Diabetes-related morbidity and mortality in a national sample of U.S. elders

Diabetes, comorbidities and increased long-term mortality in older patients admitted for geriatric inpatient care

AIMS

To study the specific impact of diabetes on long-term mortality in very old subjects with multiple comorbidities and functional disabilities.

METHODS

The prevalence of vascular disorders, global comorbidity load (cumulative illness rating scale [CIRS]) and functional disabilities (activities of daily living [ADL] and Lawton's instrumental ADL [IADL] scores) were determined according to diabetes status in a cohort of 444 patients (mean age 85.3±6.7 years; 74.0% women) admitted to our geriatric service. Also, the specific impact of diabetes on 4-year mortality was analyzed using Cox proportional-hazards models.

RESULTS

Diabetic patients had higher BMI scores (27.1±4.9 vs. 23.4±4.7 kg/m(2) in controls; P<0.001), and higher prevalences of hypertension (81.9% vs. 65.1%, respectively; P=0.003) and ischaemic heart disease (33.7% vs. 22.2%, respectively; P=0.033), but not of stroke and renal insufficiency. They also had more comorbidities (CIRS score excluding diabetes: 15.1±4.5 vs. 13.8±4.8, respectively; P=0.016) and functional disabilities. Diabetes was associated with mortality (HR: 1.42, 95% CI: 1.02-1.99; P=0.041) after adjusting for age, gender and BMI, and this persisted after adjusting for individual vascular comorbidities, but disappeared after adjusting for CIRS, ADL or IADL scores.

CONCLUSION

Diabetes was associated with 4-year mortality after adjusting for the inverse relationship between mortality and BMI. This association was better accounted for by the global comorbidity load and functional disabilities than by the individual vascular comorbidities. These findings suggest that the active management of all--rather than selected--comorbidities is the key to improving the prognosis for older diabetic patients.

Cost-effectiveness of angiotensin-converting enzyme inhibitors for the prevention of diabetic nephropathy in The Netherlands--a Markov model

OBJECTIVE

Type 2 diabetes is the main cause of end-stage renal disease (ESRD) in Europe and the USA. Angiotensin-converting enzyme (ACE) inhibitors have a potential to slow down the progression of renal disease and therefore provide a renal-protective effect. The aim of our study was to assess the most cost-effective time to start an ACE inhibitor (or an angiotensin II receptor blocker [ARB] if coughing as a side effect occurs) in patients with newly diagnosed type 2 diabetes in The Netherlands.

METHODS

A lifetime Markov decision model with simulated 50-year-old patients with newly diagnosed diabetes mellitus was developed using published data on costs and health outcomes and simulating the progression of renal disease. A health insurance perspective was adopted. Three strategies were compared: treating all patients at the time of diagnosing type 2 diabetes, screening for microalbuminuria, and screening for macroalbuminuria.

RESULTS

In the base-case analysis, the treat-all strategy is associated with the lowest costs and highest benefit and therefore dominates screening both for macroalbuminuria and microalbuminuria. A multivariate sensitivity analysis shows that the probability of savings is 70%.

CONCLUSIONS

In The Netherlands for patients with type 2 diabetes prescription of an ACE inhibitor immediately after diagnosis should be considered if they do not have contraindications. An ARB should be considered for those patients developing a dry cough under ACE inhibitor therapy. The potential for cost savings would be even larger if the prevention of cardiovascular events were considered.

Optimal glycemic control in the elderly: where is the evidence and who should be targeted?

In the near future, with the continuous increase in life expectancy observed in the population and with the aging of the baby boomers, an increase is expected in the absolute and relative number of the elderly population. With the aging phenomenon, the prevalence of a number of chronic diseases is increasing and requires interventions from different health professionals. Type 2 diabetes mellitus is a very frequent condition in the elderly and is characterized by variable degrees of hyperglycemia while ketosis is exceptional in this condition. The question of who should be offered optimal glycemic control becomes more and more pertinent as the older diabetic population grows but it has to be considered that the consequences of hypoglycemia related to the medications used to lower glycemia are not benign in the older population. Hence, the advantages and disadvantages of tight glycemic control will be reviewed in the light of recent data.

Cost-effectiveness of administering oral adsorbent AST-120 to patients with diabetes and advance-stage chronic kidney disease

AIMS

AST-120, an oral adsorbent currently on-label only in Asian countries with phase III trials ongoing in the US, slows renal disease progression in patients with diabetes and advanced-stage chronic kidney disease (CKD). The objective of this study is to evaluate the cost-effectiveness of using AST-120 to treat patients with type 2 diabetes and advanced-stage CKD.

METHODS

We used Markov model simulating the progression of diabetic nephropathy. Data were obtained from randomized trials estimating the progression of diabetic nephropathy with and without AST-120, and published literature. The base population was patients 60 years of age with type 2 diabetes and Stages 3 and 4 CKD.

RESULTS

Treating patients with diabetes and advanced-stage CKD was found to be a dominant strategy, and quality of life improved further and more money was saved (0.22 quality-adjusted life years [QALYs] and $15,019 per patient) using AST-120 than the control strategy. Sensitivity analysis results were robust with regard to cost, adherence, and quality of life associated with AST-120 therapy, as well as age at diagnosis. The model was relatively sensitive to the effectiveness of AST-120.

CONCLUSIONS

Treating patients with type 2 diabetes and advanced-stage CKD with AST-120 appears to extend life and reduce costs.

Approach to managing hypoglycemia in elderly patients with diabetes

Hypoglycemia is a common clinical problem in elderly patients with diabetes. Aging modifies the counterregulatory and symptomatic responses to hypoglycemia. Hypoglycemia in the elderly is not only due to tight blood sugar control, but also due to a multitude of other factors. Hypoglycemia often occurs with insulin, sulfonylureas, or meglitinide therapy. However, other causes may also contribute to hypoglycemia, such as decreased cognition, renal impairment, or polypharmacy. The presenting features of hypoglycemia may be atypical and misinterpreted, resulting in delayed treatment. Morbidity is greater in elderly patients, and the risk of progression to severe hypoglycemia is high because of their altered symptom profile, diminished symptom intensity, and altered glycemic thresholds. Hypoglycemia seems to be the main limiting factor in their glycemic control. In this article we discuss strategies to prevent hypoglycemic episodes.

Trends in the prevalence and comorbidities of diabetes mellitus in nursing home residents in the United States: 1995-2004

OBJECTIVES

To estimate trends in the prevalence and comorbidities of diabetes mellitus (DM) in U.S. nursing homes from 1995 to 2004.

DESIGN

SAS callable SUDAAN was used to adjust for the complex sample design and assess changes in prevalence of DM and comorbidities during the study period in the National Nursing Home Surveys. Trends were assessed using weighted least squares linear regression. Multiple logistic regressions were used to calculate predictive margins.

SETTING

A continuing series of two-stage, cross-sectional probability national sampling surveys.

PARTICIPANTS

Residents aged 55 and older: 1995 (n=7,722), 1997 (n=7,717), 1999 (n=7,809), and 2004 (n=12,786).

MEASUREMENTS

DM and its comorbidities identified using a standard set of diagnosis codes.

RESULTS

The estimated crude prevalence of DM increased from 16.9% in 1995 to 26.4% in 2004 in male nursing home residents and from 16.1% to 22.2% in female residents (all P<.05). Male and female residents aged 85 and older and those with high functional impairment showed a significant increasing trend in DM (all P<.05). In people with DM, multivariate-adjusted prevalence of cardiovascular disease increased from 59.6% to 75.4% for men and from 68.1% to 78.7% for women (all P<.05). Prevalence of most other comorbidities did not increase significantly.

CONCLUSION

The burden of DM in residents of U.S. nursing homes has increased since 1995. This could be due to increasing DM prevalence in the general population or to changes in the population that nursing homes serve. Nursing home care practices may need to change to meet residents' changing needs.

The impact of vitamin D deficiency on diabetes and cardiovascular risk

PURPOSE OF REVIEW

To review the association between vitamin D deficiency and diabetes and cardiovascular risk.

