Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies

Disability and Quality of Life Measures in older frail and prefrail people with type 2 diabetes. The MIDFRAIL-Study

AIM

To explore the individual response to a multimodal intervention on quality of life (QOL) and disability.

METHODS

843 (77.83 years, 50.65 % men) prefrail and frail individuals ≥ 70 years with type 2 diabetes mellitus. Participants were randomized to the usual care group (UCG) or the multicomponent intervention (IG). Intervention consisted in 16-week progressive resistance training program, 7 educational sessions and the achievement of HbA1c (7-8 %, 53-64 mmol/mol)) and BP (<150 mmHg) targets. QOL (EuroQol EQ-5D-5L), basic (Barthel Index, BI) and instrumental (Lawton and Brody Index) activities of daily living (ADL) were assessed. Multivariate binomial and multinomial logistic regression models were used to explore the effect of the IG, and adherence on the outcomes studied.

RESULTS

The IG was associated with a significant higher probability of improvement in the QOL [OR(95 %CI): 1.75 (1.20, 2.54), p-value 0.004] and a lower probability of deterioration in QoL [0.61 (0.87, 0.54), 0.006] and Barthel Index [0.59 (0.37, 0.93), 0.023]. A high adherence (≥93 %) was needed to achieve benefits in the QOL while > 84.38 % was needed for achieving the benefits in Barthel Index.

CONCLUSIONS

IG has proven to be effective in increasing QOL and avoiding the worsening of QOL and basic ADL.

The optimal second-line therapy for older adults with type 2 diabetes mellitus: protocol for a systematic review and network meta-analysis using individual participant data (IPD)

BACKGROUND

Due to increasing life expectancy, almost half of people with type 2 diabetes are aged 65 years or over worldwide. When metformin alone does not control blood sugar, the choice of which second-line therapy to prescribe next is not clear from currently available evidence. The existence of frailty and comorbidities in older adults further increases the complexity of medical decision-making. As only a relatively small proportion of trials report results separately for older adults, the relative efficacy and safety of second-line therapies in older adults with type 2 diabetes mellitus are unknown and require further investigation. This individual participant data (IPD) network meta-analysis evaluates the relative efficacy and safety of second-line therapies on their own or in combination in older adults with type 2 diabetes mellitus.

METHODS

All relevant published and unpublished trials will be identified. Studies published prior to 2015 will be identified from two previous comprehensive aggregate data network meta-analyses. Searches will be conducted in CENTRAL, MEDLINE, and EMBASE from 1st January 2015 onwards, and in clinicaltrials.gov from inception. Randomised controlled trials with at least 100 estimated older adults (≥ 65 years) receiving at least 24 weeks of intervention that assess the effects of glucose-lowering drugs on mortality, glycemia, vascular and other comorbidities outcomes, and quality of life will be eligible. The screening and data extraction process will be conducted independently by two researchers. The quality of studies will be assessed using the Cochrane risk of bias tool 2. Anonymised IPD of all eligible trials will be requested via clinical trial portals or by contacting the principal investigators or sponsors. Received data will be reanalysed where necessary to standardise outcome metrics. Network meta-analyses will be performed to determine the relative effectiveness of therapies.

DISCUSSION

With the increasing number of older adults with type 2 diabetes worldwide, an IPD network meta-analysis using data from all eligible trials will provide new insights into the optimal choices of second-line antidiabetic drugs to improve patient management and reduce unnecessary adverse events and the subsequent risk of comorbidities in older adults.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021272686.

Use of continuous glucose monitoring in insulin-treated older adults with type 2 diabetes

BACKGROUND

Few studies have reported the adherence to and efficacy of continuous glucose monitoring (CGM) for improving diabetes management in insulin-treated older adults with type 2 diabetes mellitus (T2DM).

METHODS

Prospective observational cohort study using FreeStyle Libre Flash CGM in insulin-treated adults > 65 years with T2DM and HbA1c between 7% and 9%. The participants wore the CGM during the 6-weeks study period. The primary outcome was time in range (TIR) between 70 and 180 mg/dL. Secondary outcomes included time below range (TBR), glycemic variability (GV), adherence, and use of glucose data for self-insulin adjustment. Linear regressions with random effects verified the changes in TBR, TIR, time above range (TAR), GV, and GMI across the three visits using CGM (baseline, 4 weeks and 6 weeks), controlled for sex, age, educational level, and health system (private or public).

RESULTS

A total of 66 participants completed the six weeks of CGM (age 72·8 ± 5·3 years; BMI 27·8 ± 3·6 kg/m2), HbA1c: 8·0 ± 0·6%, with an overall sensor utilization of 93·1 ± 6·0%. We observed a stability in TIR (baseline: 63.5 ± 18.9% vs. endpoint: 65.5 ± 18.8%; β = 1,0, p = 0.190). Despite the low TBR at the baseline, we observed statistically significant reduction over the study period (baseline: 5.8 ± 7.0% vs. endpoint: 3.8 ± 4.7%; (β=-1.00, p = 0.008). Glucose variability also reduced from the baseline (34.9 ± 7.2%) to the endpoint (33.0 ± 6.8%) (β=-0.99, p = < 0.001).

CONCLUSION

FreeStyle Libre Flash CGM is well accepted by older adults with T2DM and allows participants to make therapeutic decisions to reduce TBR and glycemic variability.

Sodium-Glucose Co-transporter Type-2 Inhibitors' Effect on Quality of Life in Older Adult Population

Introduction The global elderly population is expanding, with chronic conditions like diabetes diminishing their quality of life. Sodium-glucose co-transporter type 2 (SGLT-2) inhibitors hold promise in improving quality of life by addressing hypervolemia, obesity, and lipid irregularities. However, these drugs can lead to adverse effects, such as polyuria, dehydration, and weight loss, which may detrimentally impact older patients. We aimed to investigate the association between SGLT-2 inhibitors and quality of life in older adults with diabetes. Methods The research included 100 type II diabetes mellitus patients over 65, without active infections, malignancies, immunodeficiencies, and hematological disorders. Fifty patients were using empagliflozin or dapagliflozin and 50 patients were using other oral antidiabetics for at least six months. Patient demographics, laboratory studies, drug usage and side effects, additional diseases, Geriatric Depression Scale scores, and World Health Organization Quality of Life OLD (WHOQoL-OLD) module scores were noted. Results No significant difference between gender distribution, SGLT usage, chronic disease existence, chronic disease count, depression scores, or incidents of chronic diseases other than hyperlipidemia was observed. Hyperlipidemia incidence was significantly higher in the SGLT group, while other laboratory parameters were not statistically significantly different between groups. There were no significant differences in autonomy, past-present-future activities, social skills, death, intimacy, and total WHOQoL-OLD scores between the two groups. However, there were statistically significantly worse outcomes in patients with at least one SGLT adverse effect in terms of sensory quality of life scores. Dehydration existence was negatively correlated with lower autonomy, PPF activities, and total quality of life scores. Multivariate linear regression analysis showed no significant differences in the total WHOQoL-OLD score after adjusting for confounding factors. Conclusion Age and depression remained the main factors affecting the quality of life in diabetic patients. SGLT-2 inhibitor side effects did not decrease the quality of life in older individuals, who are more prone to unfavorable consequences.

