, accounting for 81 of the 165 total reported complications or comorbidities (49.1%). CVD was the most prevalent complication overall, affecting 37.5% of individuals within a large, aggregated study population (n = 17,537,980). However, inconsistent definitions across studies limited the ability to determine the prevalence of specific CVD subtypes. Reported CVD prevalence also varied considerably between studies. Stroke, although frequently investigated, was the least prevalent macrovascular complication, affecting 7.3% of 751,077 individuals, with ischaemic stroke being the most commonly specified subtype. PAD was reported in 10.4% of 368,798 individuals, but interpretation was complicated by the difficulty in distinguishing diabetes-specific pathophysiology from age-related vascular decline.

3.4. Microvascular Complications

Microvascular complications, namely Diabetic Retinopathy (DR), Diabetic Nephropathy (DN), and neuropathy were comparatively under-investigated, appearing in only 31 of the 165 reported complications or comorbidities (18.8%), substantially fewer than macrovascular outcomes. The number of individuals aged ≥80 years assessed for microvascular complications was also markedly lower than for macrovascular complications. DN had the highest reported prevalence at 26.7%, although this estimate was derived from a relatively small sample of 5320 individuals. DR and DN were investigated in similarly sized populations and showed comparable prevalences of 20.1% and 20.9%, respectively. Across the limited literature on microvascular complications, there was a consistent lack of reporting on key clinical variables such as diabetes duration, HbA1c levels, and treatment regimens, further limiting interpretability.

3.5. Peripheral Complications

Peripheral complications were the least studied complication group in this age demographic, investigated in only five (9.8%) of the included studies. Diabetic foot ulcers were reported in 9.4% of 948 individuals, while lower-extremity amputations were reported in 0.5% of 5969 individuals. These outcomes were rarely the primary focus of investigation and frequently co-occurred with peripheral arterial disease and/or DN.

3.6. Other Comorbidities

Three comorbidities including hypertension, obesity, and kidney impairment were consistently identified across the included literature. Hypertension was the most frequently investigated comorbidity, with the highest reported prevalence (74.5%) among individuals aged ≥80 years with diabetes. However, the lack of differentiation between isolated systolic hypertension (ISH) and other subtypes limits the clinical applicability of these findings. Obesity was assessed in a much smaller sample than either hypertension or CKD/ESRD, but emerged as the second most common comorbidity, affecting 36.5% of individuals aged ≥80 years with diabetes. Prevalence estimates were inconsistent due to methodological variation in defining obesity, including differing BMI thresholds and reliance on either clinician-reported or self-reported diagnoses. Kidney impairment (CKD/ESRD) was the least frequently reported comorbidity, identified in 19.5% of individuals aged ≥80 years. Definitions of CKD and ESRD varied across studiesfrom estimated glomerular filtration rate thresholds to diagnostic coding, and few studies stratified by disease stage or chronicity, limiting the ability to assess the specific impact of diabetes on renal function decline in this population.