RECENT FINDINGS

Vitamin D deficiency is newly recognized as a common condition of increasing prevalence worldwide. Clinically, vitamin D has an established role in calcium and bone metabolism and has recently been shown to be associated with increased risk of developing type 1 and type 2 diabetes mellitus and cardiovascular disease (CVD), as well as with cardiovascular risk factors such as hypertension and obesity. The molecular mechanisms of these associations remain incompletely understood. The active metabolite of vitamin D regulates transcription of multiple gene products with antiproliferative, prodifferentiative, and immunomodulatory effects. Although vitamin D deficiency is frequently unrecognized clinically, laboratory measurement is easy to perform and treatment of vitamin D deficiency is relatively well tolerated and inexpensive. Limited, yet promising, results of proof-of-concept intervention studies of using vitamin D in diabetes will be presented.

SUMMARY

The high prevalence of vitamin D deficiency and plausible molecular mechanisms linking this to diabetes and cardiovascular risk suggest treatment of vitamin D deficiency to prevent and/or treat diabetes is a promising field to explore.

Cost-effectiveness of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in newly diagnosed type 2 diabetes in Germany

OBJECTIVES

Type 2 diabetes is the main cause of end-stage renal disease in Europe and the United States. Angiotensin-converting enzyme (ACE) inhibitors slow down the progression of renal disease and, therefore, provide a renal-protective effect. The aim of this study was to assess the most cost-effective time to start an ACE inhibitor (or an angiotensin II receptor blocker in the event of cough) in patients with type 2 diabetes in Germany.

METHODS

Three strategies were compared: treating all patients at the time of diagnosing type 2 diabetes, screening for microalbuminuria, and screening for macroalbuminuria. A lifetime Markov decision model with simulated 50-year-old patients with newly diagnosed diabetes mellitus was developed using published data on costs and health outcomes and simulating the progression of renal disease. A statutory health insurance perspective was adopted.

RESULTS

In the base-case analysis, the treat-all strategy is associated with the lowest costs and highest benefit and, therefore, dominates screening both for macroalbuminuria and microalbuminuria. A multivariate sensitivity analysis shows that the probability of savings is 89 percent.

CONCLUSIONS

Patients with type 2 diabetes should receive an ACE inhibitor immediately after diagnosis if they do not have contraindications. The potential for cost savings would be even larger if the prevention of cardiovascular events were considered.

Glycated hemoglobin, diabetes, and cardiovascular risk in nondiabetic adults

BACKGROUND

Fasting glucose is the standard measure used to diagnose diabetes in the United States. Recently, glycated hemoglobin was also recommended for this purpose.

METHODS

We compared the prognostic value of glycated hemoglobin and fasting glucose for identifying adults at risk for diabetes or cardiovascular disease. We measured glycated hemoglobin in whole-blood samples from 11,092 black or white adults who did not have a history of diabetes or cardiovascular disease and who attended the second visit (occurring in the 1990-1992 period) of the Atherosclerosis Risk in Communities (ARIC) study.

RESULTS

The glycated hemoglobin value at baseline was associated with newly diagnosed diabetes and cardiovascular outcomes. For glycated hemoglobin values of less than 5.0%, 5.0 to less than 5.5%, 5.5 to less than 6.0%, 6.0 to less than 6.5%, and 6.5% or greater, the multivariable-adjusted hazard ratios (with 95% confidence intervals) for diagnosed diabetes were 0.52 (0.40 to 0.69), 1.00 (reference), 1.86 (1.67 to 2.08), 4.48 (3.92 to 5.13), and 16.47 (14.22 to 19.08), respectively. For coronary heart disease, the hazard ratios were 0.96 (0.74 to 1.24), 1.00 (reference), 1.23 (1.07 to 1.41), 1.78 (1.48 to 2.15), and 1.95 (1.53 to 2.48), respectively. The hazard ratios for stroke were similar. In contrast, glycated hemoglobin and death from any cause were found to have a J-shaped association curve. All these associations remained significant after adjustment for the baseline fasting glucose level. The association between the fasting glucose levels and the risk of cardiovascular disease or death from any cause was not significant in models with adjustment for all covariates as well as glycated hemoglobin. For coronary heart disease, measures of risk discrimination showed significant improvement when glycated hemoglobin was added to models including fasting glucose.

CONCLUSIONS

In this community-based population of nondiabetic adults, glycated hemoglobin was similarly associated with a risk of diabetes and more strongly associated with risks of cardiovascular disease and death from any cause as compared with fasting glucose. These data add to the evidence supporting the use of glycated hemoglobin as a diagnostic test for diabetes.

Diabetes foot ulceration in a Nigerian hospital: in-hospital mortality in relation to the presenting demographic, clinical and laboratory features

This prospective study assessed in-hospital mortality from diabetic foot ulcer in relation to the demographic, clinical and laboratory features at presentation. Forty-two patients admitted with diabetic foot ulcer were followed up from admission till discharge from hospital. Those who survived or died were compared for any differences in demographic, clinical and laboratory parameters at presentation. The mean age and duration of diabetes for the 42 patients were 56.1 +/- 1.9 years and 8.3 +/- 1.1 years, respectively. The in-hospital mortality rate amongst the 42 subjects was 40.5%. Ulcer grade > or =4, leucocytosis and anaemia were more prevalent in those who demised in comparison with survivors.

Treatment Considerations for Diabetes: A Pharmacist’s Guide to Improving Care in the Elderly

The management of diabetes in elderly patients has many nuances that are important to the pharmacist, regardless of his or her practice setting. General guidelines and treatment modalities applied to the younger population cannot necessarily be applied to the elderly population and in most cases, should be tailored to meet their needs. The purpose of this article is to gain a better understanding of the complex nature of diabetes and management in the elderly by (1) reviewing the pathogenesis and pathophysiology of diabetes in the patients, (2) understanding complications and geriatric syndromes that may affect management of diabetes, (3) becoming familiar with nationally accepted diabetes care guidelines in the elderly, (4) reviewing recent literature pertaining to management of diabetes, and (5) reviewing medications (including newer agents) to treat diabetes in the elderly.

Exercise training and dietary glycemic load may have synergistic effects on insulin resistance in older obese adults

BACKGROUND/AIMS

The aim of this study was to assess the combined effects of exercise and dietary glycemic load on insulin resistance in older obese adults.

METHODS

Eleven men and women (62 +/- 2 years; 97.6 +/- 4.8 kg; body mass index 33.2 +/- 2.0) participated in a 12-week supervised exercise program, 5 days/week, for about 1 h/day, at 80-85% of maximum heart rate. Dietary glycemic load was calculated from dietary intake records. Insulin resistance was determined using the euglycemic (5.0 mM) hyperinsulinemic (40 mU/m(2)/min) clamp.

RESULTS

The intervention improved insulin sensitivity (2.37 +/- 0.37 to 3.28 +/- 0.52 mg/kg/min, p < 0.004), increased VO(2max) (p < 0.009), and decreased body weight (p < 0.009). Despite similar caloric intakes (1,816 +/- 128 vs. 1,610 +/- 100 kcal/day), dietary glycemic load trended towards a decrease during the study (140 +/- 10 g before, vs. 115 +/- 8 g during, p < 0.04). The change in insulin sensitivity correlated with the change in glycemic load (r = 0.84, p < 0.009). Four subjects reduced their glycemic load by 61 +/- 8%, and had significantly greater increases in insulin sensitivity (78 +/- 11 vs. 23 +/- 8%, p < 0.003), and decreases in body weight (p < 0.004) and plasma triglycerides (p < 0.04) compared to the rest of the group.

CONCLUSION

The data suggest that combining a low-glycemic diet with exercise may provide an alternative and more effective treatment for insulin resistance in older obese adults.

Age- and gender-specific awareness, treatment, and control of cardiovascular risk factors and subclinical vascular lesions in a founder population: the SardiNIA Study

AIM

We investigated the gender-specific control of cardiovascular (CV) risk factors and subclinical vascular lesions in a founder population in Italy.

