Relationships between daily acute glucose fluctuations and cognitive performance among aged type 2 diabetic patients

Association of GA/HbA1c ratio and cognitive impairment in subjects with type 2 diabetes mellitus

AIMS

The aim of this study was to search for factors influencing cognitive impairment and to clarify the association between the fluctuation of blood glucose levels and cognitive impairment in elderly Japanese subjects with type 2 diabetes.

METHODS

We recruited 88 relatively elderly subjects (≥65years old) with type 2 diabetes who were hospitalized in Kawasaki Medical School from January 2014 to December 2015. We evaluated the fluctuation of blood glucose levels with glycoalbumin (GA)/hemoglobin A1c (HbA1c) ratio, and estimated cognitive impairment with Hasegawa dementia scale-revised (HDS-R) score and mini mental state examination (MMSE) score.

RESULTS

Multivariate analyses showed that GA/HbA1c ratio and urinary albumin excretion, but not hypoglycemia, were independent determinant factors for cognitive impairment in elderly Japanese subjects with type 2 diabetes.

CONCLUSIONS

The fluctuation of blood glucose levels per se is closely associated with cognitive impairment in elderly subjects with type 2 diabetes even when hypoglycemia is not accompanied. Since it is very easy to calculate GA/HbA1c ratio, we should check this ratio so that we can reduce the fluctuation of blood glucose levels especially in elderly subjects with type 2 diabetes.

Migration, Health Care Behaviors, and Primary Care for Rural Latinos with Diabetes

Many US Latinos migrate or travel between the US and Mexico on a regular basis, defined as circular migration. Latinos with diabetes (n = 250) were surveyed about circular migration and their ability to use medications and perform recommended diabetes self-care activities. A review of medical charts was performed. Twenty-eight percent (n = 70) of patients traveled to Mexico during the last 12 months. Older Latinos were more likely to report traveling to Mexico and back into the US. Among those that traveled, 29 % reported use of less medication than they wanted to or were prescribed because of travel and 20 % ran out of medications. The rate of reported problem areas while traveling were 39 % (27/70) for following a diabetic diet, 31 % (21/70) for taking medication, and 37 % (26/70) for glucose self-monitoring. The results suggest that the structure of primary care and care coordination are important for this population to fully engage in diabetes self-care.

Diabetes mellitus and cognitive impairments

There is strong evidence that diabetes mellitus increases the risk of cognitive impairment and dementia. Insulin signaling dysregulation and small vessel disease in the base of diabetes may be important contributing factors in Alzheimer’s disease and vascular dementia pathogenesis, respectively. Optimal glycemic control in type 1 diabetes and identification of diabetic risk factors and prophylactic approach in type 2 diabetes are very important in the prevention of cognitive complications. In addition, hypoglycemic attacks in children and elderly should be avoided. Anti-diabetic medications especially Insulin may have a role in the management of cognitive dysfunction and dementia but further investigation is needed to validate these findings.

Glucose fluctuations reduce quality of sleep and of life in patients with liver cirrhosis

BACKGROUND

Sleep disturbance and decreased health-related quality of life (HRQOL) are significant complaints in patients with liver cirrhosis. Although the etiology of these complications is unclear, we propose that glucose intolerance may be a predisposing factor. Therefore, our aim was to investigate the relationship between glucose intolerance and these complications.

METHODS

We assessed continuous glucose monitoring in 43 patients with chronic liver disease. Among these patients, 36 completed the Pittsburgh Sleep Quality Index (PSQI), the 36-Item Short-form Health Survey (SF-36), and the Neuropsychological Test (NPT). We also assessed the change in glucose fluctuations between preoperative periods and 1 year after liver transplantation in 13 patients.

RESULTS

Standard deviation (SD) of blood glucose was 24.15 ± 13.52. SD values correlated to glucose metabolism measures, including HbA1c and glycoalbumin. SD values also correlated to markers of liver fibrosis, including type IV collagen. Twenty-one patients (58.3 %) were classified as "poor" sleepers, with a global PSQI score ≥6. Glucose fluctuations correlated with the global PSQI score (r = 0.456, p = 0.008) and the SF-36 score (r = 0.434, p = 0.013). Multivariate regression analysis identified SD values as an independent risk factor for sleep disturbance (r = 0.12, p = 0.039) and decreased HRQOL (r = -0.32, p = 0.024). SD values did not correlate with the NPT. SD values were also improved in 11 (84.6 %) patients 1 year after liver transplantation.

CONCLUSION

Abnormal glucose fluctuations are a risk factor for sleep disturbance and decrease of HRQOL in patients with cirrhosis.

Detecting Visual Function Abnormality with a Contrast-Dependent Visual Test in Patients with Type 2 Diabetes

In addition to diabetic retinopathy, diabetes also causes early retinal neurodegeneration and other eye problems, which cause various types of visual deficits. This study used a computer-based visual test (Macular Multi-Function Assessment (MMFA)) to assess contrast-dependent macular visual function in patients with type 2 diabetes to collect more visual information than possible with only the visual acuity test. Because the MMFA is a newly developed test, this study first compared the agreement and discriminative ability of the MMFA and the Early Treatment Diabetic Retinopathy Study (ETDRS) contrast acuity charts. Then symbol discrimination performances of diabetic patients and controls were evaluated at 4 contrast levels using the MMFA. Seventy-seven patients and 45 controls participated. The agreement between MMFA and ETDRS scores was examined by fitting three-level linear mixed-effect models to estimate the intraclass correlation coefficients (ICCs). The estimated areas under the receiver operating characteristic (ROC) curve were used to compare the discriminative ability of diseased versus non-diseased participants between the two tests. The MMFA scores of patients and controls were compared with multiple linear regression analysis after adjusting the effects of age, sex, hypertension and cataract. Results showed that the scores of the MMFA and ETDRS tests displayed high levels of agreement and acceptable and similar discriminative ability. The MMFA performance was correlated with the severity of diabetic retinopathy. Most of the MMFA scores differed significantly between the diabetic patients and controls. In the low contrast condition, the MMFA scores were significantly lower for 006Eon-DR patients than for controls. The potential utility of the MMFA as an easy screening tool for contrast-dependent visual function and for detecting early functional visual change in patients with type 2 diabetes is discussed.

Understanding Post-Prandial Hyperglycemia in Patients with Type 1 and Type 2 Diabetes: A Web-based Survey in Germany, the UK, and USA

INTRODUCTION

To explore how patients with diabetes experience post-prandial hyperglycemia (PPH) or elevated blood glucose (BG) following a meal.

METHODS

A web-based survey of patients with type 1 or type 2 diabetes using bolus insulin in Germany, the USA, and the UK was conducted.