4. Discussion

4.1. Main Findings and Interpretation

This scoping review synthesised data from 51 studies reporting on diabetes-related complications and comorbidities in individuals aged ≥80 years, a population experiencing rapid demographic growth but persistent underrepresentation in clinical research. Across 169 reported outcomes, macrovascular complications were most frequently investigated (49.1%), followed by metabolic (23.7%), microvascular (20.1%), renal (5.3%), and peripheral (3.0%) complications. CVD was the most reported complication, affecting 37.5% of older adults studied, while hypertension emerged as the most prevalent comorbidity, present in 74.5% of individuals. In contrast, complications directly attributable to chronic hyperglycaemia such as DN, DR, and nephropathy were underrepresented in both volume and depth. The focus of existing literature appears misaligned with the complications most likely to affect functional capacity and independence in this age group, raising important questions about the adequacy of current research to inform person-centred diabetes care for people aged 80 years and above.
In this review, macrovascular complications were the most commonly investigated and common complication affecting those with diabetes aged ≥80, with CVD affecting 37.5%, peripheral arterial disease 10.36%, and stroke the least frequently at 7.36%. CVD was classified as a macrovascular outcome rather than a comorbidity, as many studies reported composite endpoints (e.g., myocardial infarction, heart failure, ischaemic heart disease), reflecting its vascular pathophysiology. However, heterogeneity in CVD terminology limits comparability and reduces the precision of prevalence estimates. While some studies highlight the benefit of using uniform definitions when it comes to CVD outcomes [28], current research in this age group rarely distinguishes whether CVD is a primary or secondary outcome and continues to use variable terminology, undermining the generalisability of findings.
The disproportionate focus on cardiovascular complications across the included literature reflects a longstanding emphasis in diabetes research on cardiovascular risk reduction [18,20]. This focus is historically justified as diabetes is a well-established contributor to cardiovascular morbidity and mortality and has been reinforced by major clinical guidelines and landmark trials targeting stroke, myocardial infarction, and other macrovascular endpoints [29]. In this population (>80 years), this emphasis may not be optimally aligned with clinical priorities. Competing risks, including frailty, cognitive impairment, polypharmacy, and diminished physiological reserve, often supersede long-term macrovascular risk in clinical decision making. The net benefit of intensive cardiovascular prevention strategies in this age group, therefore, remains uncertain [19,21].
Stroke was the most frequently investigated complication across the included studies, reflecting existing evidence that individuals with diabetes face a 2.25-fold increased risk of stroke, particularly those with long-standing disease [30,31]. The observed prevalence of stroke among individuals aged ≥80 in this review (7.4%) closely aligns with estimates for the general elderly population [32]. However, current studies may underestimate the true burden of cerebrovascular disease in this group, as many did not clearly specify stroke subtype or distinguish between ischaemic and haemorrhagic events. Additionally, transient ischaemic attacks (TIAs), which may be underdiagnosed or misclassified in older adults, were rarely reported despite their potential role as a silent driver of cognitive decline [33]. Given the association between cognitive impairment and reduced adherence to glucose monitoring and diabetes self-management [34], future research should prioritise the inclusion of TIAs and standardised stroke subtyping to more accurately assess cerebrovascular risk in the oldest-old with diabetes.
In contrast to macrovascular disease, microvascular complications were substantially underreported. Despite being pathognomonic for diabetes and measurable using standardised clinical tools [35], only 34 of the 165 total complications examined across 51 studies focused on microvascular outcomes. The disparity in research attention was striking: the population studied for macrovascular outcomes was nearly 45 times larger than that assessed for microvascular complications in this age group, indicating a significant misalignment in research priorities. Among individuals aged ≥80 years, nephropathy had the highest estimated prevalence at 29.6%, yet this remains markedly lower than the 30–40% typically reported in the general population with diabetes [36]. This discrepancy is likely due to substantial underreporting, with fewer than 7000 individuals over 80 assessed for nephropathy.
Similarly, DR has an estimated prevalence of 20.1% of the >80 cohort compared to global prevalence estimates of 22.3%, with rates often exceeding 30% in Africa, North America, and the Caribbean [37]. Most notably, DN was reported in just 20.8% of individuals ≥80 years, a figure considerably below the global estimate of 46.7% [38]. This underrepresentation may be due to underdiagnosis or a skew in study origin, as most included studies were conducted in high- and middle-income countries. DN prevalence often exceeds 50% in lower-income regions [39], which were underrepresented in this review. Collectively, these findings reveal a substantial underrepresentation of microvascular complications relative to their expected burden, likely reflecting a combination of limited investigation, regional disparities, and inconsistent reporting practices in the current literature.