The Impact of Glucose-Lowering Strategy on the Risk of Increasing Frailty Severity among 49,519 Patients with Diabetes Mellitus: A Longitudinal Cohort Study

Patients with diabetes mellitus (DM) have a higher risk of incident and aggravating frailty over time. Frailty-initiating risk factors have been identified, but modulators of frail severity over time remain poorly defined. We aimed to explore the influences of glucose-lowering drug (GLD) strategy on DM patients' risk of increasing frail severity. We retrospectively identified type 2 DM patients between 2008 and 2016, dividing them into "no GLD", oral GLD (oGLD) monotherapy, oGLD combination, and those receiving insulin without or with oGLD at baseline. Increasing frail severity, defined as ≥1 FRAIL component increase, was the outcome of interest. Cox proportional hazard regression was utilized to analyze the risk of increasing frail severity associated with GLD strategy, accounting for demographic, physical data, comorbidities, medication, and laboratory panel. After screening 82,208 patients with DM, 49,519 (no GLD, 42.7%; monotherapy, 24.0%; combination, 28.5%; and insulin user, 4.8%) were enrolled for analysis. After 4 years, 12,295 (24.8%) had increasing frail severity. After multivariate adjustment, oGLD combination group exhibited a significantly lower risk of increasing frail severity (hazard ratio (HR) 0.90, 95% confidence interval (CI) 0.86 - 0.94), while the risk of insulin users increased (HR 1.11, 95% CI 1.02 - 1.21) than no GLD group. Users receiving more oGLD exhibited a trend of less risk reduction relative to others. In conclusion, we discovered that the strategy of oral glucose lowering drugs combination might reduce the risk of frail severity increase. Accordingly, medication reconciliation in frail diabetic older adults should take into account their GLD regimens.

Sex-specific medication trajectories in older adults newly diagnosed with diabetes

Background

People with diabetes tend to use many medications to treat diabetes and comorbidities. Nevertheless, the evolution of polypharmacy in newly diagnosed males and females has been little studied.

Objective

The objective of this paper was to identify and describe medication trajectories in incident diabetes cases according to sex.

Methods

Data were obtained from the Quebec Integrated Chronic Disease Surveillance System. We built a population-based cohort of community-dwelling individuals aged >65 years diagnosed with diabetes in 2014 who were alive and covered with the public drug plan until March 31, 2019. Latent class models were used to identify medication trajectory groups in males and females separately.

Results

Of the 10,363 included individuals, 51.4% were males. Females were older and more likely to have more medication claims than males. Four trajectory groups were identified for males and five for females. Most trajectories showed sustained and stable number of medications over time. For each sex, only one of the trajectory groups included a mean annual number of medications lesser than five. Slight increasing trends of medication use were detected in the trajectories composed of very high users, which included older, more comorbid individuals frequently exposed to potentially inappropriate medications.

Conclusions

Most males and females with incident diabetes had a high burden of medication following the year of diagnosis and were classified in a group of sustained medication use over time. The largest increase in medication was among those who had higher level of polypharmacy of questionable quality at baseline, raising concerns about the innocuity of such medication trajectories.

Poorly controlled diabetes: Glycosylated hemoglobin (HA1c) levels >8% are the tipping point for significantly worse outcomes following hip fracture in the geriatric population

INTRODUCTION

The presence of diabetes has been associated with increased mortality risk after hip fracture, however, little has been published about the lab values of these diabetic patients and the role high labs play in morbidity and mortality. The purpose of this study is to quantify the severity of diabetes that is associated with worse outcomes in hip fracture patients.

METHODS

A consecutive series of 2430 patients >55 years old who sustained a hip fracture between October 2014-November 2021 were reviewed for demographics, hospital quality measures, and outcomes. Each patient with a diagnosis of diabetes mellitus (DM) was reviewed for hemoglobin-A1c (HA1c) and glucose values at admission. Univariable comparisons and multivariable regression analyses were conducted to assess the impact of diabetes and elevated lab values (HA1c) on outcomes such as hospital quality measures, inpatient complications, readmission rates, and mortality rates.

RESULTS

565 patients (23%) carried a diagnosis of diabetes mellitus at the time of their injury. Considerable demographic and comorbidity differences between diabetic and non-diabetic cohorts indicated that the diabetic cohort was less healthy. The diabetic cohort had longer hospitalizations, higher rates of minor complications, readmissions within 90-days, and mortality within 30-days/1-year. Stratification by HA1c levels found patients with a HA1c>8% had a significantly higher rate of major complications, and mortality at all time points (inpatient/30-day/1-year). Multivariable regression found HA1c>8% to be independently associated with a higher rate of inpatient/30-day/1-year mortality in comparison to a diagnosis of diabetes alone which was not independently significant.

CONCLUSION

While all patients with DM experienced worse outcomes than those without, those with poorly controlled diabetes (HA1c>8%) at the time of hip fracture injury experienced poorer outcomes compared to those with well-controlled diabetes. Treating physicians must recognize these patients with poorly controlled DM at the time of arrival to adjust care planning and patient expectations accordingly.

Overtreatment of older people with type 2 diabetes-a high impact frequent occurrence in need of a new definition

BACKGROUND

Diabetes overtreatment is a frequent and major issue in older people with type 2 diabetes but its definition is often inconsistent and may be misleading. This critical review has aimed at examining the definitions of diabetes overtreatment in older people used in research studies.

METHODS

Studies addressing diabetes overtreatment in people aged 65 or older were identified by searching the PubMed database according to an extensive search equation.

RESULTS

Twenty-two research studies providing a definition of diabetes overtreatment in people aged were found. Overall, 12 different definitions of diabetes overtreatment were used. All studies defined overtreatment according to a HbA_1c threshold (varying from <42 mmol/mol [<6.0%] to <64 mmol/mol [<8%]). Amongst them, 2 definitions had no consideration about glucose-lowering (GL) treatment, 6 required the prescribing of ≥1 GL agent(s), and 4 the prescribing of ≥1 GL agent(s) inducing the high risk of hypoglycaemia (i.e., sulfonylurea(s) or insulin(s)). Only 4 definitions (four studies) were individualised, using varying HbA_1c thresholds according to patients' age or health status.

CONCLUSIONS

Definitions of diabetes overtreatment are heterogeneous across research studies, which is confusing. A standardised definition, based on the individual risk of hypoglycaemia and/or its complications must be promoted in order to bring clarity and greater insight into this field, as well as to improve the quality of management of diabetes in older patients.

[Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (update 2023)]

Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leading to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current evidence and guidelines. Blood pressure values of about 130/80 mm Hg are associated with the best outcome; most importantly, at least blood pressure values < 140/90 mm Hg should be achieved in most patients. Angiotensin converting enzyme inhibitors or angiotensin receptor blockers should be preferred in patients with diabetes, especially in those who also have albuminuria or coronary artery disease. Most patients with diabetes require combination therapy to achieve blood pressure goals; agents with proven cardiovascular benefit should be used (including, besides angiotensin converting enzyme inhibitors and alternatively angiotensin receptor blockers, dihydropyridin-calcium antagonists and thiazide diuretics), preferable in single-pill combinations. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.

Glycaemic control among type 2 diabetes patients in sub-Saharan Africa from 2012 to 2022: a systematic review and meta-analysis

BACKGROUND

There is an increased burden of diabetes globally including in sub-Saharan Africa. The literature shows that glycaemic control among type 2 diabetes patients is poor in most countries in sub-Saharan Africa. Understanding the factors influencing glycaemic control in this region is therefore important to develop interventions to optimize glycaemic control. We carried out a systematic review to determine the prevalence and factors associated with glycaemic control in sub-Saharan Africa to inform the development of a glycaemic control framework in the Democratic Republic of the Congo.

METHODS

We searched five databases (African Index Medicus, Africa-Wide Information, Global Health, PubMed, and Web of Science) using the following search terms: type-2 diabetes, glycaemic control, and sub-Saharan Africa. Only peer-reviewed articles from January 2012 to May 2022 were eligible for this review. Two reviewers, independently, selected articles, assessed their methodological quality using Joanna Briggs checklists, and extracted data. A meta-analysis was performed to estimate the prevalence of glycaemic control. Factors associated with glycaemic control were presented as a narrative synthesis due to heterogeneity as assessed by the I².