RESULTS

A total of 906 respondents completed the survey. PPH was a frequent occurrence among patients with type 1 and type 2 diabetes; 61.9% of respondents had experienced PPH in the past week, and differences by diabetes type were not significant. More than half of the respondents reported that they knew they were experiencing PPH because they had measured their BG (64.8%) and/or because they "just didn't feel right" (51.9%). The most frequently reported reasons given for PPH were eating more fat/sugar than estimated (31.2%) and over-eating in terms of their calculated bolus insulin dose (30.4%). The most common situations/factors contributing to PPH were stress (27.4%), eating at a restaurant (24.9%), being busy (21.1%), and/or feeling tired (19.2%). The most frequent corrective actions respondents took following PPH were testing BG and taking bolus insulin based on the reading (62.0%), and/or eating less/more carefully at their next meal or snack (18.8%). Additionally, significant differences in the reasons and contributing factors given for PPH and corrective actions following PPH, as well as emotions experienced when taking bolus insulin, were found by diabetes type.

CONCLUSION

These findings shed light on how patients with diabetes experience and manage PPH on a day-to-day basis and have implications for improving diabetes self-management. Clinicians and diabetes educators should help patients address eating habits and lifestyle issues that may contribute to PPH.

FUNDING

This study was sponsored by Novo Nordisk.

Increased oxidative stress and apoptosis in the hypothalamus of diabetic male mice in the insulin receptor substrate-2 knockout model

Insulin receptor substrate-2-deficient (IRS2(-/-)) mice are considered a good model to study the development of diabetes because IRS proteins mediate the pleiotropic effects of insulin-like growth factor-I (IGF-I) and insulin on metabolism, mitogenesis and cell survival. The hypothalamus might play a key role in the early onset of diabetes, owing to its involvement in the control of glucose homeostasis and energy balance. Because some inflammatory markers are elevated in the hypothalamus of diabetic IRS2(-/-) mice, our aim was to analyze whether the diabetes associated with the absence of IRS2 results in hypothalamic injury and to analyze the intracellular mechanisms involved. Only diabetic IRS2(-/-) mice showed increased cell death and activation of caspase-8 and -3 in the hypothalamus. Regulators of apoptosis such as FADD, Bcl-2, Bcl-xL and p53 were also increased, whereas p-IκB and c-FLIPL were decreased. This was accompanied by increased levels of Nox-4 and catalase, enzymes involved in oxidative stress. In summary, the hypothalamus of diabetic IRS2(-/-) mice showed an increase in oxidative stress and inflammatory markers that finally resulted in cell death via substantial activation of the extrinsic apoptotic pathway. Conversely, non-diabetic IRS2(-/-) mice did not show cell death in the hypothalamus, possibly owing to an increase in the levels of circulating IGF-I and in the enhanced hypothalamic IGF-IR phosphorylation that would lead to the stimulation of survival pathways. In conclusion, diabetes in IRS2-deficient male mice is associated with increased oxidative stress and apoptosis in the hypothalamus.

Applying Atherosclerotic Risk Prevention Guidelines to Elderly Patients: A Bridge Too Far?

The primary prevention of atherosclerotic disease is on the basis of optimal management of the major risk factors. For the major risk factors of diabetes, hypertension, and dyslipidemia, management for most patients is on the basis of well developed and extensive evidence-based diagnostic and therapeutic guidelines. However, for a growing segment of the population who are at the highest risk for atherosclerotic disease (ie, older adults), the application of these guidelines is problematic. First, few studies that form the evidence base for these primary prevention guidelines actually include substantial numbers of elderly subjects. Second, elderly patients represent a special population from multiple perspectives related to their accumulation of health deficits and in their development of frailty. These patients with frailty and multiple comorbidities have been mostly excluded from the primary prevention studies upon which the guidelines are based yet comprise a very significant proportion of the very elderly population. Third, elderly people are at most risk from adverse drug reactions because of the increasing number of medications prescribed in this patient population. When applying the existing guidelines to elderly people the limitations of our knowledge must be recognized regarding how best to mitigate the high risk of heart disease in our aging population and how to generalize these recommendations to the management of the largest subgroup of elderly patients (ie, those with multiple comorbidities and frail older adults).

The Economic Burden of Post-prandial Hyperglycemia (PPH) Among People with Type 1 and Type 2 Diabetes in Three Countries

INTRODUCTION

Post-prandial hyperglycemia (PPH) among people with diabetes is a well-known clinical challenge to diabetes management. While the economic burden of diabetes is well studied, little is known about economic costs specific to PPH. The purpose of this study was to investigate costs of PPH related to work, diabetes management, and use of healthcare resources among people with diabetes taking bolus insulin.

METHODS

Data were collected in a web survey of 906 adults with type 1 (39%) and type 2 (61%) diabetes taking bolus insulin in Germany (34%), the UK (26%), and the USA (40%).

RESULTS

Sixty-two percent of respondents experienced PPH in the past week, and respondents averaged 1.7 episodes per week. Working respondents indicated that PPH affected their work productivity: 27% missed work time and 71% experienced work productivity issues while at work due to a recent episode of PPH. In terms of diabetes management, respondents with PPH in the past week measured their blood glucose (BG) more frequently than those without PPH (3.7 vs. 2.5 times/day, P < 0.001). PPH was also significantly associated with greater use of healthcare resources. Compared to those without PPH, respondents with PPH reported greater contact with healthcare professionals related to diabetes in the past year (5.5 vs. 4.4 visits, P < 0.001; 2.7 vs. 1.4 calls/emails, P < 0.001) and were more likely to report medical complications related to diabetes (72% vs. 55%, P < 0.001). Average annual costs associated with PPH due to missed work time, additional BG test strips, and physician visits were estimated to be $1239 USD per employed person in the USA.

CONCLUSION

Results indicate that PPH is associated with greater economic costs and that reducing the incidence of PPH would help mitigate such costs. Additional research is needed to better understand costs associated with PPH that may be more difficult to measure, as well as more long-term impacts and costs.

FUNDING

Novo Nordisk.

Degludec is superior to glargine in terms of daily glycemic variability in people with type 1 diabetes mellitus

To investigate the differences in glycemic variability between the long-acting insulins glargine and degludec using continuous glucose monitoring, we conducted an open-label, multicenter, prospective, observational study that enrolled 21 participants with type 1 diabetes mellitus currently receiving basal-bolus insulin therapy with glargine. To avoid the potential influence of diet and exercise on glycemic control, all participants were housed and monitored within the hospital for the duration of the study. Once glycemic control was achieved with glargine, glycemic variability was evaluated using continuous glucose monitoring for 3 days. Glargine was then replaced by degludec and glycemic variability again assessed via continuous glucose monitoring. The primary outcome measure of mean amplitude of glycemic excursions was significantly reduced with degludec (p = 0.028), as was area under the curve for daily blood glucose level <70 mg/dL (p = 0.046). The required insulin dose was reduced up to 25% in the degludec group, although 24-h mean glucose concentrations were not different between groups. In conclusion, once or twice daily glargine was successfully replaced by a daily injection of degludec. When replacing glargine with degludec, a lower dose should be utilized to avoid hypoglycemia. Degludec is an effective and promising long-acting insulin that reduced hypoglycemia and daily blood glucose variability in participants with type 1 diabetes.