Of particular concern is the limited focus on complications directly attributable to chronic hyperglycaemia, namely DR and DN, which were both under-investigated despite their well-defined diagnostic criteria and substantial impact on functional capacity in later life [18,19,22]. This signals not only a broader neglect of microvascular disease but also a specific oversight of hallmark diabetes-related sequelae that most directly reflect long-term glycaemic exposure. This imbalance suggests a misalignment between research priorities and the complications most detrimental to function and independence in the oldest-old. While stroke was investigated in 33 of the 52 studies, affecting 7.4% of individuals ≥80, DR was examined in fewer than half as many studies, despite having almost three times the prevalence in this demographic. This disparity underscores the relative neglect of this age group as a focal point in diabetes research, particularly considering the clinical implications, e.g., DR remains the leading cause of blindness worldwide [40].
Peripheral complications, specifically diabetic foot ulcers and lower-limb amputations, were markedly underrepresented, appearing in only five of the included studies. This is notable given that foot ulcers are the leading precipitating factor for lower-extremity amputation [41], particularly among individuals with T1DM [42]. The true burden of peripheral complications in people aged >80 years is likely underestimated due to both the paucity of focused research and a predominant emphasis on T2DM. These outcomes, while often preventable and amenable to clinical intervention, may be erroneously viewed as inevitable sequelae of ageing or deprioritised in populations with limited life expectancy. Such assumptions risk undertreatment bias, despite growing evidence that early detection and management of diabetic foot disease can significantly improve outcomes, even in frail, elderly patients [43].
PAD, a major risk factor for diabetic foot ulceration and lower-limb amputation [44] was reported in 10.4% of individuals aged ≥80 years in this review. This figure aligns with estimates from high-income countries, where PAD affects approximately 10% of adults over 65 years [45]. However, it likely underrepresents the true burden in the oldest-old globally. PAD prevalence is rising more rapidly in low- and middle-income countries, where rates among individuals with diabetes have been reported between 12% and 30% [46,47]. As such, the limited representation of lower-resource settings in the included studies may mask a substantially higher prevalence and risk profile in underrepresented populations.
Several comorbidities were frequently associated with diabetes in individuals aged ≥80 years. Most notably, hypertension was reported in 28 of the 52 included studies, affecting 74.3% of 16.5 million individuals. This mirrors contemporary data indicating hypertension prevalence reaches 74% in the general population aged ≥80 [48]. However, as with CVD and stroke, the clinical significance of this finding was undermined by poor phenotypic stratification. No study distinguished hypertension subtypes, despite ISH being the predominant and clinically most relevant variant in older adults [49]. ISH, associated with arterial stiffening, white-coat hypertension, and increased fall risk, alters both diagnostic thresholds and therapeutic strategies in geriatric care [50]. Failure to differentiate ISH from other forms limits the translational utility of these findings [49].
CKD and ESRD were present in 19.5% of individuals aged ≥80 years. This burden may be underestimated, particularly given the well-established overlap between obesity and renal impairment [51]. Obesity itself was identified in 36.5% of 146,934 individuals, though this sample size was markedly smaller than for hypertension or kidney impairment. Obesity not only contributes to the development of T2DM [52], hypertension, and kidney dysfunction [53], but may independently accelerate frailty and functional decline in older adults when coexisting with diabetes [54]. The tendency for these comorbidities to cluster underscores the importance of accounting for multimorbidity and frailty when assessing diabetic risk profiles in the oldest-old.
Taken together, these findings expose critical imbalances in the current research landscape. Macrovascular complications and broad comorbidity profiles remain disproportionately prioritised, while key diabetes-specific outcomes, particularly those driven by chronic hyperglycaemia, are underrepresented. The paucity of granular data on microvascular and peripheral complications, limited stratification by diabetes type and duration, and underreporting of age-relevant syndromes such as frailty all constrain meaningful interpretation. Moreover, the dominance of retrospective designs and high-income country cohorts limits the applicability of findings across diverse global populations. These gaps raise important questions about the adequacy of current evidence to inform clinical decision making in the oldest-old diabetic population and frame the rationale for the recommendations and limitations that follow.