RESULTS

A total of 74 studies, involving 21,133 participants were included in the review. The pooled prevalence of good glycaemic control was 30% (95% CI:27.6-32.9). The glycaemic control prevalence ranged from 10-60%. Younger and older age, gender, lower income, absence of health insurance, low level of education, place of residence, family history of diabetes, longer duration of diabetes, pill burden, treatment regimen, side effects, use of statins or antihypertensives, alcohol consumption, smoking, presence of comorbidities/complications, and poor management were associated with poor glycaemic control. On the other hand, positive perceived family support, adequate coping strategies, high diabetes health literacy, dietary adherence, exercise practice, attendance to follow-up, and medication adherence were associated with good glycaemic control.

CONCLUSION

Suboptimal glycaemic control is pervasive among patients with type-2 diabetes in sub-Saharan Africa and poses a significant public health challenge. While urgent interventions are required to optimize glycaemic control in this region, these should consider sociodemographic, lifestyle, clinical, and treatment-related factors. This systematic review and meta-analysis protocol is registered in PROSPERO under CRD 42021237941.

Prevalence of SGLT2i and GLP1RA use among US adults with type 2 diabetes

AIMS

To determine national prevalence of sodium-glucose contransporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonist (GLP1RA) use among adults with type 2 diabetes mellitus (T2DM).

METHODS

We studied adults with T2DM and eGFR ≥ 30 mL/min/1.73 m² who participated in the cross-sectional National Health and Nutrition Examination Survey (NHANES), focusing on the 2017-2020 examination cycle, a key time period prior to widespread dissemination of pivotal trial results and corresponding clinical practice guidelines. We tested prevalence of SGLT2i and GLP1RA use among subgroups based on demographic variables and relevant comorbidities, including chronic kidney disease (CKD), congestive heart failure (CHF), and atherosclerotic cardiovascular disease (ASCVD). We compared use of SGLT2i and GLP1RA to other glucose-lowering medications and assessed trends from prior NHANES cycles.

RESULTS

Among 1375 participants studied in 2017-2020, mean age was 60 years, 46% were women, 13% self-identified as non-Hispanic Black, 10% self-identified as Mexican American, 37% had CKD, 8.5% had CHF, and 23% had ASCVD. The prevalence of SGLT2i and GLP1RA use was 5.8% and 4.4%, respectively. Among adults with CKD, CHF, or ASCVD, SGLT2i were used by 7.7% and GLP1RA were used by 3.5%. Differences in SGLT2i or GLP1RA use were observed by age, race, ethnicity, health insurance status, body mass index, and by whether a single healthcare provider was identified as responsible for diabetes management. Biguanides, sulfonylureas, DPP-4 inhibitors, and insulin were used more frequently than SGLT2i or GLP1RA. Prevalence of SGLT2i but not GLP1RA use increased significantly from 2013-2014 to 2017-2020.

CONCLUSIONS

SGLT2i and GLP1RA use is low among adults with T2DM, including among those with strong indications. Enhanced implementation of these agents is crucial to improving kidney and cardiovascular outcomes and mitigating health disparities in T2DM.

Changes in the use of diabetes drugs among community-dwelling people with Alzheimer's disease

Background

Type 2 diabetes is common in persons with Alzheimer’s disease (AD). Management of diabetes in persons with AD is challenging due to changing goals of care and susceptibility to adverse drug events including hypoglycemia. The aim of this study was to investigate the prevalence of diabetes drug use from 5 years before to 5 years after the time of AD diagnosis among persons with and without AD.

Methods

This was a nationwide register-based study of persons with and without AD and diabetes in Finland. We analyzed data from the Medication Use and Alzheimer’s disease (MEDALZ) study that included 70,718 community-dwelling people diagnosed with AD from 2005 to 2011. The study population included 8418 persons with AD and 6666 matched persons without AD who were diagnosed with diabetes 5 years before AD diagnosis (index date). We defined the prevalence of diabetes drug use in three-month evaluation periods from 5 years before until 5 years after the index date.

Results

Nearly all people with diabetes (94% in both cohorts) used one or more diabetes drugs on the index date. The most prevalent drug metformin was used by 60.9% of people with AD and 59.1% of people without AD. The next most prevalent drugs were sulfonylureas and insulin. The prevalence of diabetes drug use was similar in people with and without AD but began to decline 1 year after AD diagnosis in the AD cohort compared to non-AD cohort.

Conclusions

The decline in diabetes drug use after AD diagnosis may be attributed to clinicians and patients seeking to avoid serious adverse drug events including hypoglycemia. In addition, the findings may reflect personalized glycemic control and unintentional weight loss in persons with AD reducing the need for diabetes drugs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02694-w.

Large discrepancy in glycaemic control appropriateness in geriatric patients with type 2 diabetes according to major clinical practice guidelines

PURPOSE

In geriatric patients with type 2 diabetes (T2D), appropriate glycaemic control is crucial to avoid overtreatment and hypoglycaemia. This study compared glycaemic control appropriateness across three major clinical practice guidelines (CPGs).

METHODS

Retrospective study of geriatric older inpatients with T2D and glucose-lowering treatment before admission. Patients were classified as appropriately treated, overtreated or undertreated using CPGs from Diabetes Canada 2018 (DC18), the Endocrine Society 2019 (ES19) and the American Diabetes Association 2021 (ADA21).

RESULTS

Of the 318 geriatric patients (median age 84 years, 54% women, 66% in poor health), 46%, 25% and 82% were appropriately treated, while 38%, 57% and 0% were overtreated, based on DC18, ES19 and ADA21, respectively.

CONCLUSION

Large discrepancy of glycaemic control appropriateness was detected across these CPGs and concerned mainly overtreatment. This finding relates to the absence in ADA21 of a lower HbA1c value, which may be an obstacle to the prevention of hypoglycaemia.

Outcomes between prediabetes and type 2 diabetes mellitus in older adults with acute myocardial infarction in the era of newer-generation drug-eluting stents: a retrospective observational study

Background

The comparative clinical outcomes between prediabetes and type 2 diabetes mellitus (T2DM) in older adults with AMI in the era of newer-generation drug-eluting stents (DES) are limited. We investigated the 2-year clinical outcomes of these patients.

Methods

A total of 5492 AMI patients aged ≥65 years were classified into three groups according to their glycemic status: normoglycemia (group A: 1193), prediabetes (group B: 1696), and T2DM (group C: 2603). The primary outcome was the occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction (Re-MI), and any repeat revascularization. The secondary outcome was stent thrombosis (ST).

Results

The primary and secondary outcomes cumulative incidences were similar between the prediabetes and T2DM groups. In both the prediabetes and T2DM groups, the cumulative incidences of MACE (adjusted hazard ratio [aHR]: 1.373; p = 0.020 and aHR: 1.479; p = 0.002, respectively) and all-cause death or MI (aHR: 1.436; p = 0.022 and aHR: 1.647; p = 0.001, respectively) were significantly higher than those in the normoglycemia group. Additionally, the cumulative incidence of all-cause death in the T2DM group was significantly higher than that in the normoglycemia group (aHR, 1.666; p = 0.003).

Conclusions

In this retrospective study, despite the 2-year clinical outcomes of the patients with prediabetes and T2DM in the older adults were worse than those in the normoglycemia group; they were similar between the prediabetes and T2DM groups. Hence, comparable treatment strategies should be strengthened between prediabetes and T2DM in older adults with AMI.

Trial registration

Retrospectively registered.

Individualisation of glycaemic management in older people with type 2 diabetes: a systematic review of clinical practice guidelines recommendations

BACKGROUND

Recommendations for individualised glycaemic management in older people with type 2 diabetes (T2D) have recently been provided in clinical practice guidelines (CPGs) issued by major scientific societies. The aim of this systematic review is to compare the content of these recommendations concerning health assessment, targets for glycaemic control, lifestyle management and glucose-lowering therapy across CPGs.