Glycemic control, inflammation, and cognitive function in older patients with type 2 diabetes

OBJECTIVE

Glycated hemoglobin (HbA1c) and C-reactive protein (CRP) have been associated with cognitive impairment independently. However, it is unclear if their combination exacerbates poor cognitive function. We assessed whether long-term glycemic level and glycemic variability modulate the association of systemic inflammation with cognitive function, in a sample of cognitively normal older people with type 2 diabetes.

METHODS

A retrospective cohort study of 777 randomly selected participants from ~11,000 patients in the Maccabi Healthcare Services Diabetes Registry, as part of the Israel Diabetes and Cognitive Decline study. Subjects averaged 18 (±9.4) HbA1c measures in the Maccabi Healthcare Services Registry, which were used to calculate long-term glycemic level (HbA1c-mean) and glycemic variability (HbA1c-standard deviation (SD)). Linear regression models assessed the interactions of CRP, a marker of systemic inflammation, with HbA1c-mean and HbA1c-SD on subjects' performance in tests of Memory, Executive Functions, Attention, and Semantic Categorization.

RESULTS

Quadratic interactions of CRP with HbA1c-SD approached significance for executive functions and overall cognition. However, after Bonferroni adjustment, none of the interactions of CRP with HbA1c were statistically significant. In partial correlations according to HbA1c-SD tertiles, CRP was weakly correlated in the middle tertile with decreased performance in the domains of semantic categorization (r = -0.166, p = 0.011), executive functions (r = -0.136, p = 0.038), and overall cognition (r = -0.157, p = 0.016).

CONCLUSIONS

Glycated hemoglobin does not substantially modulate the association of CRP with cognition in a sample of cognitively normal, community dwelling older people with relatively well-managed type 2 diabetes.

Shortfalls of the use of HbA1C-derived eAG in older adults with diabetes

AIMS

The hemoglobin HbA1C (HbA1C) value, translated into estimated average glucose concentration (eAG), is commonly used to assess glycaemic control and manage treatment regimens in people with diabetes. However, the relationships among HbA1C-derived eAG, and mean glucose concentration derived from continuous glucose monitoring (CGM) in different populations have not been well studied. We examined this relationship in older people with diabetes and compared the results to those currently used in clinical practice.

METHODS

Data from three studies evaluating CGM in older adults (≥70 years of age), with stable glycaemic control were analyzed retrospectively. Mean glucose and mean amplitude of glucose excursion (MAGE) were calculated from CGM data and correlated with HbA1C and HbA1C-derived eAG using the ADAG study formula.

RESULTS

HbA1C and CGM data were analyzed from 90 patients with mean age 76±5 years, HbA1C 7.9±1.2% (63±13 mmol/mol) and 77% with Type 2 diabetes. The HbA1C and HbA1C-derived eAG correlated significantly with CGM-measured mean glucose (r(2)=0.30, p<0.0001) and MAGE (r(2)=0.16, p=0.00013) in this population and all its subgroups, but the slopes of the relationship between HbA1C and eAG or CGM-measured mean glucose were significantly different.

CONCLUSIONS

HbA1C-derived eAG values may not accurately reflect CGM-measured mean glucose or MAGE in older adults with diabetes. Wide glucose excursions should be considered and HbA1C should be interpreted cautiously when making treatment changes based on HbA1C.

Multisite Study of an Implanted Continuous Glucose Sensor Over 90 Days in Patients With Diabetes Mellitus

BACKGROUND

Continuous glucose monitoring (CGM), which enables real-time glucose display and trend information as well as real-time alarms, can improve glycemic control and quality of life in patients with diabetes mellitus. Previous reports have described strategies to extend the useable lifetime of a single sensor from 1-2 weeks to 28 days. The present multisite study describes the characterization of a sensing platform achieving 90 days of continuous use for a single, fully implanted sensor.

METHOD

The Senseonics CGM system is composed of a long-term implantable glucose sensor and a wearable smart transmitter. Study subjects underwent subcutaneous implantation of sensors in the upper arm. Eight-hour clinic sessions were performed every 14 days, during which sensor glucose values were compared against venous blood lab reference measurements collected every 15 minutes using mean absolute relative differences (MARDs).

RESULTS

All subjects (mean ± standard deviation age: 43.5 ± 11.0 years; with 10 sensors inserted in men and 14 in women) had type 1 diabetes mellitus. Most (22 of 24) sensors reported glucose values for the entire 90 days. The MARD value was 11.4 ± 2.7% (range, 8.1-19.5%) for reference glucose values between 40-400 mg/dl. There was no significant difference in MARD throughout the 90-day study (P = .31). No serious adverse events were noted.

CONCLUSIONS

The Senseonics CGM, composed of an implantable sensor, external smart transmitter, and smartphone app, is the first system that uses a single sensor for continuous display of accurate glucose values for 3 months.

Association between Visit-to-Visit Glucose Variability and Cognitive Function in Aged Type 2 Diabetic Patients: A Cross-Sectional Study

Background and Purpose

Diabetes is associated with cognitive decline as well as the development of dementia. Although mean blood glucose levels are typically used to assess the status of diabetic patients, glucose variability is also involved in the manifestation of macro- and microvascular complications in this population. Thus, the present study sought to determine whether visit-to-visit glucose variability contributes to cognitive decline in patients with type 2 diabetes.

Methods

The present study assessed 68 patients with type 2 diabetes using several validated neuropsychological measures. All patients had no cerebrovascular disease, history of hypoglycemia, psychiatric conditions, or other medical illnesses. Standard deviations (SDs) and coefficients of variance (CVs) of the patients’ blood glucose (after fasting and 2 hours postprandial; FBS and PP2), and glycated hemoglobin (HbA1c) values were used as indices of glucose variability. The cognitive outcome parameters were transformed with z-scores and entered into a multiple linear regression model that included educational status, age, sex, vascular risk factors, and mean glucose parameters as covariates.