4.2. Strengths and Limitations

This review is the first to comprehensively map diabetes-related complications and comorbidities specifically in adults aged ≥80 years, a population largely overlooked in the literature. Methodological rigour was maintained through adherence to established frameworks, including Arksey and O’Malley’s model and the PRISMA-ScR checklist. A broad search strategy across MEDLINE, Embase, Web of Science, and grey literature helped maximise study capture and minimise publication bias. Dual independent screening and piloted data extraction enhanced reliability, while the structured classification of outcomes into macrovascular, microvascular, peripheral, and comorbidity domains enabled nuanced synthesis. The inclusion of over 17 million individuals aged ≥80 across five continents lends weight to the findings, while also illuminating unique gaps in the literature, particularly the consistent underrepresentation of microvascular, peripheral, and geriatric-specific outcomes in this age group.
While these strengths enhance the credibility and breadth of the review, it is equally important to consider its limitations to contextualise the findings and guide future research. This review is limited by the geographic skew of included studies, with the vast majority conducted in HICs. While this likely reflects longer life expectancy and more developed diagnostic infrastructure in these regions, it restricts applicability to LMICs, where diabetes prevalence is increasing rapidly and complication patterns may differ [55,56,57]. The near-total absence of LMIC data risks overlooking divergent disease trajectories, particularly for microvascular and peripheral complications, which are often more prevalent in resource-limited settings. Furthermore, the exclusion of non-English papers in this review may have led to the underrepresentation of data from diverse healthcare systems and population settings. Ethnic disparities, such as higher cardiovascular risk in White populations versus greater microvascular burden in Black and Asian groups, were also rarely reported, further limiting the global relevance of findings [58].
Study design was another key limitation. The overwhelming majority of included papers were retrospective observational studies, introducing risks of selection bias and limiting causal inference. These studies frequently relied on hospital records or administrative databases, which are more likely to capture acute macrovascular events and underreport chronic, often subclinical, complications such as neuropathy or retinopathy. The Complication definitions varied widely; for example, CVD was inconsistently reported either as broad composite outcomes or as separate pathologies like myocardial infarction or heart failure. This definitional heterogeneity precluded meta-analysis and reduced the precision of pooled prevalence estimates.
Data granularity was also poor. Only 9.4% of studies focused exclusively on individuals aged ≥80 years, while most embedded this group within broader age brackets (e.g., ≥65 or ≥75). Few studies specified diabetes type, duration, time since diagnosis, glycaemic control, treatment intensity, or adherence, restricting interpretation of whether outcomes reflected ageing, disease burden, or management differences. Key covariates such as frailty and cognitive status were also rarely included. Future research should routinely report these variables and incorporate sex-stratified analyses, regional comparisons, and adjustments for diabetes duration to better capture biological, social, and environmental heterogeneity in the oldest-old population.
Collectively, these limitations introduced considerable heterogeneity and constrained statistical synthesis, but they also expose critical gaps in the existing evidence base. Addressing these methodological weaknesses, particularly through improved age stratification, standardised outcome definitions, and better global representation, will be essential to inform tailored, equitable care for the world’s fastest-growing diabetic demographic.

5. Conclusions

This scoping review reveals a fundamental misalignment between the diabetes-related complications most frequently studied and those most clinically impactful in adults aged ≥80 years. Macrovascular outcomes, particularly CVD and stroke, continue to dominate the literature, largely driven by historical precedent and hospital-derived data. In contrast, microvascular and peripheral complications that directly impair autonomy, mobility, and quality of life, such as retinopathy, neuropathy, nephropathy, and foot disease, remain markedly underreported, despite their diagnostic clarity and relevance to functional ageing.
To enable equitable, person-centred care for the oldest-old, future research must move beyond conventional macrovascular endpoints and prioritise outcomes that reflect lived experience and functional decline. Studies should adopt standardised definitions, stratify by diabetes phenotype and duration, and incorporate age-relevant metrics, especially frailty. Acknowledging the heterogeneity of diabetes in advanced age, including among type 1 diabetes survivors, is essential. Strengthening understanding of complications and comorbidities in this population will also be vital for developing age-appropriate clinical guidelines. Ensuring that future research captures gender, ethnic, and regional diversity will be essential for producing evidence that supports equitable, person-centred diabetes care for the oldest-old. While these findings underscore the need for age-specific, function-oriented diabetes care, their translation into global policy should be guided by future prospective and longitudinal studies to ensure sustainability and generalisability across settings.