METHODS

The CPGs on T2D management in people aged ≥65 years published in English after 2015 by major scientific societies were systematically reviewed in accordance with the PRISMA statement. The quality of the CPGs included was assessed using the AGREE-II tool. The recommendations for individualised glycaemic management were extracted, and their level of evidence (LOE) and strength of recommendation recorded.

RESULTS

Three CPGs of high methodological quality were included, namely those from the American Diabetes Association 2020, the Endocrine Society 2019 and the Diabetes Canada Expert Committee 2018. They made 27 recommendations addressing individualised glycaemic management, a minority of which (40%) had a high LOE. Comparison of the 27 recommendations identified some discrepancies between CPGs, e.g. the individualised values of HbA1c targets. The 13 strong recommendations addressed 10 clinical messages, five of which are recommended in all three CPGs, i.e. assess health status, screen for cognitive impairment, avoid hypoglycaemia, prioritise drugs with low hypoglycaemic effects and simplify complex drug regimens.

CONCLUSIONS

Although there is a consensus on avoiding hypoglycaemia in older patients with T2D, significant discrepancies regarding individualised HbA1c targets exist between CPGs.

Insulin resistance and muscle weakness are synergistic risk factors for silent lacunar infarcts: the Bunkyo Health Study

Insulin resistance and muscle weakness are risk factors for silent lacunar infarcts (SLI), but it is unclear whether they are still independent risk factors when adjusted for each other. In addition, the effect of their combination on SLI is completely unknown. We evaluated SLI, insulin sensitivity, and knee extensor muscle strength by magnetic resonance imaging, PREDIM, and dynamometer, respectively, in 1531 elderly people aged 65–84 years living in an urban area of Tokyo. Among the study subjects, 251 (16.4%) had SLI. Impaired insulin sensitivity (High; 1.00 [reference], Medium; 1.53 [95% confidence interval (CI) 0.94–2.48], Low; 1.86 [1.02–3.39], p for trend 0.047) and reduced muscle strength (High; 1.00 [reference], Medium; 1.40 [0.98–2.02], Low; 1.49 [1.04–2.15], p for trend 0.037) were independently associated with increased risk for SLI in the fully adjusted model. In terms of combined, subjects classified as having the lowest insulin sensitivity and lowest strength were 4.33 times (95% CI 1.64–11.45) more likely to have a SLI than those classified as having the highest insulin sensitivity and highest strength. Impaired insulin sensitivity and reduced muscle strength were independently associated with higher risk of SLI in elderly subjects, and their combination synergistically increased this risk.

Efficacy / safety balance of DPP-4 inhibitors versus SGLT2 inhibitors in elderly patients with type 2 diabetes

Dipeptidyl peptidase-4 inhibitors (DPP-4is) and sodium-glucose cotransporter type 2 inhibitors (SGLT2is) offer new options for the oral management of type 2 diabetes mellitus (T2DM), with the advantage in the elderly population to be devoid of a high risk of hypoglycaemia. SGLT2is have also shown benefits regarding cardiovascular (heart failure) and renal protection, including in patients with T2DM aged ≥ 65 years while DPP-4is have only proved cardiovascular and renal safety without superiority compared with placebo. The glucose-lowering efficacy of the two pharmacological classes is almost similar including in older patients with T2DM. However, the tolerance and safety profile may be highly different and overall more favourable with DPP-4is than with SGLT2is. Some adverse events have been reported with SGLT2is which may be more prevalent or severe in older patients than in younger patients. The present comprehensive review focuses on the benefit/risk balance in the elderly population with T2DM by comparing the profile of DPP-4is and SGLT2is regarding the following potential issues: metabolic disorders (hypoglycaemia and diabetic ketoacidosis); cardiac and vascular issues (atheromatous cardiovascular disease, heart failure, volume reduction hypotension, and lower limb amputations); renal endpoints including acute renal injury; risk of infections; digestive disorders; bone and skin adverse events; and cancer risk. Both DPP-4is and SGLT2is have their own advantages and disadvantages. Personalised treatment is recommended based upon the efficacy/safety profile of each drug class and individual patient characteristics that may be markedly different among the heterogeneous population of older individuals with T2DM.

Factors associated with potential over- and undertreatment of hyperglycaemia and annual measurement of HbA1c in type 2 diabetes in norwegian general practice

AIMS

To identify individual and general practitioner (GP) characteristics associated with potential over- and undertreatment of hyperglycaemia in type 2 diabetes and with HbA1c not being measured.

METHODS

A cross-sectional study that included 10233 individuals with type 2 diabetes attending 282 GPs. Individuals with an HbA1c measurement during the last 15 months were categorized as potentially overtreated if they were prescribed a sulphonylurea and/or insulin when the HbA1c was less than 53 mmol/mol (7%) when aged over 75 years or less than 48 mmol/mol (6.5%) when aged between 65 and 75 years. Potential undertreatment was defined as age less than 60 years and HbA1c > 64 mmol/mol (8.0%) or HbA1c > 69 mmol/mol (8.5%) and treated with lifestyle modification and/or monotherapy. We used multilevel binary and multinominal logistic regression models to examine associations.

RESULTS

Overall, 4.1% were potentially overtreated, 7.8% were potentially undertreated and 11% did not have HbA1c measured. Characteristics associated with potential overtreatment were as follows: long diabetes duration, prescribed antihypertensive medication, cardiovascular disease and renal failure. Potential undertreatment was associated with male gender, non-western origin and low educational level. Characteristics associated with not having an HbA1c measurement performed were male gender, age < 50 years and cardiovascular diseases. GP specialist status and GPs' use of a Noklus diabetes application reduced the risk of not having an HbA1c measurement performed.

CONCLUSION

Potential overtreatment in elderly individuals with type 2 diabetes was relatively low. Nevertheless, appropriate de-intensification or intensification of treatment and regular HbA1c measurement in identified subgroups is warranted.

Daytime Glycemic Variability and Frailty in Older Patients with Diabetes: a Pilot Study Using Continuous Glucose Monitoring

We investigated the relationship between glucose variability and frailty. Forty-eight type 2 diabetic patients aged ≥ 65 years were enrolled. The FRAIL scale was used for frailty assessment, and participants were classified into 'healthy & pre-frail' (n = 24) and 'frail' (n = 24) groups. A continuous glucose monitoring (CGM) system was used for a mean of 6.9 days and standardized CGM metrics were analyzed: mean glucose, glucose management indicator (GMI), coefficient of variation, and time in range, time above range (TAR), and time below range. The demographics did not differ between groups. However, among the CGM metrics, mean glucose, GMI, and TAR in the postprandial periods were higher in the frail group (all P < 0.05). After multivariate adjustments, the post-lunch TAR (OR = 1.12, P = 0.019) affected the prevalence of frailty. Higher glucose variability with marked daytime postprandial hyperglycemia is significantly associated with frailty in older patients with diabetes.

American Diabetes Association Framework for Glycemic Control in Older Adults: Implications for Risk of Hospitalization and Mortality

OBJECTIVE

The 2021 American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults that are based on comorbid health status. We assessed risk of mortality and hospitalizations in older adults with diabetes across glycemic control (A1C <7%, 7 to <8%, ≥8%) and ADA-defined health status (healthy, complex/intermediate, very complex/poor) categories.

RESEARCH DESIGN AND METHODS

Prospective cohort analysis of older adults aged 66-90 years with diagnosed diabetes in the Atherosclerosis Risk in Communities (ARIC) study.