Results

The mean age of the total patient population was 70.9 years; 46 (67.6%) of the patients were men, and the median follow-up duration at our endocrinology outpatient clinic was 4.8 years. The mean FBS and PP2 glucose levels of the patients were 132 mg/dL and 199 mg/dL, respectively, and the mean HbA1c level was 8.0%. A univariable analysis revealed that only the PP2 value was associated with the Mini-Mental State Examination (MMSE) score, and multivariable analysis revealed that a high SD and/or CV for PP2 glucose were associated with low scores on the Rey Complex Figure Copy test and/or the Verbal Learning Test. Additionally, a high SD and a higher CV for HbA1c level were significantly associated with low MMSE and Digit Span test scores even after adjusting for mean HbA1c values.

Conclusions

The present data indicate that a greater degree of visit-to-visit glucose variability influenced specific types of cognitive function in type 2 diabetic patients independently of mean blood glucose levels. Future studies should focus on whether reductions in glycemic variability will improve the cognitive decline observed in type 2 diabetic patients.

[Association of cognitive impairments with carbohydrate and lipid metabolic parameters in type 2 diabetes mellitus patients undergoing coronary bypass surgery]

AIM. To comparatively analyze neuropsychological parameters in patients with coronary artery disease (CAD) depending on the presence of type 2 diabetes mellitus (DM) and to evaluate their relationship to carbohydrate and lipid metabolic parameters.

SUBJECTS AND METHODS

Fifty-two male patients with type 2 DM (mean age 58.0 ± 5.7 years) and 46 male patients without this condition (mean age 57.1 ± 6.2 years) were examined. Besides standard clinical examination, neurophysiological testing and determinations of glycated hemoglobin (HbA(1c),) and insulin concentrations, QUICKI index, and blood lipid profile were made.

RESULTS

The patients with DM differed from those without DM in the lower speeds of sensorimotor reactions during neurodynamic testing and in worse attention values. In the patients with type 2 DM, the worse neuropsychological status was associated with the higher plasma concentrations of glucose, insulin, HbA(1c), total cholesterol, low-density lipoproteins, and triglycerides and with the lower levels of high-density lipoproteins. These relationships were not observed in the patients without DM.

CONCLUSION

The patients with CAD concurrent with DM had a worse neurophysiological status than those without DM. Only the DM group demonstrated a relationship between cognitive impairments and carbohydrate metabolic markers. Carbohydrate and lipid metabolic disturbances may be assumed to make a negative contribution to the development of cognitive impairments in patients with CAD concurrent with type 2 DM.

Utility of different glycemic control metrics for optimizing management of diabetes

The benchmark for assessing quality of long-term glycemic control and adjustment of therapy is currently glycated hemoglobin (HbA1c). Despite its importance as an indicator for the development of diabetic complications, recent studies have revealed that this metric has some limitations; it conveys a rather complex message, which has to be taken into consideration for diabetes screening and treatment. On the basis of recent clinical trials, the relationship between HbA1c and cardiovascular outcomes in long-standing diabetes has been called into question. It becomes obvious that other surrogate and biomarkers are needed to better predict cardiovascular diabetes complications and assess efficiency of therapy. Glycated albumin, fructosamin, and 1,5-anhydroglucitol have received growing interest as alternative markers of glycemic control. In addition to measures of hyperglycemia, advanced glucose monitoring methods became available. An indispensible adjunct to HbA1c in routine diabetes care is self-monitoring of blood glucose. This monitoring method is now widely used, as it provides immediate feedback to patients on short-term changes, involving fasting, preprandial, and postprandial glucose levels. Beyond the traditional metrics, glycemic variability has been identified as a predictor of hypoglycemia, and it might also be implicated in the pathogenesis of vascular diabetes complications. Assessment of glycemic variability is thus important, but exact quantification requires frequently sampled glucose measurements. In order to optimize diabetes treatment, there is a need for both key metrics of glycemic control on a day-to-day basis and for more advanced, user-friendly monitoring methods. In addition to traditional discontinuous glucose testing, continuous glucose sensing has become a useful tool to reveal insufficient glycemic management. This new technology is particularly effective in patients with complicated diabetes and provides the opportunity to characterize glucose dynamics. Several continuous glucose monitoring (CGM) systems, which have shown usefulness in clinical practice, are presently on the market. They can broadly be divided into systems providing retrospective or real-time information on glucose patterns. The widespread clinical application of CGM is still hampered by the lack of generally accepted measures for assessment of glucose profiles and standardized reporting of glucose data. In this article, we will discuss advantages and limitations of various metrics for glycemic control as well as possibilities for evaluation of glucose data with the special focus on glycemic variability and application of CGM to improve individual diabetes management.

Glucose regulation, cognition, and brain MRI in type 2 diabetes: a systematic review

Type 2 diabetes is associated with cognitive dysfunction and structural brain changes. Abnormalities in glucose regulation are involved in several complications related to type 2 diabetes, but their role in these cerebral complications is unclear. We systematically reviewed studies of the association between glucose regulation (glycaemia, hypoglycaemic events, insulin concentration, insulin resistance, and glucose-lowering treatment) and cognitive function and brain abnormalities on MRI in people with type 2 diabetes. The 86 papers included showed that glycaemia, particularly high HbA1c concentration and glucose variability, are negatively associated with cognitive function in people with type 2 diabetes without dementia. However, the strength of this association is weak, and HbA1c generally accounted for less than 10% of the variance in cognition. Importantly, few studies have measured long-term cerebral outcomes, such as dementia and structural brain changes on MRI, and the effect of glucose-lowering treatment on these outcomes. More randomised controlled trials are needed to establish the effect of glucose-lowering treatment on long-term cognitive function in people with type 2 diabetes.

Differential subtypes of diabetic older adults diagnosed with Alzheimer's disease

AIM

The clinical management of diabetic elderly patients with Alzheimer's disease (AD) is hindered by several difficulties. The present study aimed to clarify the clinical characteristics and pathophysiological properties of AD in diabetic older adults.

METHODS

A total of 91 patients with type 2 diabetes mellitus and 161 non-diabetic individuals who were diagnosed with AD were recruited. Diabetic patients were classified into two groups with glycated hemoglobin (HbA1c) < 7.0% or ≥ 7.0%. The demographics, cognition, daily-life function, metabolic changes, treatment, and behavioral and psychological symptoms of dementia (BPSD), as well as brain pathophysiology, were compared among the three groups.

RESULTS

Patients with higher HbA1c had increased diabetic vascular complications and impaired activities of daily living with decreased levels of serum high-molecular-weight adiponectin and 25-hydroxyvitamin D. Although cognitive status was similar among the three groups, BPSD, including apathy, overeating and excessive daytime sleeping appeared to be increased in the patients with HbA1c ≥ 7.0%. The frequency of apolipoprotein E4 carriers and of posterior cerebral hypoperfusion (AD-pattern) on single-photon emission computed tomography in poorly controlled diabetic subjects was similar to that in non-diabetic AD patients, whereas diabetic patients with HbA1c <7.0% included fewer apolipoprotein E4 carriers and fewer patients with an AD pattern on single-photon emission computed tomography.