Author Contributions

Conceptualisation, A.E. and K.C.; methodology, A.E. and K.C.; software, A.E. and C.W.-B.; validation, C.W.-B. and K.C.; formal analysis, C.W.-B.; investigation, C.W.-B. and A.E.; resources, K.C., L.N.C. and T.P.; data curation, C.W.-B.; writing—original draft preparation, C.W.-B.; writing—review and editing, K.C., L.N.C. and C.W.-B.; visualisation, C.W.-B.; supervision, K.C., L.N.C. and T.P.; project administration, K.C.; funding acquisition, K.C., L.N.C. and T.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were generated in this study. All data extracted from included studies are available in Table A1, provided in Appendix A of this article.

Acknowledgments

The authors gratefully acknowledge the academic guidance and institutional support provided by staff at Queen’s University Belfast during the preparation of this review. We would particularly like to thank Richard Fallis, Information Specialist at QUB, for his invaluable assistance in refining the search strategy.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
BMIBody Mass Index
CVDCardiovascular Disease
CKDChronic Kidney Disease
DRDiabetic Retinopathy
DNDiabetic Neuropathy
ESRDEnd-Stage Renal Disease
HICHigh-Income Country
HTNHypertension
ISHIsolated Systolic Hypertension
LMICLow-Middle Income Country
TIATransient Ischaemic Attack
T1DMType-1 Diabetes Mellitus
T2DMType-2 Diabetes Mellitus
UKUnited Kingdom
USAUnited States of America