RESULTS

Of the 1,841 participants (56% women, 29% Black), 32% were classified as healthy, 42% as complex/intermediate, and 27% as very complex/poor health. Over a median 6-year follow-up, there were 409 (22%) deaths and 4,130 hospitalizations (median [25th-75th percentile] 1 per person [0-3]). In the very complex/poor category, individuals with A1C ≥8% (vs. <7%) had higher mortality risk (hazard ratio 1.76 [95% CI 1.15-2.71]), even after adjustment for glucose-lowering medication use. Within the very complex/poor health category, individuals with A1C ≥8% (vs. <7%) had more hospitalizations (incidence rate ratio [IRR] 1.41 [95% CI 1.03-1.94]). In the complex/intermediate group, individuals with A1C ≥8% (vs. <7%) had more hospitalizations, even with adjustment for glucose-lowering medication use (IRR 1.64 [1.21-2.24]). Results were similar, but imprecise, when the analysis was restricted to insulin or sulfonylurea users (n = 663).

CONCLUSIONS

There were substantial differences in mortality and hospitalizations across ADA health status categories, but older adults with A1C <7% were not at elevated risk, regardless of health status. Our results support the 2021 ADA guidelines and indicate that <7% is a reasonable treatment goal in some older adults with diabetes.

Muscle relaxant use and the associated risk of incident frailty in patients with diabetic kidney disease: a longitudinal cohort study

Background:

Patients with diabetic kidney disease (DKD) are at an increased risk of frailty. The exposure to muscle relaxants frequently leads to adverse effects despite their modest therapeutic efficacy, but whether muscle relaxants predispose users to frailty remains unclear.

Methods:

Patients with DKD from a population-based cohort, the Longitudinal Cohort of Diabetes Patients, were identified between 2004 and 2011 (N = 840,000). Muscle relaxant users were propensity score-matched to never-users in a 1:1 ratio based on demographic features, comorbidities, outcome-relevant medications, and prior major interventions. Incident frailty, the study endpoint, was measured according to a modified FRAIL scale. We used Kaplan–Meier analyses and Cox proportional hazard regression to analyze the association between cumulative muscle relaxant use (⩾ 28 days) and the risk of incident frailty.

Results:

Totally, 11,637 users and matched never-users were enrolled, without significant differences regarding baseline clinical features. Cox proportional hazard regression showed that patients with DKD and received muscle relaxants had a significantly higher risk of incident frailty than never-users [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.04–1.53]. This increase in frailty risk paralleled that in cumulative muscle relaxant dosages (quartile 1 versus 2 versus 3 versus 4, HR 0.91 versus 1.22 versus 1.38 versus 1.45, p = 0.0013 for trend) and in exposure durations (quartile 1 versus 2 versus 3 versus 4, HR 1.12 versus 1.33 versus 1.23 versus 1.34, p = 0.0145 for trend) of muscle relaxants.

Conclusion:

We found that cumulative muscle relaxant exposure might increase frailty risk. It is prudent to limit muscle relaxant prescription in patients with DKD.

Plain language summary

Does cumulative muscle relaxant exposure increase the risk of incident frailty among patients with diabetic kidney disease?

Background: Frailty denotes a degenerative feature that adversely influences one’s survival and daily function. Patients with diabetes and chronic kidney disease are at a higher risk of developing frailty, but whether concurrent medications, especially muscle relaxants, aggravate this risk remains undefined.

Methods: In this population-based study including 11,637 muscle relaxant users and matched never-users with diabetic kidney disease, we used a renowned frailty-assessing tool, FRAIL scale, to assess frailty severity and examined the incidence of frailty brought by muscle relaxant exposure.

Results: We found that users exhibited a 26% higher risk of developing incident frailty compared with never-users, and the probability increased further if users were prescribed higher doses or longer durations of muscle relaxants.

Conclusion: We concluded that in those with diabetic kidney disease, cumulative muscle relaxant use was associated with a higher risk of incident frailty, suggesting that moderation of muscle relaxant use in this population can be of potential importance.

Inappropriate intensification of glucose-lowering treatment in older patients with type 2 diabetes: the global DISCOVER study

INTRODUCTION

Although individualized target glycated hemoglobin (HbA_1c) levels are recommended in older people with type 2 diabetes, studies report high levels of potential overtreatment. We aimed to investigate the proportion of older patients (aged ≥65 years) who potentially received an inappropriately intensive treatment (HbA_1c level <7.0% (53.0 mmol/mol)) in a global study. Factors associated with intensive glycemic management and using glucose-lowering medications associated with a high risk of hypoglycemia (high-risk medications (insulin, sulfonylureas, and meglitinides)) were also assessed.

RESEARCH DESIGN AND METHODS

DISCOVER is a 3-year observational study program of 15 992 people with type 2 diabetes initiating second-line glucose-lowering therapy in 38 countries. Data were collected at baseline (initiation of second-line therapy) and at 6, 12, and 24 months. Factors associated with an inappropriately intensive treatment or using high-risk medications were assessed using a hierarchical regression model.

RESULTS

Of the 3344 older patients with baseline HbA_1c data in our analytic cohort, 23.5% received inappropriate treatment intensification. Among those who had follow-up HbA_1c data, 55.2%, 54.2%, and 53.5% were inappropriately tightly controlled at 6, 12, and 24 months, respectively, with higher proportions in high-income than in middle-income countries. The proportion of patients receiving high-risk medications was higher in middle-income countries than in high-income countries. Gross national income (per US$5000 increment) was associated with increased odds of inappropriately intensive treatment but with decreased odds of receiving high-risk medications.

CONCLUSIONS

A large proportion of older DISCOVER patients received an inappropriately intensive glucose-lowering treatment across the 2 years of follow-up, with substantial regional variation. The use of high-risk medications in these patients is particularly concerning.

Careful use to minimize adverse events of oral antidiabetic medications in the elderly

INTRODUCTION

An increasing number of older patients has type 2 diabetes treated with different oral antidiabetic agents whose safety may raise concern considering some particularities of a heterogeneous elderly population.

AREAS COVERED

This article discusses some characteristics of older patients that could increase the risk of adverse events, with a focus on hypoglycemia. It describes the most frequent and/or severe complications reported in the elderly in both randomized controlled trials and observational studies with metformin, sulfonylureas, meglitinides, alpha-glucosidase inhibitors, thiazolidinediones, dipeptidyl peptidase-4 inhibitors (gliptins) and sodium-glucose cotransporter type 2 inhibitors (gliflozins).

EXPERT OPINION

Old patients may present comorbidities (renal impairment, vascular disease, heart failure, risk of dehydration, osteoporosis, cognitive dysfunction) that could increase the risk of severe adverse events. Sulfonylureas (and meglitinides) induce hypoglycemia, which may be associated with falls/fractures and cardiovascular events. Medications lacking hypoglycemia should be preferred. Gliptins appear to have the best tolerance/safety profile whereas gliflozins exert a cardiorenal protection. However, data are lacking in very old or frailty old patients so that caution and appropriate supervision of such patients are required. Taking advantage of a large choice of pharmacotherapies, personalized treatment is recommended based upon both drug safety profiles and old patient individual characteristics.

Transplantation of Apoptosis-Resistant Endothelial Progenitor Cells Improves Renal Function in Diabetic Kidney Disease

Background

Diabetic kidney disease is associated with glomerulosclerosis and poor renal perfusion. Increased capillary formation and improved perfusion may help to halt or reverse the injury. Transplanting apoptosis‐resistant p53‐silenced endothelial progenitor cells (p53sh‐EPCs) may help improve vascularization and renal perfusion and could be more beneficial than another stem cell such as the mouse mesenchymal stromal cell (mMSC).