CONCLUSION

Subtypes of older diabetic patients with AD were identified based on clinical features and brain pathophysiology. Physical and psychological complications of dementia are prevalent in patients with higher HbA1c. It seems likely that difficulties in the management of diabetes with AD are due not only to non-adherence to diabetes treatment, but also several symptoms and pathophysiological characteristics of dementia.

Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.

Glycemic variability and oxidative stress: a link between diabetes and cardiovascular disease?

Diabetes is associated with a two to three-fold increase in risk of cardiovascular disease. However, intensive glucose-lowering therapy aiming at reducing HbA1c to a near-normal level failed to suppress cardiovascular events in recent randomized controlled trials. HbA1c reflects average glucose level rather than glycemic variability. In in vivo and in vitro studies, glycemic variability has been shown to be associated with greater reactive oxygen species production and vascular damage, compared to chronic hyperglycemia. These findings suggest that management of glycemic variability may reduce cardiovascular disease in patients with diabetes; however, clinical studies have shown conflicting results. This review summarizes the current knowledge on glycemic variability and oxidative stress, and discusses the clinical implications.

A systematic review of type 2 diabetes mellitus and hypertension in imaging studies of cognitive aging: time to establish new norms

The rising prevalence of type 2 diabetes (T2DM) and hypertension in older adults, and the deleterious effect of these conditions on cerebrovascular and brain health, is creating a growing discrepancy between the "typical" cognitive aging trajectory and a "healthy" cognitive aging trajectory. These changing health demographics make T2DM and hypertension important topics of study in their own right, and warrant attention from the perspective of cognitive aging neuroimaging research. Specifically, interpretation of individual or group differences in blood oxygenation level dependent magnetic resonance imaging (BOLD MRI) or positron emission tomography (PET H2O(15)) signals as reflective of differences in neural activation underlying a cognitive operation of interest requires assumptions of intact vascular health amongst the study participants. Without adequate screening, inclusion of individuals with T2DM or hypertension in "healthy" samples may introduce unwanted variability and bias to brain and/or cognitive measures, and increase potential for error. We conducted a systematic review of the cognitive aging neuroimaging literature to document the extent to which researchers account for these conditions. Of the 232 studies selected for review, few explicitly excluded individuals with T2DM (9%) or hypertension (13%). A large portion had exclusion criteria that made it difficult to determine whether T2DM or hypertension were excluded (44 and 37%), and many did not mention any selection criteria related to T2DM or hypertension (34 and 22%). Of all the surveyed studies, only 29% acknowledged or addressed the potential influence of intersubject vascular variability on the measured BOLD or PET signals. To reinforce the notion that individuals with T2DM and hypertension should not be overlooked as a potential source of bias, we also provide an overview of metabolic and vascular changes associated with T2DM and hypertension, as they relate to cerebrovascular and brain health.

The role of self-monitoring of blood glucose in patients treated with SGLT-2 inhibitors: a European expert recommendation

The role for the novel treatment approach of sodium-glucose cotransporter-2 (SGLT-2) in type 2 diabetes is increasing. Structured self-monitoring of blood glucose (SMBG), based on a less intensive and a more intensive scheme, may contribute to an optimization of SGLT-2 inhibitor based treatment. The current expert recommendation suggests individualized approaches of SMBG, using simple and clinically applicable schemes. Potential benefits of SMBG in SGLT-2 inhibitor based treatment approaches are early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions, and support of diabetes management and education. The length and frequency of SMBG should depend on the clinical setting and the quality of metabolic control.

Different antihyperglycaemic drug effects on glycaemic variability in Type 2 diabetic patients

Optimizing treatments for type 2 diabetes mellitus (T2DM) remains an urgent issue. In addition to T2DM treatment strategies, such as glycaemic goals (glucose and glycated haemoglobin ? HbА1c) among different patient populations, the influence of glycaemic variability (GV) on the prognosis of patients with T2DM is also important. According to recent data, GV is associated with cardiovascular complications arising from T2DM. However, although the influence of GV on the development of vascular complications arising from diabetes and underlying mechanisms has been extensively investigated, few studies have investigated the effects of different glucose-lowering medications on GV, and there are even fewer reviews of this topic. This type of analysis is highly relevant, particularly because new classes of antidiabetic medications with potent glucose-dependent insulinotropic effects have been developed. These include groups of drugs that mimic or enhance incretin activity, such as glucagon-like peptide (GLP)-1 analogues/mimetics and dipeptidyl peptidase (DPP)-4 inhibitors. A glucose-dependent mechanism suggests that these groups of antidiabetic medications have beneficial effects on GV. Thus, the current study focusses on the comparative analysis of drugs based on their incretin effects (GLP-1 analogues/mimetics and DPP-4 inhibitors) and оther antidiabetic medications with regard to GV in the patients with T2DM.

Neurocognitive changes and their neural correlates in patients with type 2 diabetes mellitus

As the prevalence and life expectancy of type 2 diabetes mellitus (T2DM) continue to increase, the importance of effective detection and intervention for the complications of T2DM, especially neurocognitive complications including cognitive dysfunction and dementia, is receiving greater attention. T2DM is thought to influence cognitive function through an as yet unclear mechanism that involves multiple factors such as hyperglycemia, hypoglycemia, and vascular disease. Recent developments in neuroimaging methods have led to the identification of potential neural correlates of T2DM-related neurocognitive changes, which extend from structural to functional and metabolite alterations in the brain. The evidence indicates various changes in the T2DM brain, including global and regional atrophy, white matter hyperintensity, altered functional connectivity, and changes in neurometabolite levels. Continued neuroimaging research is expected to further elucidate the underpinnings of cognitive decline in T2DM and allow better diagnosis and treatment of the condition.

Self-monitoring of blood glucose: a prerequisite for diabetes management in outcome trials

Evidence for the value of self-monitoring of blood glucose (SMBG) with regard to the achievement of treatment targets, detection of postprandial glucose excursions, and minimization of glycemic variability is increasing. In large clinical trials, SMBG is a key component for the optimization of diabetes treatment in insulin-treated diabetes. It also plays an essential role in outcome studies. However, details of SMBG use in both the methods and results sections of clinical articles are frequently scarce. Also, a discussion of the SMBG data and its impact on insulin therapy is valuable. In the recently completed Outcome Reduction with an Initial Glargine INtervention (ORIGIN) trial, SMBG was described in detail and insulin titration was largely driven by SMBG. Both aspects largely contributed to the fact that near-normal control was achieved over a long-term period.