METHODS AND RESULTS

6148 subjects were enrolled (aged 14-102 years) from four towns. Hypertension (HT), diabetes mellitus (DM) and dyslipidemia (LIP) were defined in accordance with guidelines. A self-reported diagnosis defined awareness of these conditions, and the current use of specific medications as treatment. Prevalence was HT 29.2%, DM 4.8%, LIP 44.1% and was higher in men than in women. Disease prevalence increased with age for every CV risk factor. Men were less likely than women to take anti-HT drugs and to reach BP control (9.9% vs. 16%). Only 17.6% of HT > 65 years had a BP < or =140/90 mmHg, though 48.5% were treated. The use of statins was very low (<1/3 of eligible subjects > 65 years, those with the highest treatment rate). The ratio of control-to-treated HT was lower in subjects with, than in those without, thicker carotid arteries (31.5% vs. 38.8%, p < 0.05) or stiffer aortas (26.0% vs. 40.0%, p < 0.05) or carotid plaques (26.3% vs. 41.1%, p<0.05).

CONCLUSION

A large number of subjects at high CV risk are not treated and the management of subclinical vascular lesions is far from optimal.

Status of diabetes management in the nursing home setting in 2008: a retrospective chart review and epidemiology study of diabetic nursing home residents and nursing home initiatives in diabetes management

PURPOSE

Diabetes mellitus (DM) is associated with significant morbidity and mortality, and can present with atypical signs and symptoms in elderly residents of nursing homes who often have altered functional and cognitive capacity representing a particularly challenging population to manage. Researchers conducted this study to better understand the current status of DM management in the long-term care facility from the perspective of the facility (use of guidelines, policies, and so forth) as well as that of a resident.

METHODS

Thirteen nursing home facilities in 6 states were studied. A 13-question survey instrument was used to collect data from interviews of the directors of nursing and medical directors. A 26-question data collection form was also used to perform a retrospective chart review of studied residents.

RESULTS

Data from the interview surveys showed that only 15% of facilities studied had a policy for the use of treatment algorithms to manage residents with DM. In addition, only 1 of 13 facilities had a quality improvement tool to evaluate compliance with current policies. In regard to hemoglobin A1C (A1C) testing, only 7.1% of facilities had a house policy in place. Furthermore, only 1% of studied residents had an established target for their A1C despite American Diabetes Association (ADA), American Geriatrics Society (AGS), and American Medical Directors Association (AMDA) guidelines recommending target values and monitoring frequency for A1C testing. The survey instrument also found that just 30.8% of facilities had a policy in place for blood glucose monitoring. Data from the chart review shows that only 57% of residents in this study were taking aspirin or clopidogel bisulfate, although prevention of cardiovascular disease (CVD) is recommended by the American Heart Association (AHA) and ADA in persons with diabetes who are older than 40. Data from this study indicate serious hypoglycemia occurs only occasionally in the nursing home because hypoglycemic episodes requiring hospitalization occurred in only 1% of studied residents. Furthermore, researchers found each of these residents were sent to the hospital only once in the preceding 6 months. One unanticipated finding of the study reports the incidence of delusions from patients' Minimum Data Set (MDS) was 87.63% compared with the national average of 3.7%.

CONCLUSION

Data obtained through this study demonstrates numerous opportunities for improvement in the quality of care for nursing home residents with DM. A multidisciplinary approach is required to properly manage this complex disease in a challenging elderly population. The development of protocols and tools that embrace the latest strategies and treatment algorithms for the management of DM in the geriatric resident are necessary, while implementation of a quality improvement tool can help facilities to further improve on management of DM in the long-term care setting.

Sex differences in the incidence of hemorrhagic and ischemic stroke among diabetics in Taiwan

BACKGROUND

Diabetes mellitus is an important risk factor for stroke, but whether there is differential gender-specific risk has not been fully elucidated. We aimed to explore the impact of gender on incidence and relative risks of hemorrhagic and ischemic stroke among the diabetic population in Taiwan.

METHODS

In this study, 500,868 diabetic patients and 500,248 age matched and-sex-matched nondiabetic individuals were linked to inpatient claims (1997-2002) to identify hospitalizations for nontraumatic hemorrhagic and ischemic stroke. Incidence density was calculated with the Poisson assumption, and Kaplan-Meier analysis was used to assess the cumulative incidence over a 6-year follow-up period. We also evaluated the relative hazards of stroke in relation to diabetes with the Cox proportional hazard model, adjusted with demographics and geographic regions.

RESULTS

The incidence of hemorrhagic stroke in diabetic women was less than that in diabetic men except in those aged > or =85, but the difference between male and female diabetic patients was less pronounced with ischemic stroke. The hazard ratios (HRs) of hemorrhagic and ischemic stroke among diabetic women were increased by a magnitude of 1.2 and 1.32, respectively, which were significantly higher than those of diabetic men. Further age-stratified analysis indicated that young and middle-aged diabetic women tended to have higher HRs and that diabetic women aged <35 suffered from particularly high HRs (HR 7.69, 95% confidence interval [CI] 1.81-32.75 for hemorrhagic stroke, and HR = 8.46, 95% CI 4.28-16.75 for ischemic stroke).

CONCLUSIONS

There was a significant gender-diabetes interactive effect on the incidence of hemorrhagic and ischemic stroke. Additionally, young Taiwanese diabetic patients were most vulnerable to an increased relative risk of hemorrhagic and ischemic stroke. Comprehensive diabetic care with stroke prevention measures should be emphasized in young diabetic people in order to prevent premature disability.

How safe is the use of thiazolidinediones in clinical practice?

BACKGROUND

Thiazolidinediones (TZDs) are widely used antidiabetic drugs with proven efficacy regarding mainly surrogate markers of diabetes management. However, efficacy on surrogate markers may not always translate into benefits in clinical outcomes. Thiazolidinediones are usually well tolerated; however, their use may be associated with several adverse effects. The first TZD, troglitazone, was withdrawn from the market owing to serious hepatotoxicity. However, this does not seem to be the case with newer TZDs.

OBJECTIVE

The aim of the present review is to discuss the safety profile of this drug class.

METHODS

We searched PubMed up to July 2008 using relevant keywords.

CONCLUSIONS

Common side effects associated with TZDs include edema, weight gain, macular edema and heart failure. Moreover, they may cause hypoglycemia when combined with other antidiabetic drugs as well as decrease hematocrit and hemoglobin levels. Increased bone fracture risk is another TZD-related side effect. Thiazolidinediones tend to increase serum low density lipoprotein cholesterol levels, with rosiglitazone having a more pronounced effect compared with pioglitazone. Moreover, rosiglitazone increases low density lipoprotein particle concentration in contrast to pioglitazone where a decrease is observed. Rosiglitazone has been associated with an increase in myocardial infarction incidence. On the other hand, pioglitazone may reduce cardiovascular events. Overall, TZDs are valuable drugs for diabetes management but physicians should keep in mind that they are associated with several adverse events, the most prominent of which is heart failure.

A review of systematic reviews evaluating diabetes interventions: focus on quality of life and disparities

PURPOSE

This article reviews the literature on definitions and issues related to measurement of quality of life in people with diabetes and summarizes reviews of evidence of intervention studies, with a particular focus on interventions targeted for underserved and minority populations.

METHODS

An integrative literature review of reviews was conducted on adult diabetes interventions and outcomes. Five electronic databases were searched. Eligible publications were those published between 1999 and 2006 that described outcome measures. Twelve review articles are included.

RESULTS

Review studies were heterogeneous in terms of intervention type, content, participants, setting, and outcome measures. Interventions used variable operational definitions and frequently lacked adequate description; therefore, comparisons of findings proved difficult. A clinical outcome, A1C, was the most frequently assessed, with little inclusion of quality-of-life measures. Several reviews and independent studies did not explicitly consider interventions aimed at the underserved. When quality of life was considered, measures and operational definition of domains were limited.

CONCLUSIONS

Understanding the relationship between interventions and resulting outcomes, particularly quality of life, will require attention to operational definitions and better conceptual models. There is an evidence base emerging about important characteristics of effective intervention programs. This evidence base can guide public health and clinical program planners to better understand and make prudent decisions about assessment, planning, implementation, and evaluation of interventions for people with complex chronic illnesses such as diabetes.

Underuse of cardioprotective treatment by the elderly with type 2 diabetes

AIMS

To assess whether elderly patients with type 2 diabetes use a comprehensive cardioprotective regimen (CCR) of antihypertensive, lipid-lowering and antiplatelet drugs in the year following oral antidiabetic drug initiation and, if so, to identify the determinants of such use.