Appendix A

Table A1. Characteristics of included studies reporting diabetes-related complications and comorbidities in adults aged ≥80 years.
Table A1. Characteristics of included studies reporting diabetes-related complications and comorbidities in adults aged ≥80 years.
AuthorsCountryStudy DesignMean Age (Years)Total Sample SizeParticipants Aged 80+ with Diabetes (Overall)Reported Outcomes in Study (T1DM, T2DM)Complication (%)
Sinclair 2008 [19]UKPopulation-based case–control study7580690BothCVD(15.5%) Stroke(17.1%) PAD(28.2%)
HTN(30.1%) DN(35.1%)
Chang 2021 [59]South KoreaRetrospective cohort study7018,5672708BothStroke(10%)
Jie 2021 [60]MalaysiaRetrospective cohort study65.6179,2103325BothCVD(8.7%) Stroke(1.2%)
HTN(63%)
Sukkar 2020 [61]AustraliaRetrospective cohort study65.4931380BothStroke(4.8%)
HTN(73.4%)
Obesity(43.5%)
Gershater 2021 [43]SwedenRetrospective cohort study811008500BothCVD(13.7%)
DR(13.2%)
Amputation(2.6%) DN(6.6%)
Yotsapon 2016 [62]ThailandRetrospective cohort study872859266BothStroke(18%)
PAD(19.5%)
DR(16.5%)
CKD(55%)
Tanasescu 2023 [63]RomaniaRetrospective cohort studyn/A22820BothCVD(45%)
Stroke(10%)
Obesity(55%)
Amputation(70%)
Sattar 2019 [64]SwedenRetrospective cohort study61.8241,2785449BothCVD(1.3%) Stroke(1.43%)
Amputations(0.1%)
Kissela 2005 [65]USARetrospective cohort study7246644264BothCVD(22%) Stroke(100%)
HTN(79%)
Bertoni 2005 [66]USARetrospective cohort study74144,11532,040BothCVD(20.7%)
DR(17.1%)
HTN(71.5%) DN(17%)
Hangaard 2019 [67]DenmarkRetrospective cohort studyn/A12,701836Both CVD(30.5%)
Foot ulcer (0.5%)
Obesity (54%)
Chima 2017 [68]USARetrospective cohort studyn/A82,767,32116,557,870BothCVD(27%)(38.9%) * HTN(55%)(75%) * CKD(17.3%)(19.1%) *
Clau-Espuny 2017 [69]SpainRetrospective cohort study81.2932315BothHTN(84.1%) PAD(13.9%)
Stroke(28.3%)
Huang 2014 [70]USARetrospective cohort study7172,31010,846T2DMCVD(87.3%)
Stroke(21%)
PAD(22.2%)
DN(3.4%)
DPV Initiative 2012 [71]Germany; AustriaRetrospective cohort study67.1120,18317,353T2DMDR(15.6%)
HTN(26.9%)
Wong 2024 [72]MalaysiaRetrospective cohort study81.1384384T2DMCVD(27.2%) Stroke(100%)
HTN(90.8%)
Win 2016 [73]USARetrospective cohort study72.61014,879265,766T2DMCVD(25.3%)
Alonso-Moran 2014 [74]SpainRetrospective cohort studyn/A134,42148,407T2DMCVD(4.3%)
Stroke(7%)
DR(7.2%)
DN(1.3%)
C. LI. Morgan 1999 [75]UKRetrospective cohort study61.510,287112T2DMCVD(40%) Stroke(20%)
DR(19%)
Diabetic Foot(21%) Nephropathy(4%)
Bong-Ki Lee 2016 [76]South KoreaRetrospective cohort study83.2289289T2DMHTN(75.1%) Stroke(17%)
DR(33.5%)
Tang 2020 [77]USAProspective cohort study75.55791852BothCVD(36.4%)
HTN(91.8%)
Obesity(49.2%)
Gual 2020 [78]SpainProspective cohort study63.112,7921720BothCVD(11.1%) Stroke(4.4%) HTN(27.6%)
Regidor 2012 [79]SpainProspective cohort studyn/A4008132Both CVD(18.1%)
Stroke(6.6%)
HTN(71%)