Variability in phenylalanine control predicts IQ and executive abilities in children with phenylketonuria

A number of studies have revealed significant relationships between cognitive performance and average phenylalanine (Phe) levels in children with phenylketonuria (PKU), but only a few studies have been conducted to examine the relationships between cognitive performance and variability (fluctuations) in Phe levels. In the current study, we examined a variety of indices of Phe control to determine which index best predicted IQ and executive abilities in 47 school-age children with early- and continuously-treated PKU. Indices of Phe control were mean Phe, the index of dietary control, change in Phe with age, and several indices of variability in Phe (standard deviation, standard error of estimate, and percentage of spikes). These indices were computed over the lifetime and during 3 developmental epochs (<5, 5.0-9.9, and ≥10 years of age). Results indicated that variability in Phe was generally a stronger predictor of cognitive performance than other indices of Phe control. In addition, executive performance was better predicted by variability in Phe during older than younger developmental epochs. These results indicate that variability in Phe should be carefully controlled to maximize cognitive outcomes and that Phe control should not be liberalized as children with PKU age.

Cognitive status and foot self care practice in overweight diabetics, engaged in different levels of physical activity

Background

Type 2 diabetes along with chronic hyperglycemia may result in cognitive impairment. This can negatively affect the patient’s adherence to diabetes treatment. The purpose of this study was to compare the cognitive status and foot self care practice in overweight type 2 diabetic patients who exercised regularly and those who did not.

Methods

The comparative study was conducted on 160 consecutive patients from an outpatient diabetes clinic. They were divided into two groups: The active group comprised of 80 patients engaged in regular exercise for at least 15–30 minutes, three times per week during the past 6 months. The control group included 80 patients who had not exercised regularly for the past 12 months, matched for sex, age, education, diabetes duration, hemoglobin A1C and body mass index (BMI: 25–29.9Kg/m²). Data on the patients’ demographic information, foot care practice and physical activity habits were gathered using a questionnaire. The Mini Mental Status examination (MMSE) was applied to assess cognitive status.

Results

MMSE score was significantly higher in the active group. A significant negative correlation was noted between MMSE scores and BMI in the control group (r = −0.2, P = 0.03). A significant difference was noted in the four domains of foot self care practice between the active (4.77 ± 0.77) and control (4.45 ± 0.83) groups (P < 0.01).

Conclusions

Regular physical activity can help promote cognitive status and foot self care practice in overweight patients with type 2 diabetes.

Association between health literacy and child and adolescent obesity

OBJECTIVE

We tested the association between child and parental health literacy (HL) and odds of child and adolescent obesity.

METHODS

We conducted an anonymous cross-sectional survey of a convenience sample of English-speaking child-parent dyads. Newest Vital Sign (NVS) measured HL. We used multivariable logistic regression to test adjusted association between child and parental NVS and obesity. Analyses were stratified for school-aged children (aged 7-11) vs. adolescents (aged 12-19).

RESULTS

We surveyed 239 child-parent dyads. Median child age was 11 [inter-quartile range 9-13]; 123 (51%) were male; 84% Medicaid recipients; 27% obese. For children, the odds of obesity [adjusted odds ratio (95% confidence interval)] decreased with higher parent NVS [0.75 (0.56,1.00)] and increased with parent obesity [2.53 (1.08,5.94)]. For adolescents, odds of obesity were higher for adolescents with the lowest category of NVS [5.00 (1.26, 19.8)] and older parental age [1.07 (1.01,1.14)] and lower for Medicaid recipients [0.21 (0.06,0.78)] and higher parental education [0.38 (0.22,0.63)].

CONCLUSION

Obesity in school-aged children is associated with parental factors (obesity, parental HL); obesity in adolescents is strongly associated with the adolescent's HL.

PRACTICE IMPLICATIONS

Strategies to prevent and treat obesity should consider limited HL of parents for child obesity and of adolescents for adolescent obesity.

Effect of eating vegetables before carbohydrates on glucose excursions in patients with type 2 diabetes

The aim of this review was to evaluate whether eating vegetables before carbohydrates could reduce the postprandial glucose, insulin, and improve long-term glycemic control in Japanese patients with type 2 diabetes. We studied the effect of eating vegetables before carbohydrates on postprandial plasma glucose, insulin, and glycemic control for 2.5 y in patients with type 2 diabetes. The postprandial glucose and insulin levels decreased significantly when the patients ate vegetables before carbohydrates compared to the reverse regimen, and the improvement of glycemic control was observed for 2.5 y. We also compared the postprandial glucose and glucose fluctuations assessed by continuous glucose monitoring system for 72-h in patients with type 2 diabetes and subjects with normal glucose tolerance when subjects ate vegetables before carbohydrates and carbohydrates before vegetables in a randomized crossover design. The glycemic excursions and incremental glucose peak were significantly lower when the subjects ate vegetables before carbohydrates compared to the reverse regimen. This evidence supports the effectiveness of eating vegetables before carbohydrates on glucose excursions in the short-term and glycemic control in the long-term in patients with type 2 diabetes.

Subgroups of Alzheimer's disease associated with diabetes mellitus based on brain imaging

BACKGROUND/AIMS

We attempted to define possible subgroups of Alzheimer's disease (AD) associated with diabetes mellitus (DM) based on brain imaging.

METHODS

We classified 175 patients with clinically diagnosed AD and type 2 DM into 4 subgroups on the basis of the presence or absence of cerebrovascular disease (CVD) on MRI (CVD or no CVD) and posterior cerebral hypoperfusion on SPECT (AD pattern or no AD pattern). Differences in the clinical characteristics among the subgroups were examined.

RESULTS

The subgroup showing neither a CVD pattern nor an AD pattern had significantly older age, higher hemoglobin A1c level, longer duration of diabetes, higher frequency of insulin therapy, lower frequency of apolipoprotein E4 carriers, less severe medial temporal lobe atrophy, more impaired attention, less impaired word recall, and slower progression of cognitive impairment than the subgroup showing an AD pattern. We found no characteristic features of other subgroups.

CONCLUSION

The clinical features of subjects with AD associated with DM may differ depending on brain imaging patterns. Among them, there may be a dementia subgroup with characteristics predominantly associated with DM-related metabolic abnormalities.

The influence of subclinical cardiovascular disease and related risk factors on cognition in type 2 diabetes mellitus: The DHS-Mind study

We hypothesized that measures of coronary artery calcified plaque (CAC) collected at baseline from the Diabetes Heart Study (DHS) would explain associations between cognition and diabetes collected at follow-up approximately 7 years later. The DHS is a sibling study of cardiovascular disease (CVD) in a cohort with a high prevalence of type 2 diabetes (~80%). Associations between baseline CAC and cognitive performance were tested using generalized estimating equations and mixed effects models to adjust for familial relationships. Diabetes status was associated (p<0.05) with poorer performance on tests of verbal memory, processing speed, and semantic fluency adjusting for age, sex, education, and hypertension status. As hypothesized, including CAC in the statistical model attenuated this association. Additionally, CAC and fasting glucose predicted performance in tasks not associated with diabetes status in this study (Stroop Task, Phonemic Fluency). These results confirm work attributing the heterogeneity of cognitive outcomes in type 2 diabetes to subclinical risk factors that combine to affect different aspects of brain function. Importantly, these results imply that risk factor intervention should begin before comorbidities, particularly CVD, become clinically apparent.