Methods and Results

Hyperglycemia and proteinuria were confirmed at 8 to 10 weeks in streptozotocin‐induced type1 diabetic C57Bl/6 mice, followed by transplantation of 0.3 million p53sh‐EPCs, Null‐EPCs (control), or mMSC under each kidney capsule. Urine was collected weekly for creatinine and protein levels. Blood pressure was measured by direct arterial cannulation and renal perfusion was measured by renal ultrasound. The kidneys were harvested for histology and mRNA expression. Reduction of protein/creatinine (AUC) was observed in p53sh‐EPC‐transplanted mice more than null‐EPC (1.8‐fold, P=0.03) or null‐mMSC (1.6‐fold, P=0.04, n=4) transplanted mice. Markers for angiogenesis, such as endothelial nitric oxide synthase (1.7‐fold, P=0.06), were upregulated post p53sh‐EPC transplantation compared with null EPC. However, vascular endothelial growth factor‐A expression was reduced (7‐fold, P=0.0004) in mMSC‐transplanted mice, compared with p53sh‐EPC‐transplanted mice. Isolectin‐B4 staining of kidney section showed improvement of glomerular sclerosis when p53sh‐EPC was transplanted, compared with null‐EPC or mMSC. In addition, mean and peak renal blood velocity (1.3‐fold, P=0.01, 1.4‐fold, P=0.001, respectively) were increased in p53sh‐EPC‐transplanted mice, relative to null‐EPC transplanted mice.

Conclusions

Apoptosis‐resistant p53sh EPC transplantation could be beneficial in the treatment of diabetic kidney disease by decreasing proteinuria, and improving renal perfusion and glomerular architecture.

Outcome of fragility hip fractures in elderly patients: Does diabetes mellitus and its severity matter?

AIMS

Diabetes mellitus (DM) and osteoporosis are both diseases of epidemic proportions with an increasing incidence worldwide. Fragility hip fractures (FHF) are associated with elevated morbidity, mortality, social burden and medical costs. The aim of this study was to determine whether patients with DM have worse medical and surgical outcomes following FHFs and whether the Diabetes Complications Severity Index (DCSI) can predict in-hospital complications and one-year mortality.

METHODS

A single centre retrospective cohort study including 1343 patients older than 65 years who underwent surgery for FHFs was conducted. The data collected included length of hospital stay, time-to-surgery, blood loss, complications and mortality during the first post-operative year.

RESULTS

408 patients with a DM diagnosis were compared with 935 without DM. Pre-operatively, patients with DM had lower haemoglobin levels, higher platelet counts and worse renal function. Following surgery, patients with DM were more likely to be transferred to another department or intensive care. One-year mortality was significantly higher in the DM group [23.3% vs. 17.1%, odds ratio 1.36 (CI 1.029-1.799, p = 0.03)]. Higher DCSI scores were related with elevated one-year mortality rates in the DM group. Cerebrovascular events were found to be nearly five times more prevalent in the DM group. Patients with DM were more likely to continue treatment in a rehabilitation centre and had a higher probability to be re-hospitalized in the first post-operative year (p.<0.001).

CONCLUSIONS

Our results emphasize the increased vulnerability of this patient population and the importance of specialized care during the peri-operative period of FHFs.

Worldwide inertia to the use of cardiorenal protective glucose-lowering drugs (SGLT2i and GLP-1 RA) in high-risk patients with type 2 diabetes

The disclosure of proven cardiorenal benefits with certain antidiabetic agents was supposed to herald a new era in the management of type 2 diabetes (T2D), especially for the many patients with T2D who are at high risk for cardiovascular and renal events. However, as the evidence in favour of various sodium-glucose transporter-2 inhibitor (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA) accumulates, prescriptions of these agents continue to stagnate, even among eligible, at-risk patients. By contrast, dipeptidyl peptidase-4 inhibitors (DPP-4i) DPP-4i remain more widely used than SGLT2i and GLP-1 RA in these patients, despite a similar cost to SGLT2i and a large body of evidence showing no clear benefit on cardiorenal outcomes. We are a group of diabetologists united by a shared concern that clinical inertia is preventing these patients from receiving life-saving treatments, as well as placing them at greater risk of hospitalisation for heart failure and progression of renal disease. We propose a manifesto for change, in order to increase uptake of SGLT2i and GLP-1 RA in appropriate patients as a matter of urgency, especially those who could be readily switched from an agent without proven cardiorenal benefit. Central to our manifesto is a shift from linear treatment algorithms based on HbA1c target setting to parallel, independent considerations of atherosclerotic cardiovascular disease, heart failure and renal risks, in accordance with newly updated guidelines. Finally, we call upon all colleagues to play their part in implementing our manifesto at a local level, ensuring that patients do not pay a heavy price for continued clinical inertia in T2D.

Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies

Older people (those aged 65 years or more) with diabetes comprise a heterogenous group of patients with special needs and features; this is particularly true for those aged 75 years or more. It is important that individualized glycemic targets be adopted in this population, after considering life expectancy, presence of diabetic complications and other comorbidities. In general, less rigorous targets and avoidance of overtreatment seems to be a reasonable strategy in daily clinical settings. There is a paucity of data regarding the efficacy and safety of various hypoglycemic agents, especially for those aged over 75. The evidence suggests that sulfonylureas and insulin regimens should be used with caution due to a high risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors are a good choice for the management of diabetes in older age groups, although a warning against the use of specific agents in people with heart failure is valid. There are insufficient data to decide whether the cardiorenal protective properties of sodium-glucose co-transporter 2 inhibitors outweigh the risks associated with these drugs. The use of glucagon-like peptide-1 receptor agonists by older patients is supported not only by their good safety and efficacy profiles, but also by their potential to improve glucose-independent outcomes, through their pleiotropic actions. The aim of this narrative review is to summarize the evidence on glycemic targets and optimal therapeutic approaches for older patients with type 2 diabetes and discuss the risk-benefit balance of various therapeutic approaches in this group.

Diabetes in ageing: pathways for developing the evidence base for clinical guidance

Older adults with diabetes are heterogeneous in their medical, functional, and cognitive status, and require careful individualisation of their treatment regimens. However, in the absence of detailed information from clinical trials involving older people with varying characteristics, there is little evidence-based guidance, which is a notable limitation of current approaches to care. It is important to recognise that older people with diabetes might vary in their profiles according to age category, functional health, presence of frailty, and comorbidity profiles. In addition, all older adults with diabetes require an individualised approach to care, ranging from robust individuals to those residing in care homes with a short life expectancy, those requiring palliative care, or those requiring end-of-life management. In this Review, our multidisciplinary team of experts describes the current evidence in several important areas in geriatric diabetes, and outlines key research gaps and research questions in each of these areas with the aim to develop evidence-based recommendations to improve the outcomes of interest in older adults.

The type 2 diabetes-specific dementia risk score (DSDRS) is associated with frailty, cognitive and functional status amongst Mexican community-dwelling older adults

Background

The type 2 diabetes (T2D) specific dementia-risk score (DSDRS) was developed to evaluate dementia risk in older adults with T2D. T2D-related factors have been shown increase the risk of age-related conditions, which might also increase dementia risk. Here, we investigate the associations of DSDRS with frailty, disability, quality of life (QoL) and cognition in community-dwelling older adults with T2D.

Methods

We included 257 community-dwelling older adults with T2D to evaluate the association between DSDRS and Mini-mental state examination (MMSE), Isaac’s set-test (IST), clock drawing test (CDT), quality of life (SF-36), risk of malnutrition (Mini-Nutritional Assessment or MNA), as well as frailty, Katz’ and Lawton-Brody scores. We also assessed the phenotype and correlates of high-estimated dementia risk by assessing individuals with DSDRS >75th age-specific percentiles.