METHODS

Using the Quebec Diabetes Surveillance System administrative database, we carried out an inception cohort study of individuals aged 66 years and over who began oral antidiabetic therapy between 1998 and 2002. Those individuals with at least one claim in the year after starting antidiabetic treatment for an antihypertensive, a lipid-lowering and an antiplatelet drugs were deemed to be using a CCR. A multivariate logistic regression model was built to identify the characteristics associated with CCR use.

RESULTS

Of the 48,505 individuals included in the study, 9912 (20.4%) used a CCR during the year following the first antidiabetic claim. Those more likely to use a CCR were men (odds ratio [OR]: 1.2; 99% confidence intervals [CI]: 1.1-1.3), those who had used an antihypertensive (1.6; 1.4-1.7), lipid-lowering (7.4; 6.8-8.0) or antiplatelet (7.3; 6.7-7.9) drug in the year before the first antidiabetic claim and those with a preexisting diagnosis of cardiovascular disease (1.9; 1.8-2.1). The odds of using a CCR increased every year.

CONCLUSIONS

CCR use by the elderly with type 2 diabetes in the year following antidiabetic initiation is low, and prior use of individual cardioprotective drugs is a strong predictor of its use. These findings suggest that the treatment of important modifiable risk factors for cardiovascular disease is suboptimal.

Risk factors in V-shaped risk associations with all-cause mortality in type 2 diabetes-The Hong Kong Diabetes Registry

BACKGROUND

Body mass index (BMI) is associated with death in a V-shaped manner in general populations but it is unknown whether BMI or other risk factors also exhibit V-shaped relationships with death in type 2 diabetic patients.

METHODS

A prospective cohort of 7534 Chinese, type 2 diabetic patients enrolled since 1995 were censored on 30 July 2005. Spline Cox regression analysis with a stepwise algorithm (p < 0.05) was used to select predictors. Hazard ratio (HR) curves were used to explore the relationships, which were confirmed by standard Cox models.

RESULTS

763 patients died during the 5.5 years of follow-up. BMI, high-density lipoprotein cholesterol (HDL-C) and white blood cell (WBC) count were related to all-cause mortality in a V-shaped manner. The nadirs of the risk curves were at 26 kg/m(2) for BMI, 1.15 mmol/L for HDL-C and 6.25 x 10(9) counts/L for WBC. The multivariate hazard ratio of BMI away from 26.0 kg/m(2) was 1.08; HDL-C, 1.06 per mmol/L for values less than the nadir and 6.97 per mmol/L for greater than the nadir; and WBC, 1.16 per 10(9) count/L for less than 6.25 x 10(9) and 1.47 for greater than the nadir. Respiratory and neoplastic deaths were the major contributors to the increased death in patients with low or high BMI. Neoplastic death was the major contributor to the increased death in those with low WBC. Genitourinary death was the major contributor to the increased death in those with low and high HDL-C.

CONCLUSION

BMI, HDL-C and WBC are associated with death in a V-shaped manner in type 2 diabetic patients.

Variation in treatment preferences and care goals among older patients with diabetes and their physicians

BACKGROUND

Older persons with diabetes are heterogeneous with respect to life expectancy and frailty, and new guidelines recommend individualizing care.

OBJECTIVES

(1) To describe variation in the preferences of older patients with diabetes regarding aggressiveness of glycemic control and avoiding diabetic complications. (2) To determine correlates of patient preferences and physician treatment goals. (3) To assess whether physicians' goals were consistent with their patients' preferences.

RESEARCH DESIGN

Cross-sectional surveys and chart reviews in urban academic clinics.

SUBJECTS

: Four hundred seventy-three patients with diabetes age 65 or older and 64 physicians.

MEASURES

Patient preferences (utilities on a scale from 0 to 1, 0 = death, 1 = perfect health) for diabetic complications and intensity of treatment, and physician target treatment goals and ratings of aggressiveness of approach.

RESULTS

Eighty percent of the patients were African American, 63% were women, average age was 73.7 +/- 5.9 years and 26% expected to live 5 years or less. Patient preferences/utilities showed significant variation: blindness 0.39 (SD, 0.32), lower leg amputation 0.45 (0.34), conventional treatment 0.76 (0.27), and intensive insulin treatment 0.64 (0.32). Physicians' hemoglobin A1c goal was < or =7% in 69% of patients. Greater estimated patient life expectancy was consistently associated with higher patient utilities and was associated with physicians' willingness to use aggressive treatments. Physicians' treatment goals and approaches were associated with patients' utilities for treatment.

CONCLUSIONS

Older patients vary greatly in their preferences regarding diabetic complications and treatments. Acknowledging patient preferences, along with life goals and prognostic data, may improve quality of treatment decisions.

Interventions for being active among individuals with diabetes: a systematic review of the literature

PURPOSE

The purpose of this systematic review is to assess and summarize evidence and gaps in the literature regarding the intervention for being active (exercise) among individuals with diabetes.

METHODS

Twelve electronic databases were searched. Publications eligible for inclusion specifically studied learning, behavioral, clinical, and humanistic outcomes for exercise interventions in adult patients with type 1 and type 2 diabetes.

RESULTS

Seven reviews (2 systematic reviews, 3 meta-analyses, 2 technical reviews) and 34 individual, nonreview studies (18 randomized controlled trials, 16 nonrandomized trials) met inclusion criteria. For type 2 diabetes, findings suggested that exercise had a positive effect on glycemic control and decreased cardiovascular risk, but the impact of exercise on behavioral and humanistic outcomes was unclear; long-term outcomes and adherence to exercise interventions is unknown because most studies were of short duration. The overall impact of varied types of exercise in type 1 diabetes was unclear, especially regarding glycemic control. Potential benefits of exercise in type 1 may include improved cardiovascular health.

CONCLUSION

The review did not identify specific successful intervention details because of the heterogeneity of studies, subjects, and research gaps. General findings suggest that physical activity is better than no exercise at all; intensive regimens, if tolerated by patients, achieved better clinical outcomes than less intensive regimens. Reviewed studies using structured exercise regimens exhibited a more significant impact on outcomes. Substantial gaps in the literature include studies measuring direct effects of exercise in the US minority populations most affected by type 2 diabetes and economic evaluations of exercise interventions. Interventions must be tailored to individual patient needs to succeed.

Insulin use in elderly diabetic patients

The prevalence of type 2 diabetes is increasing among older adults as is their diabetes-related mortality rate. Studies suggest that tighter glucose control reduces complications in elderly patients. However, too low a glycosylated hemoglobin (HbA_1c) value is associated with increased hypoglycemia. Moreover, the appropriateness of most clinical trial data and standards of care related to diabetes management in elderly patients is questionable given their heterogeneity. Having guidelines to safely achieve glycemic control in elderly patients is crucial. One of the biggest challenges in achieving tighter control is predicting when peak insulin action will occur. The clinician’s options have increased with new insulin analogs that physiologically match the insulin peaks of the normal glycemic state, enabling patients to achieve the tighter diabetes control in a potentially safer way. We discuss the function of insulin in managing diabetes and how the new insulin analogs modify that state. We offer some practical considerations for individualizing treatment for elderly patients with diabetes, including how to incorporate these agents into current regimens using several methods to help match carbohydrate intake with insulin requirements. Summarizing guidelines that focus on elderly patients hopefully will help reduce crises and complications in this growing segment of the population.

A clinical and economic evaluation of endoscopic ultrasound for patients at risk for familial pancreatic adenocarcinoma

BACKGROUND AND AIMS

Approximately 10% of pancreatic adenocarcinoma is familial. Approximately 50% of 1st-degree relatives (FDRs) have endoscopic ultrasound (EUS) findings of chronic pancreatitis. We modeled the natural history of these patients to compare 4 management strategies.

METHODS

We performed a systematic review, and created a Markov model for 45-year-old male FDRs, with findings of chronic pancreatitis on screening EUS. We compared 4 strategies: doing nothing, prophylactic total pancreatectomy (PTP), annual surveillance by EUS, and annual surveillance with EUS and fine needle aspiration (EUS/FNA). Outcomes incorporated mortality, quality of life, procedural complications, and costs.