Ambulant 24-h glucose rhythms mark calendar and biological age in apparently healthy individuals

Glucose metabolism marks health and disease and is causally inferred in the aging process. Ambulant continuous glucose monitoring provides 24-h glucose rhythms under daily life conditions. We aimed to describe ambulant 24-h glucose rhythms measured under daily life condition in relation to calendar and biological age in apparently healthy individuals. In the general population and families with propensity for longevity, we studied parameters from 24-h glucose rhythms; glucose levels; and its variability, obtained by continuous glucose monitoring. Participants were 21 young (aged 22-37 years), 37 middle-aged (aged 44-72 years) individuals from the general population, and 26 middle-aged (aged 52-74 years) individuals with propensity for longevity. All were free of diabetes. Compared with young individuals, middle-aged individuals from the general population had higher mean glucose levels (5.3 vs. 4.7 mmol L(-1) , P < 0.001), both diurnally (P < 0.001) and nocturnally (P = 0.002). Glucose variability was higher in the middle-aged compared with the young (standard deviation 0.70 vs. 0.57 mmol L(-1) , P = 0.025). Compared with middle-aged individuals from the general population, middle-aged individuals with propensity for longevity had lower overall mean glucose levels (5.2 vs. 5.4 mmol L(-1) , P = 0.047), which were more different nocturnally (4.8 vs. 5.2 mmol L(-1) , P = 0.003) than diurnally (5.3 vs. 5.5 mmol L(-1) , P = 0.14). There were no differences in glucose variability between these groups. Results were independent of body mass index. Among individuals without diabetes, we observed significantly different 24-h glucose rhythms depending on calendar and biological age.

Self-monitoring of blood glucose in type 2 diabetes: recent studies

The increasing role for structured and personalized self-monitoring of blood glucose (SMBG) in management of type 2 diabetes has been underlined by randomized and prospective clinical trials. These include Structured Testing Program (or STeP), St. Carlos, Role of Self-Monitoring of Blood Glucose and Intensive Education in Patients with Type 2 Diabetes Not Receiving Insulin, and Retrolective Study Self-Monitoring of Blood Glucose and Outcome in Patients with Type 2 Diabetes (or ROSSO)-in-praxi follow-up. The evidence for the benefit of SMBG both in insulin-treated and non-insulin-treated patients with diabetes is also supported by published reviews, meta-analyses, and guidelines. A Cochrane review reported an overall effect of SMBG on glycemic control up to 6 months after initiation, which was considered to subside after 12 months. Particularly, the 12-month analysis has been criticized for the inclusion of a small number of studies and the conclusions drawn. The aim of this article is to review key publications on SMBG and also to put them into perspective with regard to results of the Cochrane review and current aspects of diabetes management.

GERODIAB: Glycaemic control and 5-year morbidity/mortality of type 2 diabetic patients aged 70 years and older: 1. Description of the population at inclusion

AIMS

The GERODIAB study is the first French multicentre, prospective, observational study that aims, through a 5-year cohort follow-up, to evaluate the link between glycaemic control and morbidity/mortality of type 2 diabetic (T2D) patients aged 70 years and older. This first report describes the study population at inclusion.

PATIENTS AND METHODS

A total of 987 T2D autonomous patients, aged ≥70 years, were recruited between June 2009 and July 2010 at 56 investigator centres. Their general parameters, diabetes characteristics and standard geriatric parameters were recorded.

RESULTS

The patients' mean age was 77±5 years, with 65.2% aged 75 years or more. The mean BMI was close to 30 kg/m(2). Hypertension was found in 89.7% of patients, and 85.0% had at least one cholesterol abnormality. The mean duration of the diabetes was around 18 years, and the mean HbA(1c) level was about 7.5%. During the previous six months, 33.6% of patients had experienced one or several hypoglycaemias. Also, 26% of patients presented with diabetic retinopathy, 37.3% had a GFR<60 mL/min, 31.2% had coronary insufficiency, 10.1% had heart failure, 15.8% had cerebrovascular involvement and 25.6% had peripheral vascular disease of the lower extremities. In addition, 30.5% of patients had orthostatic hypotension, 12.4% had malnutrition and 28.8% had cognitive impairment, all of which were often diagnosed at inclusion. Three-quarters of patients were taking an oral antidiabetic drug and nearly six in every 10 patients were using insulin.

CONCLUSION

This population can be considered representative of elderly, autonomous T2D patients, and its follow-up should clarify the link between glycaemic control and mortality/morbidity.

Cognitive impairment in diabetic patients: Can diabetic control prevent cognitive decline?

It is well recognized that the prevalence of dementia is higher in diabetic patients than non‐diabetic subjects. The incidence of diabetes has been increasing because of dramatic changes in lifestyles, and combined with longer lifespans as a result of advances in medical technology, this has brought about an increase in the number of elderly diabetic patients. Together, aging and diabetes have contributed to dementia becoming a serious problem. Progression to dementia reduces quality of life, and imposes a burden on both patients themselves and the families supporting them. Therefore, preventing the complication of dementia will become more and more important in the future. Although many mechanisms have been considered for an association between diabetes and cognitive dysfunction, glucose metabolism abnormalities such as hyperglycemia and hypoglycemia, and insulin action abnormalities such as insulin deficiency and insulin resistance can be causes of cognitive impairment. Recent large‐scale longitudinal studies have found an association between glycemic control and cognitive decline, although it is still unclear how cognitive decline might be prevented by good glycemic control. However, at an early stage, it is necessary to detect moderate cognitive dysfunction and try to reduce the risk factors for it, which should result in prevention of dementia, as well as vascular events. In the present review, in addition to outlining an association between diabetes and cognitive function, we discuss how glycemic control and cognitive decline are related.

Brain accumulation of amyloid β protein visualized by positron emission tomography and BF-227 in Alzheimer's disease patients with or without diabetes mellitus

AIM

Although diabetes mellitus (DM) is considered to be one of the most consistent risks for developing dementia, it is not known if the pathology in dementia patients with DM is similar to or distinct from typical pathological features of Alzheimer's disease (AD). To discover the mechanism of developing dementia in AD patients with DM in a living state, we studied the distribution of amyloid β (Αβ) protein of diabetic AD patients.