Results

Mean age of participants was 78.0 ± 6.2 years. DSDRS showed a significant correlation with MMSE test, IST, CDT, SF-36, MNA, Lawton-Brody and Katz scores, and an increasing number of frailty components. DSDRS was higher among frail, pre-frail, and subjects with limited ADL and IADL (p < 0.001). Participants with DSDRS >75th age-specific percentiles had lower education, MMSE, IST, SF-36, MNA, Katz, Lawton-Brody, and higher frailty scores. High-estimated 10-year dementia risk was associated with ADL and IADL disability, frailty and risk of malnutrition. When assessing individual components of DSDRS, T2D-related microvascular complications were associated to all outcome measures.

Conclusion

The DSDRS is associated with frailty, disability, malnutrition and lower cognitive performance. These findings support that T2D-related factors have significant burden on functional status, QoL, disability and dementia risk.

Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: A nationwide register-based cohort study

AIMS

To examine if personnel resources and organisational features in Swedish primary health-care centres (PHCCs) are associated to all-cause mortality (ACM) in people with type 2 diabetes mellitus (T2DM).

METHODS

A total of 187,570 people with T2DM registered in the Swedish National Diabetes Register (NDR) during 2013 were included in this nationwide cohort study. Individual NDR data were linked to data from a questionnaire addressing personnel resources and organisational features for 787 (68%) PHCCs as well as to individual data on socio-economic status and comorbidities. Furthermore, data on ACM were obtained and followed up until 30 January 2018. Hierarchical Cox regression analyses were applied.

RESULTS

After a median follow-up of 4.2 years, 27,136 (14.5%) participants had died. An association was found between number of whole-time-equivalent (WTE) general practitioner's (GP's) devoted to diabetes care/500 people with T2DM and lower risk of early death (hazard ratio 0.919 [95% confidence interval 0.895-0.945] per additional WTE GP; p = 0.002). No other personnel resources or organisational features were significantly associated with ACM.

CONCLUSIONS

This nationwide register-based cohort study suggests that the number of WTE GPs devoted to diabetes care have an impact on the risk of early death in people with T2DM.

Identification and prevalence of frailty in diabetes mellitus and association with clinical outcomes: a systematic review protocol

INTRODUCTION

Diabetes mellitus is common and growing in prevalence, and an increasing proportion of people with diabetes are living to older age. Frailty is, therefore, becoming an important concept in diabetes. Frailty is associated with older age and describes a state of increased susceptibility to decompensation in response to physiological stress. A range of measures have been used to quantify frailty. This systematic review aims to identify measures used to quantify frailty in people with diabetes (any type); to summarise the prevalence of frailty in diabetes; and to describe the relationship between frailty and adverse clinical outcomes in people with diabetes.

METHODS AND ANALYSIS

Three electronic databases (Medline, Embase and Web of Science) will be searched from 2000 to November 2019 and supplemented by citation searching of relevant articles and hand searching of reference lists. Two reviewers will independently review titles, abstracts and full texts. Inclusion criteria include: (1) adults with any type of diabetes mellitus; (2) quantify frailty using any validated frailty measure; (3) report the prevalence of frailty and/or the association between frailty and clinical outcomes in people with diabetes; (4) studies that assess generic (eg, mortality, hospital admission and falls) or diabetes-specific outcomes (eg, hypoglycaemic episodes, cardiovascular events, diabetic nephropathy and diabetic retinopathy); (5) cross-sectional and longitudinal observational studies. Study quality will be assessed using the Newcastle-Ottawa Scale for observational studies. Clinical and methodological heterogeneity will be assessed, and a random effects meta-analysis performed if appropriate. Otherwise, a narrative synthesis will be performed.

ETHICS AND DISSEMINATION

This manuscript describes the protocol for a systematic review of observational studies and does not require ethical approval.

PROSPERO REGISTRATION NUMBER

CRD42020163109.

Optimizing drug therapy in frail patients with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) is closely linked with ageing. In frail diabetic patients, the risks of intensive antidiabetic therapy outweigh the potential benefits.

AIMS

To study the prevalence of T2DM in frail elderly patients, to identify inappropriate prescription (IP) of antidiabetic drugs and to study the relationship between patients' frailty index (FI) with polypharmacy and IP.

METHODS

This was a prospective, descriptive, observational study of elderly patients. Each patient's antidiabetic treatment was analysed by applying the patient-centred prescription model (PCP), which centres therapeutic decisions on the patient's global assessment and individual therapeutic goal.

RESULTS

210 patients with T2DM were included (25.15% prevalence). They were characterised by high multimorbidity and frailty. 93.3% presented polypharmacy and 51% excessive polypharmacy. IP was identified in 66.2% of patients. A statistically significant relationship was found between the progression in FI degree and IP prevalence (p < 0.05. During the admission, drug therapy regimens were modified in 97.1% of cases with IP (n = 136).

DISCUSSION

These results suggest that in clinical practice T2DM treatment is not individualised, but rather is based on the same general recommendations for the population as a whole.

CONCLUSIONS

There is a high prevalence of T2DM in the elderly. As the frailty of patients increases, so does the prevalence of IP. The application of PCP model enables drug therapy optimization in frail patients according to their main therapeutic goal, and contributes to provide clinical evidences on the applicability of a set of knowledge areas from the theoretical framework to the daily clinical practice.

Challenges and Strategies for Inpatient Diabetes Management in Older Adults

Adults older than 65 years of age are the fastest growing segment of the U.S. population. Aging is also one of the most important risk factors for diabetes, and about one-third of all individuals with diabetes are in this age-group. Older people with diabetes are more likely to have comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and cognitive impairment, which lead to higher rates of hospital admissions compared with individuals without diabetes. Professional organizations have recommended patient-centric individualized glycemic reduction approaches, with an emphasis on potential harms of intensive glycemic control and overtreatment in older adults. Insulin therapy remains a mainstay of diabetes management in the inpatient setting regardless of patients' age; however, there is uncertainty about optimal glycemic targets during the hospital stay. Increasing evidence supports selective use of dipeptidyl peptidase-4 inhibitors, alone or in combination with low-dose basal insulin, in older noncritically ill patients with mild to moderate hyperglycemia. This article reviews the prevalence, diagnosis, and monitoring of, and the available treatment strategies for, diabetes among elderly patients in the inpatient setting.

Walking Speed is the Sole Determinant Criterion of Sarcopenia of Mild Cognitive Impairment in Japanese Elderly Patients with Type 2 Diabetes Mellitus

Diabetes mellitus is a risk factor for mild cognitive impairment (MCI) and dementia. However, how the clinical characteristics of MCI patients with type 2 diabetes mellitus are linked to sarcopenia and/or its criteria remain to be elucidated. Japanese patients with type 2 diabetes mellitus were categorized into the MCI group for MoCA-J (the Japanese version of the Montreal cognitive assessment) score <26, and into the non-MCI group for MoCA-J ≥26. Sarcopenia was defined by a low skeletal mass index along with low muscle strength (handgrip strength) or low physical performance (walking speed <1.0 m/s). Univariate and multivariate-adjusted odds ratio models were used to determine the independent contributors for MoCA-J <26. Among 438 participants, 221 (50.5%) and 217 (49.5%) comprised the non-MCI and MCI groups, respectively. In the MCI group, age (61 ± 12 vs. 71 ± 10 years, p < 0.01) and duration of diabetes mellitus (14 ± 9 vs. 17 ± 9 years, p < 0.01) were higher than those in the non-MCI group. Patients in the MCI group exhibited lower hand grip strength, walking speed, and skeletal mass index, but higher prevalence of sarcopenia. Only walking speed (rather than muscle loss or muscle weakness) was found to be an independent determinant of MCI after adjusting for multiple factors, such as age, gender, body mass index (BMI), duration of diabetes mellitus, hypertension, dyslipidemia, smoking, drinking, estimated glomerular filtration rate (eGFR), HbA1c, and history of coronary heart diseases and stroke. In subgroup analysis, a group consisting of male patients aged ≥65 years, with BMI <25, showed a significant OR for walking speed. This study showed that slow walking speed is a sole determinant criterion of sarcopenia of MCI in patients with type 2 diabetes mellitus. It was suggested that walking speed is an important factor in the prediction and prevention of MCI development in patients with diabetes mellitus.