RESULTS

In the Do Nothing strategy, the lifetime risk of cancer was 20%. Doing nothing provided the greatest remaining years of life, the lowest cost, and the greatest remaining quality-adjusted life years (QALYs). PTP provided the fewest remaining years of life, and the fewest remaining QALYs. Screening with EUS provided nearly identical results to PTP, and screening with EUS/FNA provided intermediate results between PTP and doing nothing. PTP provided the longest life expectancy if the lifetime risk of pancreatic cancer was at least 46%, and provided the most QALYs if the risk was at least 68%.

CONCLUSIONS

FDRs from familial pancreatic cancer kindreds, who have EUS findings of chronic pancreatitis, have increased risk for cancer, but their precise risk is unknown. Without the ability to further quantify that risk, the most effective strategy is to do nothing.

Depression screening disparities among veterans with diabetes compared with the general veteran population

OBJECTIVE

We sought to describe the proportion of veterans with diabetes screened for depression compared with the general population of veterans.

RESEARCH DESIGN AND METHODS

Electronic medical records (fiscal years 2001-2004) from a Midwestern Veterans Health Administration (VHA) facility and VHA External Peer Review Program (EPRP) data were used for the study. Facility-level data included inpatient and outpatient encounters, which included depression screen results. EPRP data were facility-level summary data, which detailed the proportion of general population veterans nationwide and patients at the Midwestern facility who were screened for depression. Logistic regression tested for associations between depression screen receipt and screening positive and demographic/clinical characteristics among patients with diabetes.

RESULTS

Depression screening among those with diabetes improved from 62% in fiscal year 2001 to 83% in 2004. Screening was 9-23% lower and 11-22% lower in patients with diabetes compared with the general population of veterans nationwide and patients at the Midwestern facility, respectively. Seventeen percent of subjects with diabetes screened positive, which is two times higher than in the general population. Women (odds ratio 0.45 [95% CI 0.35-0.60]) and subjects with unknown A1C (0.40 [0.34-0.46]) were less likely to be screened for depression. A >or=50% service-connected disability rating was inversely associated with screening (0.84 [0.72-0.99]) but positively associated with screening positive for depression (1.56 [1.33-1.82]).

CONCLUSIONS

Screening for depression among veterans with diabetes improved 21% but is considerably lower than the proportion of general population veterans screened nationally and at the facility of interest. Targeted interventions to improve screening in patients with diabetes are required based on evidence that screening translates into increased provider recognition and treatment of depression.

An insight into undiagnosed impaired glucose regulation

Type 2 diabetes is responsible for considerable morbidity, mortality and cost to society. There is good evidence that lifestyle modification and pharmacological intervention are effective means of delaying, and possibly preventing, the onset of type 2 diabetes in individuals with impaired glucose regulation. The aim of this study was to estimate the number of patients treated at our district general hospital over a 28-day period who had impaired glucose regulation and so would be suitable candidates for intervention. The results reveal that 518 patients passed through our hospital during this period with evidence of impaired glucose regulation, but only 95 of these patients were formally investigated for diabetes. Of those who were investigated further, over one fifth were shown to have impaired glucose regulation. We suggest that a random plasma glucose test may provide a useful means to identify a population for formal screening for diabetes.

Risk factors for mortality among patients with diabetes: the Translating Research Into Action for Diabetes (TRIAD) Study

OBJECTIVE

We sought to examine demographic, socioeconomic, and biological predictors of all-cause, cardiovascular, and noncardiovascular mortality in patients with diabetes.

RESEARCH DESIGN AND METHODS

Survey, medical record, and administrative data were obtained from 8,733 participants in the Translating Research Into Action for Diabetes Study, a multicenter, prospective, observational study of diabetes care in managed care. Data on deaths (n = 791) and cause of death were obtained from the National Death Index after 4 years. Predictors examined included age, sex, race, education, income, duration, and treatment of diabetes, BMI, smoking, microvascular and macrovascular complications, and comorbidities.

RESULTS

Predictors of adjusted all-cause mortality included older age (hazard ratio [HR] 1.04 [95% CI 1.03-1.05]), male sex (1.57 [1.35-1.83]), lower income (< $15,000 vs. > $75,000, HR 1.82 [1.30-2.54]; $15,000-$40,000 vs. > $75,000, HR 1.58 [1.15-2.17]), longer duration of diabetes (> or = 9 years vs. < 9 years, HR 1.20 [1.02-1.41]), lower BMI (< 26 vs. 26-30 kg/m2, HR 1.43 [1.13-1.69]), smoking (1.44 [1.20-1.74]), nephropathy (1.46 [1.23-2.73]), macrovascular disease (1.46 [1.23-1.74]), and greater Charlson index (> or = 2-3 vs. < 1, HR 2.01 [1.04-3.90]; > or = 3 vs. < 1, HR 4.38 [2.26-8.47]). The predictors of cardiovascular and noncardiovascular mortality were different. Macrovascular disease predicted cardiovascular but not noncardiovascular mortality.

CONCLUSIONS

Among people with diabetes and access to medical care, older age, male sex, smoking, and renal disease are important predictors of mortality. Even within an insured population, socioeconomic circumstance is an important independent predictor of health.

Killer proteases and little strokes--how the things that do not kill you make you stronger

The phenomenon of ischemic preconditioning was initially observed over 20 years ago. The basic tenant is that if stimuli are applied at a subtoxic level, cells upregulate endogenous protective mechanisms to block injury induced by subsequent stress. Since this discovery, many conserved signaling mechanisms that contribute to activation of this potent protective program have been identified in the brain. A clinical correlate of this basic research finding can be found in patients with a history of transient ischemic attack (TIA), who have a decreased morbidity after stroke. In spite of multidisciplinary efforts to design safer, more effective stroke therapies, we have thus far failed to translate our understanding of endogenous protective pathways to treatments for neurodegeneration. This review is designed to provide clinicians and basic scientists with an overview of stress biology after TIA and preconditioning, discuss new therapeutic strategies to target the protein dysfunction that follows ischemic injury, and propose enhanced biochemical profiling to identify individuals at risk of stroke after TIA. We pay particular attention to the unanticipated consequences of overly aggressive intervention after TIA in which we have found that traditional cytotoxic agents such as free radicals and apoptosis associated proteases is essential for neuroprotection and communication in the stressed brain. These data emphasize the importance of understanding the complex interplay between chaperones, apoptotic proteases including caspases, and the proteolytic degradation machinery in adaptation to neurological injury.

Assessment of two culturally competent diabetes education methods: individual versus individual plus group education in Canadian Portuguese adults with type 2 diabetes

OBJECTIVE

To examine the impact of two culturally competent diabetes education methods, individual counselling and individual counselling in conjunction with group education, on nutrition adherence and glycemic control in Portuguese Canadian adults with type 2 diabetes over a three-month period.

DESIGN

The Diabetes Education Centre is located in the urban multicultural city of Toronto, Ontario, Canada. We used a three-month randomized controlled trial design. Eligible Portuguese-speaking adults with type 2 diabetes were randomly assigned to receive either diabetes education counselling only (control group) or counselling in conjunction with group education (intervention group). Of the 61 patients who completed the study, 36 were in the counselling only and 25 in the counselling with group education intervention. We used a per-protocol analysis to examine the efficacy of the two educational approaches on nutrition adherence and glycemic control; paired t-tests to compare results within groups and analysis of covariance (ACOVA) to compare outcomes between groups adjusting for baseline measures. The Theory of Planned Behaviour was used to describe the behavioural mechanisms that influenced nutrition adherence.

RESULTS

Attitudes, subjective norms, perceived behaviour control, and intentions towards nutrition adherence, self-reported nutrition adherence and glycemic control significantly improved in both groups, over the three-month study period. Yet, those receiving individual counselling with group education showed greater improvement in all measures with the exception of glycemic control, where no significant difference was found between the two groups at three months.

CONCLUSIONS

Our study findings provide preliminary evidence that culturally competent group education in conjunction with individual counselling may be more efficacious in shaping eating behaviours than individual counselling alone for Canadian Portuguese adults with type 2 diabetes. However, larger longitudinal studies are needed to determine the most efficacious education method to sustain long-term nutrition adherence and glycemic control.