Apelqvist 1992 [80]SwedenProspective cohort study7031447Both DR(29.6%)
Nephropathy(22.2%)
Andrew J. Karter 2015 [81]USAProspective cohort study72115,53822,058Both Stroke(1%)
DR(21%)
ESRD(2%)
Huang 2023 [82]USAProspective cohort study74.3105,78623,273T2DMCVD(18.2%) Stroke(4.9%)
PAD(17.4%)
HTN(91.1%)
DN(8%)
Obesity(44.2%)
Morton 2022 [83]AustraliaProspective cohort studyn/A1,235,759246,261T2DMCVD(45.5%)
Stroke(3.6%)
PAD(6.2%)
ESRD(14%)
Beard 2009 [84]USAPopulation-based study812034540Both CVD(74%)
DR(55.1%)
HTN(71.4%)
Obesity(70%)
Huang 2015 [85]TaiwanPopulation-based study7113,5511290Both Stroke(17.2%) HTN(59%)
MacDonald 2008 [86]UKPopulation-based study75116,5566504Both CVD(53.4%) Stroke(32.9%)
PAD(38%)
Klein 2002 [87]USAPopulation-based study78.529681Both DR(16%)
Wang 2020 [88]ChinaPopulation-based study673205119T2DMStroke(21.9%)
Wingard 1993 [89]USAPopulation-based study702234335T2DMCVD(51.1%) Stroke(29.5%) PAD(12.6%)
Jedidiah I. Morton 2022 [90]AustraliaPopulation-based study70.21,160,155253,336T2DMCVD(13.9%)
Stroke (3.5%)
Olesen 2022 [91]DenmarkPopulation-based study59383,32534,996T2DMCVD(6.3%) Stroke(5%)
Obesity(21%)
Lee 2023 [92]South KoreaCross-sectional study7211624BothCVD(50%)
HTN(79%)
DR(100%)
Ferrer 2012 [93]SpainCross-sectional study85328328BothCVD(30.6%) Stroke(14%)
HTN(89.4%)
Kalyani 2010 [94]USACross-sectional study70.46097156BothCVD(45%)
Stroke(14%)
PAD(21%)
HTN(71.8%) DN(34%)
CKD(74%)
Barrio-Cortes 2024 [95]SpainCross-sectional study701063439BothCVD (12.2%)
Stroke(6.1%)
HTN(70%)
Obesity(32.4%)
CKD(5.8%)
VanMark 2020 [96]GermanyCross-sectional study70.8396,71980,643T2DMStroke(25.1%) PAD(17.1%)
DR(28.8%)
HTN(77%) DN(40.8%)
Obesity(31.7%) CKD(73.1%)
Sazlina 2014 [97]MalaysiaCross-sectional study71.3 10,363875T2DMCVD(11.4%) Stroke(12%)
DR(9%)
HTN(41.6%) Nephropathy(12.3%)
Mok 2019 [98]Hong KongCross-sectional study65.335,1094134T2DMDR(36%)
HTN(81%)
DN(9.7%)
Obesity(53.2%) Nephropathy(31.6%)
Yau 2012 [99]USALongitudinal cohort study80367367BothCVD(34%)
ESRD(5%)
Weiss 2009 [100]IsraelLongitudinal cohort study7912160BothCVD(6.7%) Stroke(36.7%)
HTN(56.7%)
Rodriguez-Saldana 2002 [101]MexicoLongitudinal cohort studyn/A78511BothStroke(8.4%)
HTN(74%)
Obesity(32%)
Sinclair 2000 [102]UKCase–control studyn/A77040BothDR(40%)
Shen 2023 [103]ChinaCase–control study81.5231231BothCVD(35%) Stroke(22%)
HTN(86.6%) CKD(37%)
Hirakawa 2017 [29]JapanObservational cohort study5838,854417BothCVD(8%)
Stroke(3%)
Benbow 1997 [104]UKObservational cohort study80.91611109BothStroke(21%) PAD(33.1%)
DN(18.3%)
Orces 2018 [105]EcuadorCross-sectional, population-based survey71.62298308T1DMHTN(53.8%)
Schutt 2012 [106]Germany and AustriaObservational, cross-sectional analysis22.864,609377T1DMCVD(10.1%) Stroke(7.7%)
DR(41.4%)
HTN(31.2%)
* First bracket T1DM, Second bracket T2DM. n/A = not available