METHODS

To evaluate the accumulation of Aβ, we examined 14 normal controls, four diabetic patients with AD and 11 non-diabetic patients with AD by positron emission tomography (PET) using BF-227, a currently developed Aβ tracer.

RESULTS

The analysis of PET images among the three groups showed an abundant aggregated Aβ accumulation in the cerebral cortex of both AD patients with and without DM. The extent and distributions of BF-227 accumulation in diabetic AD patients were not significantly different from these of non-diabetic AD patients.

CONCLUSION

These results suggest that the degree and extent of Aβ deposition is not significantly different between AD with DM and AD alone.

Continuous glucose monitoring: a review for behavioral researchers

OBJECTIVE

Continuous glucose monitoring (CGM) systems collect and store glucose data in an ongoing fashion for several days at a time. The main advantage of CGM is that it can help identify fluctuations and trends that would otherwise go unnoticed with other glucose measures. Here, we provide a review of CGM for behavioral researchers.

METHODS

We begin with a brief review of diabetes and glucose measurement and then describe what CGM is and reference the commercial CGM systems currently available. We discuss the challenges involved in using CGM in behavioral research. We then present a broad overview of CGM in behavioral research, including data from ours and others' research programs. Finally, we cover some practical issues to be considered when using CGM, suggest reporting guidelines for the behavioral researcher, and offer suggestions for future research.

RESULTS

Only a handful of behavioral researchers are using CGM, although its use is increasing. The main ways that CGM is being used in behavioral research is to investigate basic biobehavioral processes, to assess the effects of behavioral interventions on diabetes control, and to use CGM itself as a behavior modification and teaching tool in diabetes self-management interventions.

CONCLUSIONS

Continuous glucose monitoring holds promise to help behavioral researchers unravel the complex relationships among glucose and intrapersonal, interpersonal, and contextual factors. However, the uptake of CGM for this purpose is limited, and the possibilities for its use are largely unmet. We encourage behavioral researchers to implement CGM in their protocols and to do so in a way that maximizes its explanatory power.

The role of self-monitoring of blood glucose in glucagon-like peptide-1-based treatment approaches: a European expert recommendation

The role of glucagon-like peptide (GLP)-1-based treatment approaches for type 2 diabetes mellitus (T2DM) is increasing. Although self-monitoring of blood glucose (SMBG) has been performed in numerous studies on GLP-1 analogs and dipeptidyl peptidase-4 inhibitors, the potential role of SMBG in GLP-1-based treatment strategies has not been elaborated. The expert recommendation suggests individualized SMBG strategies in GLP-1-based treatment approaches and suggests simple and clinically applicable SMBG schemes. Potential benefits of SMBG in GLP-1-based treatment approaches are early assessment of treatment success or failure, timely modification of treatment, detection of hypoglycemic episodes, assessment of glucose excursions, and support of diabetes management and diabetes education. Its length and frequency should depend on the clinical setting and the quality of metabolic control. It is considered to play an important role for the optimization of diabetes management in T2DM patients treated with GLP-1-based approaches.

Dipeptidyl peptidase-4 inhibitors in the elderly: more benefits or risks?

Several studies have shown a high prevalence of type 2 diabetes mellitus (T2DM) in the elderly, characterized by a paucity of symptoms, which represents an obstacle for an early diagnosis. Frequently, T2DM in the elderly is diagnosed when a complication occurs, among which are cognitive disorders and/or affective disturbances. Moreover, hypoglycemia is a frequent side effect of therapeutic treatment with insulin, sulfonylureas or glinides, while other treatments (metformin, acarbose, thiazolidinediones, glucagon-like peptide-1 [GLP-1] receptor agonists, and dipeptidyl peptidase-4 [DPP4] inhibitors) are capable of reducing hyperglycemia without inducing hypoglycemia. Thus, considering that older persons are a very heterogeneous group of individuals, management of T2DM in the elderly is challenging but there are no available specific treatment goals or treatment algorithms for older diabetic patients. Metformin is the recommended first-line therapy in all T2DM patients. When metformin is not sufficient to achieve the desired therapeutic targets, a second drug can be added. Available options include sulfonylureas, meglitinides, alfa-glucosidase inhibitors, pioglitazone, insulin, GLP-1 receptor agonists, and DPP-4 inhibitors. The most intriguing therapy for older patients is the one based on the so-called incretins, i.e., gastrointestinal hormones that, mainly secreted in the postprandial phase, stimulate insulin secretion and inhibit glucagon secretion. The two most important human incretins are GLP-1 and glucose-dependent insulinotropic peptide (GIP). These hormones potentiate the acute effects of glucose on pancreatic alfa and beta cells, thus stimulating insulin secretion, and only GLP-1 inhibits glucagon secretion in a glucose-dependent manner (that is, only when glucose levels are increased); as a result, they reduce hyperglycemia with virtually no hypoglycemic risk. Due to their characteristics, DPP-4 inhibitors seem to be particularly interesting as potential agents for the treatment of older patients with T2DM.

Diabetes management and hyperglycemia in safety sensitive jobs

The chronic and acute effects of hyperglycemia affecting cognition and work are as important as those of hypoglycemia. Its impact, considering that majority of diabetic patients fail to reach therapeutic targets, would be potentially significant. Self monitoring of blood glucose, recognition of body cues and management interventions should be geared not only towards avoidance of disabling hypoglycemia, but also towards unwanted hyperglycemia. Over the long term, chronic hyperglycemia is a risk for cognitive decline. Acute episodes of hyperglycemia, above 15 mmol/L have also been shown to affect cognitive motor tasks. Maintaining blood sugar to avoid hyperglycemia in diabetic workers will help promote safety at work.

Addressing schemes of self-monitoring of blood glucose in type 2 diabetes: a European perspective and expert recommendation

Self-monitoring of blood glucose (SMBG) in type 2 diabetes has increasingly been shown to display beneficial effects on glycemic control. SMBG is not only associated with a reduction of hemoglobin A1c but has also been demonstrated to increase patients' awareness of the disease. SMBG has also the potential to visualize and predict hypoglycemic episodes. International guidelines by the International Diabetes Federation, the European Society of Cardiology, and the European Association for the Study of Diabetes and also the International Society for Pediatric and Adolescent Diabetes emphasize that SMBG is an integral part of self-management. More recently, two European consensus documents have been published to give recommendations for frequency and timing of SMBG also for various clinical scenarios. Recently, a European expert panel was held to further facilitate and enhance standardized approaches to SMBG. The aim was to present simple, clinically meaningful, and standardized SMBG strategies for type 2 diabetes. The panel recommended a less intensive and an intensive scheme for SMBG across the type 2 diabetes continuum. The length and frequency of SMBG performance depend on the clinical circumstances and the quality of glycemic control. The expert panel also recommended further evaluation of various schemes for SMBG in type 2 diabetes in clinical studies.