Patient decision making: strategies for diabetes diet adherence intervention

BACKGROUND

Patient self-care is critical in controlling diabetes and its complications. Lack of diet adherence is a particular challenge to effective diabetes intervention. The Transtheoretical Model (TTM) of Change, decision-making theory, and self-efficacy have contributed to successful tailoring of interventions in many target behaviors.

OBJECTIVE

The purpose of this study was to develop a diagnostic tool, including TTM measures for the stages of change, decisional balance, and self-efficacy, that pharmacists involved in diabetes intervention can use for patients resistant to a diet regimen.

METHODS

A questionnaire was developed through a literature review, interviews with diabetic patients, an expert panel input, and pretesting. Cross-sectional implementation of the questionnaire among a convenience sample of 193 type 1 and type 2 diabetic patients took place at 4 patient care sites throughout the southeastern United States. Validated measures were used to collect respondent self-report for the TTM variables and for demographic and diabetes history variables. Social desirability was also assessed.

RESULTS

Relationships among TTM measures for diet adherence generally replicated those established for other target behaviors. Salient items were identified as potential facilitators (decisional balance pros) or barriers (decisional balance cons and self-efficacy tempting situations) to change. Social desirability exhibited a statistically significant relationship with patient report of diet adherence, with statistically significant differences in mean social desirability across race categories.

CONCLUSIONS

The TTM measures for the stages of change, decisional balance, and self-efficacy are useful for making decisions on individually tailored interventions for diet adherence, with caution asserted about the potential of diabetes patients to self-report the target behavior in a socially desirable manner. Future research directions, implications, and limitations of the findings are also presented.

Age and sex may significantly interact with diabetes on the risks of lower-extremity amputation and peripheral revascularization procedures: evidence from a cohort of a half-million diabetic patients

OBJECTIVE

Using the National Health Insurance claim data, we prospectively investigated the age- and sex-specific incidence density and relative hazards of nontraumatic lower-extremity amputation (LEA) and peripheral revascularization procedure (PRP) of the diabetic population in Taiwan.

RESEARCH DESIGN AND METHODS

A total of 500,868 diabetic patients and 500,248 age- and sex-matched control subjects, selected from the ambulatory care claim (1997) and the registry for beneficiaries, respectively, were linked to inpatient claims (1997-2002) to identify hospitalizations due to nontraumatic LEA and PRP. Incidence density was calculated under the Poisson assumption, and the Kaplan-Meier analysis was used to assess the cumulative event rates over a 6-year follow-up period. We also evaluated the age- and sex-specific relative hazards of nontraumatic LEA and PRP in relation to diabetes with Cox proportional hazard regression model adjusted for demographics and regional areas.

RESULTS

The estimated incidence density of nontraumatic LEA and PRP for diabetic men was 410.3 and 317.0 per 100,000 patient-years, respectively. The corresponding data for diabetic women were relatively low at 115.2 and 86.0 per 100,000 patient-years. Compared with control subjects with the same age and sex, diabetic patients consistently suffered from significantly elevated relative hazards of nontraumatic LEA. Young and female patients were especially vulnerable to experience increased risks of nontraumatic LEA, but such effect modification by age and sex was less apparent for PRP.

CONCLUSIONS

Multidisciplinary diabetes foot care systems, including the provision of revascularization procedures, should be further enforced to reduce subsequent risks of nontraumatic LEA, especially in young and female diabetic patients.

Impact of influenza vaccination on major cause-specific mortality

The efficacy of influenza vaccination is not well understood for major cause-specific mortality except pneumonia. For 10 months we followed the mortality data of 35,637 vaccinated elderly (>65 years old) in a county with 102,698 elderly in southern Taiwan. A multivariate Cox model showed that vaccination was significantly associated with lower mortality for all causes, [hazards ratio (HR)=0.56], stroke (HR=0.35), renal disease (HR=0.40), diabetes mellitus (HR=0.45), pneumonia (HR=0.47), COPD (HR=0.55), malignancy (HR=0.74), and heart diseases (HR=0.78), p<0.05. Influenza vaccination was strongly associated with reducing major cause-specific mortality.

Mortality in pharmacologically treated older adults with diabetes: the Cardiovascular Health Study, 1989-2001

BACKGROUND

Diabetes mellitus (DM) confers an increased risk of mortality in young and middle-aged individuals and in women. It is uncertain, however, whether excess DM mortality continues beyond age 75 years, is related to type of hypoglycemic therapy, and whether women continue to be disproportionately affected by DM into older age.

METHODS AND FINDINGS

From the Cardiovascular Health Study, a prospective study of 5,888 adults, we examined 5,372 participants aged 65 y or above without DM (91.2%), 322 with DM treated with oral hypoglycemic agents (OHGAs) (5.5%), and 194 with DM treated with insulin (3.3%). Participants were followed (1989-2001) for total, cardiovascular disease (CVD), coronary heart disease (CHD), and non-CVD/noncancer mortality. Compared with non-DM participants, those treated with OHGAs or insulin had adjusted hazard ratios (HRs) for total mortality of 1.33 (95% confidence interval [CI], 1.10 to 1.62) and 2.04 (95% CI, 1.62 to 2.57); CVD mortality, 1.99 (95% CI, 1.54 to 2.57) and 2.16 (95% CI, 1.54 to 3.03); CHD mortality, 2.47 (95% CI, 1.89 to 3.24) and 2.75 (95% CI, 1.95 to 3.87); and infectious and renal mortality, 1.35 (95% CI, 0.70 to 2.59) and 6.55 (95% CI, 4.18 to 10.26), respectively. The interaction of age (65-74 y versus > or =75 y) with DM was not significant. Women treated with OHGAs had a similar HR for total mortality to men, but a higher HR when treated with insulin.

CONCLUSIONS

DM mortality risk remains high among older adults in the current era of medical care. Mortality risk and type of mortality differ between OHGA and insulin treatment. Women treated with insulin therapy have an especially high mortality risk. Given the high absolute CVD mortality in older people, those with DM warrant aggressive CVD risk factor reduction.

Burden of diabetes in an aging population: prevalence, incidence, mortality, characteristics and quality of care

The purpose of this work is to review the recent publications on prevalence, incidence, mortality, characteristics and quality of care related to diabetes in the elderly population. In France, the prevalence of drug-treated diabetes peaks at 14% by age 75-79 years, and at least one million people aged over 65 years have diabetes. Incidence rates for Northern Europeans rank between 3 and 7 per 1,000 person-years. The World Health Organization expects prevalent cases to further increase, due to better case ascertainment, better survival of people with diabetes, increase in obesity leading to a true increase in diabetes incidence, and, in developed countries, the important impact of population aging. The burden of diabetes in the elderly population is already high. Even in the oldest age-groups, excess mortality risks associated with diabetes are significant and mostly related to cardiovascular disease, accounting for the loss of 3 to 6 years of life. The cardiovascular risk of elderly people with diabetes is poorly controlled, increasing risks of diabetes complications, loss of cognitive functions and mobility, and dependency. Screening for lipid abnormalities and diabetes complications to prevent further damage is insufficient, and antihypertensive and hypolipidemic treatments are, in this population, underused, as in other countries. Specific adjustments of medical nutrition therapy are lacking. In long-term care facilities where the prevalence of diabetes is especially high (8 to 25%), quality of diabetes care is often poorer. As the burden of diabetes is becoming heavier, specific monitoring of the health, quality of care and needs of elderly people with diabetes is required for adequate public health planning.

Limb deficiency and prosthetic management. 4. Comorbidities associated with limb loss

This self-directed learning module highlights common comorbidities found in people with amputations and their impact on functional outcome. It is part of the study guide on limb deficiency and vascular rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article focuses on prosthetic considerations, functional outcome, and potential complications for a woman with the comorbidities of stroke and diabetes who experiences a dysvascular amputation. Formulation of the differential diagnosis, management of limb pain, and evaluation of the potential psychosocial issues arising after amputation are also discussed.

OVERALL ARTICLE OBJECTIVE

To analyze common comorbidities of people with amputations and to delineate their impact on functional outcome.