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Diabetology 06 00152 g001
Figure 1. PRISMA Flow Diagram of Study Selection for Scoping Review on Diabetes-Related Complications and Comorbidities.
Figure 1. PRISMA Flow Diagram of Study Selection for Scoping Review on Diabetes-Related Complications and Comorbidities.
Diabetology 06 00152 g001
Table 1. Summary of database search strategies and terms used to identify studies.
Table 1. Summary of database search strategies and terms used to identify studies.
EMBASE (1974–2024)Medline All (1946–2024)Web of Science Core (All Fields, No Data Restriction)
  • Comorbidity/
  • Multiple Chronic Conditions/
  • Cardiovascular Diseases/
  • Isolated Systolic
    Hypertension/
  • Stroke/
  • Diabetes Complications/
  • Diabetes mellitus/
  • Neuropathy/
  • Diabetic Retinopathy/
  • Hyperglycaemia/
  • Very elderly/
  • 2 OR 3 OR 4 OR 5
  • 6 OR 7 OR 8 OR 9 OR 10
  • 1 AND 11 AND 12 AND 13
  • Limit 14 to (human and
    English language)
  • Comorbidity/
  • Multiple Chronic Conditions/
  • Cardiovascular Diseases/
  • Isolated Systolic
    Hypertension/
  • Stroke/
  • Diabetes Complications/
  • Diabetes mellitus/
  • Neuropathy/
  • Diabetic Retinopathy/
  • Hyperglycaemia/
  • 1 OR 2 OR 3 OR 4 OR 5
  • 6 OR 7 OR 8 OR 9 OR 10
  • 12 AND 13
  • Limit 13 to (human and English language
    and aged <80 + years >)
(Comorbidity or
“multiple chronic
conditions” or
“cardiovascular
disease” or stroke or
“isolated systolic
hypertension”)
AND
(“Diabetes mellitus” or
neuropathy or
“diabetic retinopathy”
or “Diabetes
complications”)
AND
(“Aged 80 or over” or
“very elderly” or “80+
years”)
* n = 589* n = 758* n = 426
* n = number of studies yielded by database search.
Table 2. Eligibility Criteria Based on the PCC Framework and Study Design.
Table 2. Eligibility Criteria Based on the PCC Framework and Study Design.
InclusionExclusion
PopulationHuman participants aged >80 years with a primary diagnosis of diabetes mellitus (any type)Human participants aged <80 years
Human participants categorised as ‘oldest-old’ with no details on actual age of participants
Non-human subjects
ContextStudies reporting on diabetes-related complications and comorbidities including: CVD 1, PAD 2, Stroke, Nephropathy, Neuropathy, Retinopathy, Foot ulceration, Amputation, HTN 3, Obesity or CKD 4/ESRD 5Studies where diabetes is not the primary exposure
Studies reporting only general comorbidity without diabetes diabetes-specific focus
ConceptStudies conducted in any healthcare setting or country
All income settings (higher, middle, lower-income countries)		Non-English language publications
Review articles, editorials, opinion pieces
Studies without full-text availability
Types of EvidenceOriginal research including:
Retrospective/prospective cohort studies
Cross-sectional studies
Case–control studies
Randomised controlled trials
Grey literature where full data was available		Systematic reviews
Scoping reviews
Meta-analysis
Narrative reviews
1 Cardiovascular Disease, 2 Peripheral arterial disease, 3 Hypertension, 4 Chronic kidney disease, 5 End-stage renal disease.
Table 3. Frequency, population coverage, and prevalence of diabetes-related complications and comorbidities in individuals aged ≥80 years across included studies.
Table 3. Frequency, population coverage, and prevalence of diabetes-related complications and comorbidities in individuals aged ≥80 years across included studies.
Complication ComorbidityNumber of Studies (n)Individuals ≥ 80 Years (×103)Number Affected (×103)Mean Prevalence
(%) *
MacrovascularCardiovascular Diseasen = 3317,538657737.5%
Peripheral Arterial Diseasen = 1136,3693810.4%
Stroken =37751557.3%
MicrovascularNephropathyn = 55.31.426.7%
Neuropathyn = 92004220.9%
Retinopathyn = 172084220.1%
PeripheralFoot ulcern = 20.950.099.3%
Amputationn = 36.00.030.5%
Other ComorbiditiesHypertensionn = 2816,73112,46574.5%
Obesityn = 111465336.5%
CKD/ESRDn = 916,662325019.5%
* Percentages are unweighted and not pooled due to heterogeneity in study design and reporting.
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Ward-Bradley, C.; Erwin, A.; Peto, T.; Cushley, L.N.; Curran, K. Complications and Comorbidities in Individuals >80 Years with Diabetes: A Scoping Review. Diabetology 2025, 6, 152. https://doi.org/10.3390/diabetology6120152

AMA Style

Ward-Bradley C, Erwin A, Peto T, Cushley LN, Curran K. Complications and Comorbidities in Individuals >80 Years with Diabetes: A Scoping Review. Diabetology. 2025; 6(12):152. https://doi.org/10.3390/diabetology6120152

Chicago/Turabian Style

Ward-Bradley, Christian, Adam Erwin, Tunde Peto, Laura N. Cushley, and Katie Curran. 2025. "Complications and Comorbidities in Individuals >80 Years with Diabetes: A Scoping Review" Diabetology 6, no. 12: 152. https://doi.org/10.3390/diabetology6120152

APA Style

Ward-Bradley, C., Erwin, A., Peto, T., Cushley, L. N., & Curran, K. (2025). Complications and Comorbidities in Individuals >80 Years with Diabetes: A Scoping Review. Diabetology, 6(12), 152. https://doi.org/10.3390/diabetology6120152

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