Indications for and utilization of ACE inhibitors in older individuals with diabetes. Findings from the National Health and Nutrition Examination Survey 1999 to 2002

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) improve cardiovascular outcomes in high-risk individuals with diabetes. Despite the marked benefit, it is unknown what percentage of patients with diabetes would benefit from and what percentage actually receive this preventive therapy.

OBJECTIVES

To examine the proportion of older diabetic patients with indications for ACE or ARB (ACE/ARB). To generate national estimates of ACE/ARB use.

DESIGN AND PARTICIPANTS

Survey of 742 individuals> or =55 years (representing 8.02 million U.S. adults) self-reporting diabetes in the 1999 to 2002 National Health and Nutrition Examination Survey.

MEASUREMENTS

Prevalence of guideline indications (albuminuria, cardiovascular disease, hypertension) and other cardiac risk factors (hyperlipidemia, smoking) with potential benefit from ACE/ARB. Prevalence of ACE/ARB use overall and by clinical indication.

RESULTS

Ninety-two percent had guideline indications for ACE/ARB. Including additional cardiac risk factors, the entire (100%) U.S. noninstitutionalized older population with diabetes had indications for ACE/ARB. Overall, 43% of the population received ACE/ARB. Hypertension was associated with higher rates of ACE/ARB use, while albuminuria and cardiovascular disease were not. As the number of indications increased, rates of use increased, however, the maximum prevalence of use was only 53% in individuals with 4 or more indications for ACE/ARB.

CONCLUSIONS

ACE/ARB is indicated in virtually all older individuals with diabetes; yet, national rates of use are disturbingly low and key risk factors (albuminuria and cardiovascular disease) are being missed. To improve quality of diabetes care nationally, use of ACE/ARB therapy by ALL older diabetics may be a desirable addition to diabetes performance measurement sets.

Quality of health care for older women: What do we know?

As the proportion of the population age 65 and over continues to grow--to a projected 20.5% or 77.2 million by the year 2040--tracking the quality, access, and receipt of care for older women becomes more important, since the majority of older citizens are women. This article establishes a rough baseline for the quality of care, primarily preventive care, received by older women compared to older men, using selected measures and data of the 2004 National Healthcare Quality Report and National Healthcare Disparities Report. It highlights significant differences between women and men, as well as differences for racial, ethnic, and educational subgroups. Generally, older non-Hispanic white women frequently score higher than their Hispanic and non-Hispanic black counterparts, and more educated women often score significantly higher than their less-educated peers on several measures of quality of care. Compared to their male counterparts, older women are significantly less likely to have any colorectal screening test, to keep high blood pressure under control, and to receive aspirin or beta-blockers upon hospital admission or discharge for acute myocardial infarction. Results are mixed for the process measures related to diabetes, but improvements are clearly needed toward increased rates of eye and foot examinations. Rates of influenza and pneumococcal vaccinations are low but can be improved through Medicare-covered services. We also found that older women are screened less often for breast cancer than those ages 40 to 64. There is still a pervasive lack of knowledge in the research and clinical communities about the unique health care needs of and appropriate processes of care for older adults. More research needs to focus on the quality of care for this growing population in order to allow the development of geriatric-based quality measures and models of care that will set the standards of healthcare for older adults in general, and older women in particular.

Diabetes, hyperglycaemia and mortality in disabled older women: The Women's Health and Ageing Study I

AIMS

Diabetes is associated with increased mortality in older adults, but the specific contributions of diabetes-associated clinical conditions and of increasing hyperglycaemia to mortality risk are unknown. We evaluated whether cardiovascular disease, comorbidities, or degree of hyperglycaemia, particularly severe hyperglycaemia, affected diabetes-related mortality risk in older, disabled women.

METHODS

Six-year mortality follow-up of a random sample of 576 disabled women (aged 65-101 years), recruited from the Medicare eligibility list in Baltimore (MD, USA). All-cause and cardiovascular mortality were evaluated by diabetes status: no diabetes; diabetes with mild, moderate, and severe hyperglycaemia [defined by tertiles of glycosylated haemoglobin (GHB) among women with diabetes].

RESULTS

Diabetes with mild, moderate, and severe hyperglycaemia was associated with an increased hazard rate (HR) for all-cause mortality, even after adjustment for demographics, risks for cardiovascular disease, cardiovascular and non-cardiovascular conditions, and other known mortality risks. A dose-response effect was suggested [mild hyperglycaemia, HR 1.81, 95% confidence interval (CI) 1.03, 3.17; moderate hyperglycaemia, HR 2.02, 95% CI 1.34, 3.57; severe hyperglycaemia, HR 2.22, 95% CI 1.17, 4.25]. Women with diabetes had a significantly increased HR for non-cardiovascular death, but not for cardiovascular death, compared with those without diabetes.

CONCLUSIONS

Diabetes, whether characterized by mild, moderate or severe hyperglycaemia, appears to be an independent risk factor for excess mortality in older disabled women and this risk may increase with increasing hyperglycaemia. This mortality risk is not completely explained by vascular complications, and involves non-cardiovascular deaths. Risks and benefits of diabetes management, including glycaemic control and management of vascular and other comorbidities, should be studied in older people with complications and comorbidities.

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes

AIM

Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular-related hospitalization and mortality.

METHODS

We conducted a retrospective cohort analysis, using Saskatchewan Health administrative databases to identify new users of oral antidiabetic drugs. Subject groups were defined by medication use during 1991-1999: sulphonylurea monotherapy, metformin monotherapy, or combination therapy. Deaths and non-fatal hospitalizations recorded during the study period were identified as cardiovascular-related from ICD-9 codes. The main outcome was a composite of first non-fatal hospitalization or death. Standard multivariate techniques, including propensity scores, were used to adjust for potential confounding. Multivariate Cox proportional hazard models were used to examine the relationship between metformin use and the composite endpoint.

RESULTS

Metformin monotherapy was associated with a lower risk of the composite endpoint (adjusted hazard ratio 0.81; 95% confidence interval 0.68, 0.97) compared with sulphonylurea monotherapy. Combination therapy with meformin and a sulphonylurea was associated with lower mortality, but had similar hospitalization rates, to sulphonylurea monotherapy.

CONCLUSIONS

Metformin monotherapy was associated with a lower risk of cardiovascular-related morbidity and mortality, and combination metformin and sulphonylurea therapy was associated with a reduced risk of fatal cardiovascular events, when compared with sulphonylurea monotherapy.

Gender Differences in Drug Use and Expenditures in a Privately Insured Population of Older Adults

We examine gender differences in use and expenditures for prescription drugs among Medicare and privately insured older adults aged 65 and over, using data on a nationally representative sample of prescription drug purchases collected for the Medical Expenditure Panel Survey Household Component. Overall, women spent about $1,178 for drugs, about 17% more than the $1,009 in average expenditures by men. Older women constituted 50.7% of the population and had average annual aggregate expenditures for prescribed medicines of $6.93 billion compared to $5.77 billion for men. Women were more likely than men to use drugs from a number of therapeutic classes-analgesics, hormones and psychotherapeutic agents-and therapeutic subclasses-thyroid drugs, COX-2 inhibitors and anti-depressants. Women also had higher average prescriptions per user for a number of therapeutic classes-hormones, psychotherapeutic agents and analgesics-and therapeutic subclasses-anti-diabetic drugs and beta blockers. Prescribed medications are, arguably, the most important healthcare technology in preventing illness, disability, and death in older adults. It is critical that older women and men have proper access to prescribed medicines. Given the financial vulnerability of this priority population, particularly women, the expanded drug coverage available under the Medicare Modernization Act is of particular relevance in meeting this goal.

Urinary Incontinence in Men

BACKGROUND

Despite similar rates of voiding dysfunction in older men and women, most funded research has focused on women. Strategic treatment plans for managing urinary incontinence and other lower urinary tract symptoms in men are limited by sparse or absent direct clinical evidence with most interventions supported by data extrapolated from studies in women.

OBJECTIVES

To explore what is known about the epidemiology and etiology of incontinence in men, highlight some of the gaps in the current knowledge, address limitations in existing research, and consider future directions in men's continence care.

METHODS

Existing literature on urinary incontinence in men was analyzed to generate a plan for future research.

RESULTS

Gaps in our knowledge of urinary incontinence in men remain in the areas of etiology, psychosocial consequences, and treatment efficacy.

CONCLUSIONS

Clinical research addressing incontinence in men is critical to explore the barriers or facilitators to seeking care, elucidate the biomechanical aspects of pelvic floor function, provide a clear description of the natural history of bladder dysfunction, and highlight the quality of life impact from incontinence.

Mortality and causes of death in a national sample of diabetic patients in Taiwan

OBJECTIVE

To determine the mortality rate, causes of death, and standardized mortality ratio (SMR) in Taiwanese diabetic patients.

RESEARCH DESIGN AND METHODS

A cohort of 256036 diabetic patients (118855 men and 137181 women, aged 61.2 +/- 15.2 years) using the National Health Insurance were assembled during the years 1995-1998 and followed up to the end of 2001. Deaths were verified by indexing to the National Register of Deaths. Underlying causes of death were determined from death certificates coded according to the ninth revision of the International Classification of Diseases. The general population of Taiwan was used as reference for SMR calculation.

RESULTS

With a total of 1124348.4 person-years of follow-up, 43888 patients died and the crude mortality rate was 39.0/1000 person-years. Mortality rates increased with age, and diabetic men had a significantly higher risk of death than women. However, mortality rate ratio for men versus women attenuated with increasing age. The overall SMR was 1.63 (1.62-1.65), and SMRs also attenuated in the elderly. Causes of death ascribed to diabetes; cancer; cardiopulmonary disease; stroke; disease of arteries, arterioles, and capillaries; nephropathy; infection; digestive diseases; accidents; and suicide were 28.8, 18.5, 9.0, 10.5, 0.3, 4.8, 6.4, 7.9, 3.2, and 0.8%, respectively.

CONCLUSIONS

Approximately 71.2% of the diabetes-related deaths would not be ascribed to diabetes on death certificates in Taiwan. The diabetic men have higher risk of dying than women, and diabetic patients have excess mortality when compared with the general population. For underlying causes of death not listed as diabetes, total cardiovascular death, including cardiopulmonary disease, stroke, and disease of arteries, arterioles, and capillaries, is the most common cause of death, followed by cancer.

Identifying undiagnosed primary immunodeficiency diseases in minority subjects by using computer sorting of diagnosis codes

BACKGROUND

Primary immunodeficiency diseases occur in all populations, but these diagnoses are rarely made in minority subjects in the United States.

OBJECTIVE

We sought to develop and validate a method to identify patients without diagnoses but with immunodeficiency in an urban hospital with a substantial minority patient population.

METHODS

We developed a scoring algorithm on the basis of International Classification of Disease, Ninth Revision (ICD-9) codes to identify all hospitalized patients age 60 years or less who had been given a diagnosis of 2 or more of 174 ICD-9-coded complications associated with immunodeficiency. Codes were weighted for severity and expressed as a sum for all admissions between October 1, 1995, and December 31, 2002. Patients with, for example, cancer or HIV or those after transplantation or major surgery were excluded. Demographic features of subjects with aggregated ICD-9 codes suggestive of immunodeficiency were compared with those of other inpatients; 59 computer-selected subjects were then tested for immune defects.

RESULTS

The computer-identified group contained 533 patients (0.4% of all inpatients), who had been hospitalized 2683 times. The median age was 6.6 years. Sixty-five percent were African American or Hispanic, and 61% were insured by Medicaid, which is significantly more than other inpatients younger than 60 years of age (median age, 32.6 years; 37% minority, 27% insured by Medicaid; P<.0001). Primary immunodeficiency was found in 17 (29%) of the 59 subjects tested. Thirteen other patients had secondary immune defects, and 86% of immunodeficient subjects were Hispanic or African American.

CONCLUSIONS

An ICD-9-based scoring algorithm identifies patients demographically different from other hospitalized subjects who have multiple illnesses suggestive of immunodeficiency. This group contains undiagnosed minority patients with immunodeficiency.

Heart failure prevalence, incidence, and mortality in the elderly with diabetes

OBJECTIVE

The goal of this study was to determine heart failure prevalence and incidence rates, subsequent mortality, and risk factors for heart failure among older populations in Medicare with diabetes.

RESEARCH DESIGN AND METHODS

We used a national 5% sample of Medicare claims from 1994 to 1999 to perform a population-based, nonconcurrent cohort study in 151,738 beneficiaries with diabetes who were age > or =65 years, not in managed care, and were alive on 1 January 1995. Prevalent heart failure was defined as a diagnosis of heart failure in 1994; incident heart failure was defined as a new diagnosis in 1995-1999 among those without prevalent heart failure. Mortality was assessed through 31 December 1999.

RESULTS

Heart failure was prevalent in 22.3% in 1994. Among individuals without heart failure in 1994, the heart failure incidence rate was 12.6 per 100 person-years (95% CI 12.5-12.7 per 100 person-years). Incidence was similar by sex and race and increased significantly with age and diabetes-related comorbidities. The adjusted hazard of incident heart failure increased for individuals with the following: metabolic complications of diabetes (a proxy for poor control and/or severity) (hazards ratio 1.23, 95% CI 1.18-1.29), ischemic heart disease (1.74, 1.70-1.79), nephropathy (1.55, 1.45-1.67), and peripheral vascular disease (1.35, 1.31-1.39). Over 60 months, incident heart failure among older adults with diabetes was associated with high mortality-32.7 per 100 person-years compared with 3.7 per 100 person-years among those with diabetes who remained heart failure free.

CONCLUSIONS

These data demonstrate alarmingly high prevalence, incidence, and mortality for heart failure in individuals with diabetes. Prevention of heart failure should be a research and clinical priority.

Hypoglycaemia in Elderly Patients with Diabetes Mellitus

Achieving target glycaemic goals while avoiding hypoglycaemia is a major challenge in the management of elderly patients with diabetes mellitus. Repeated episodes of hypoglycaemia may cause extreme emotional distress in such patients, even when the episodes are relatively mild. Moreover, evidence is mounting that hypoglycaemia among elderly patients is a very real and costly health concern. The strongest predictors of severe hypoglycaemia in the elderly are advanced age, recent hospitalisation and polypharmacy. Education is the key to preventing recurrent or severe hypoglycaemia. As such, there should be close coordination of care between the patient, physician and all other healthcare providers in identifying the cause of hypoglycaemia in elderly patients, and appropriate steps should be taken to prevent further episodes. Prevention of hypoglycaemia has the potential to improve psychosocial aspects of elderly health, including enhanced quality of life, boosted confidence, improved compliance with antidiabetic regimens and avoidance of long-term complications. Since the elderly population represents a unique group, it is imperative to focus on the aetiologies that are exclusive to this group. Advanced age itself is a risk factor for hypoglycaemia, and elderly patients with comorbidities are at increased risk when they are hospitalised. Elderly patients with diabetes often have compromised renal function, which intereferes with drug elimination and thus predisposes them to prolonged life-threatening hypoglycaemia. In addition, patients on five or more prescription medications are prone to drug-associated hypoglycaemia. Although sulfonylurea-associated hypoglycaemia is common, drugs such as ACE inhibitors and nonselective beta-adrenoceptor antagonists can also predispose patients to hypoglycaemia. Greater attention should be paid to the avoidance of hypgolycaemia in nursing home residents. Recurrent hypoglycaemia in elderly patients is not only detrimental to achieving good glycaemic control, it is also a substantial economic burden. Once the causes of hypoglycaemia have been identified, it is crucial to formulate and institute a prevention plan. Firstly, global evaluation of the patient should be carried out to identify possible predisposing risk factors. Secondly, target glycaemic goals should be tailored to each patient. Thirdly, selection of antidiabetic agents should be judicious, then patients and family should be educated to recognise and treat hypoglycaemia. Finally, coordinated care should be provided to identify, treat and prevent hypoglycaemia.

Does dietary sugar and fat influence longevity?

Simultaneous consideration of the influence of the different types of carbohydrates and fats in human diets on mortality rates (especially the diseases of aging), and the probable retardation of such diseases by caloric restriction (CR) leads to the hypothesis that restriction of foods with a high glycemic index and saturated or hydrogenated fats would avoid or delay many diseases of aging and might result in life extension. Many of the health benefits of CR might thereby be available to humans without the side effects or unacceptability of semi-starvation diets.