Renal Complication and Glycemic Control in Korean Veterans with Type 2 Diabetes: A 10-Year Retrospective Cohort Study

OBJECTIVE

Tight glycemic control reduces the risk of diabetes complications, but it may increase the risk of hypoglycemia or mortality in elderly patients. This study is aimed at evaluating the incidence and progression of renal complications and its association with glycemic control in elderly patients with type 2 diabetes.

METHODS

This retrospective cohort study examined the data of 3099 patients with type 2 diabetes who were followed for at least 10 years at the Korean Veterans Hospital and for whom glycated hemoglobin (HbA1c) was measured in 2008 and 2017. Participants were divided into six groups according to their baseline or dynamic HbA1c levels. Extended Cox models were used to calculate adjusted hazard ratios for the development of chronic kidney disease (CKD) and end-stage renal disease (ESRD) associated with specific HbA1c ranges.

RESULTS

During the 10-year follow-up period, 30% of patients developed new CKD, 50% showed progression, and ESRD developed in 1.7%. The risk of CKD was associated with baseline HbA1c from the first year of the study and dynamic HbA1c throughout the study period. The adjusted hazard ratios for CKD were 1.98 and 2.32 for baseline and dynamic HbA1c, respectively, at the level of ≥69 mmol/mol. There was no increased risk for any complications in baseline and dynamic HbA1c below 58 mmol/mol.

CONCLUSIONS

A higher HbA1c ≥ 58 mmol/mol was associated with an increased risk of diabetes complications. A less stringent glycemic target of HbA1c could be used as the threshold of renal complications.

Suitable Use of Injectable Agents to Overcome Hypoglycemia Risk, Barriers, and Clinical Inertia in Community-Dwelling Older Adults with Type 2 Diabetes Mellitus

The management of type 2 diabetes mellitus in older adults requires a comprehensive understanding of the relationship between the disease (medical) and the functional, psychological/cognitive, and social geriatric domains, to individualize both glycemic targets and therapeutic approaches. Prevention of hypoglycemia is a major priority that should be addressed as soon as its presence or risk is detected, adjusting the target and therapeutics accordingly. Nonetheless, treatment intensification should not be neglected when applicable, consistent with recommendations from organizations such as the American Geriatrics Society and the American Diabetes Association, to reduce not only long-term macrovascular and microvascular complications (individualization), but also short-term complications from hyperglycemia (polyuria, volume depletion, urinary incontinence). Such complications can negatively impact the physical and cognitive function of older adults, worsen their quality of life, and additionally affect their families and society. We emphasize individualization, utilizing the multiple classes of antihyperglycemic agents available. Metformin remains as first-line therapy, and additional agents offer advantages and disadvantages that ought to be considered when developing a patient-centric plan of care. For selected cases, injectable therapies such as long-acting basal insulin analogs and glucagon-like peptide-1 receptor agonists can offer advantages to counter hypoglycemia risk, patient-related barriers, and clinical inertia. Furthermore, some injectable agents could potentially simplify regimens while providing safe and effective glycemic control. In this review, we discuss the use of injectable therapies for selected community-dwelling older adults, barriers to transition to injectable therapy, and measures aimed at removing these barriers and assisting physicians and their teams to transition older patients to injectable therapies when appropriate.

Relationship between glycated hemoglobin level and duration of hypoglycemia in type 2 diabetes patients treated with sulfonylureas: A multicenter cross-sectional study

AIMS/INTRODUCTION

Sulfonylurea-related hypoglycemia increases the risk of cardiovascular sequela, such as cardiac arrhythmia. This study aimed to clarify the relationship between the level of glycated hemoglobin (HbA1c ) and the duration of hypoglycemia in type 2 diabetes patients treated with sulfonylureas.

MATERIALS AND METHODS

Glucose levels in the enrolled patients (n = 300) were investigated with a professional continuous glucose monitoring device in the outpatient setting at six diabetes centers in Japan.

RESULTS

A total of 269 participants completed the study. The duration of hypoglycemia with glucose values of <54 mg/dL was significantly longer in patients with an HbA1c level of ≤6.4% than in those with an HbA1c level of ≥8.0%, and that of hypoglycemia with glucose values of <70 mg/dL was significantly longer in patients with an HbA1c level of ≤6.4%, 6.5-6.9% or 7.0-7.4% than in those with an HbA1c level of ≥8.0%. Patients with an HbA1c level of ≤6.4% were exposed to glucose values of <70 mg/dL for >10% of the time in daily life (6.8 ± 5.6 min/h). The duration of hypoglycemia with glucose values of <70 mg/dL was longer at night than during the daytime, and the nadir of glucose values occurred between 03.00 and 05.00 hours irrespective of HbA1c level. The duration of hypoglycemia was associated with the duration of diabetes and sulfonylurea dose.

CONCLUSIONS

The duration of hypoglycemia was inversely correlated with HbA1c level and was longer during the night-time than daytime in type 2 diabetes patients treated with sulfonylureas.

Mortality Implications of Prediabetes and Diabetes in Older Adults

OBJECTIVE

Diabetes in older age is heterogeneous, and the treatment approach varies by patient characteristics. We characterized the short-term all-cause and cardiovascular mortality risk associated with hyperglycemia in older age.

RESEARCH DESIGN AND METHODS

We included 5,791 older adults in the Atherosclerosis Risk in Communities Study who attended visit 5 (2011-2013; ages 66-90 years). We compared prediabetes (HbA1c 5.7% to <6.5%), newly diagnosed diabetes (HbA1c ≥6.5%, prior diagnosis <1 year, or taking antihyperglycemic medications <1 year), short-duration diabetes (duration ≥1 year but <10 years [median]), and long-standing diabetes (duration ≥10 years). Outcomes were all-cause and cardiovascular mortality (median follow-up of 5.6 years).

RESULTS

Participants were 58% female, and 24% had prevalent cardiovascular disease. All-cause mortality rates, per 1,000 person-years, were 21.2 (95% CI 18.7, 24.1) among those without diabetes, 23.7 (95% CI 20.8, 27.1) for those with prediabetes, 33.8 (95% CI 25.2, 45.5) among those with recently diagnosed diabetes, 29.6 (95% CI 25.0, 35.1) for those with diabetes of short duration, and 48.6 (95% CI 42.4, 55.7) for those with long-standing diabetes. Cardiovascular mortality rates, per 1,000 person-years, were 5.8 (95% CI 4.6, 7.4) among those without diabetes, 6.6 (95% CI 5.2, 8.5) for those with prediabetes, 11.5 (95% CI 7.0, 19.1) among those with recently diagnosed diabetes, 8.2 (95% CI 5.9, 11.3) for those with diabetes of short duration, and 17.3 (95% CI 13.8, 21.7) for those with long-standing diabetes. After adjustment for other cardiovascular risk factors, prediabetes and newly diagnosed diabetes were not significantly associated with a higher risk of all-cause mortality (hazard ratio [HR] 1.03 [95% CI 0.85, 1.23] and HR 1.31 [95% CI 0.94, 1.82], respectively) or cardiovascular mortality (HR 1.00 [95% CI 0.70, 1.43] and HR 1.35 [95% CI 0.74, 2.49], respectively). Excess mortality risk was primarily concentrated among those with long-standing diabetes (all-cause: HR 1.71 [95% CI 1.40, 2.10]; cardiovascular: HR 1.72 [95% CI 1.18, 2.51]).

CONCLUSIONS

In older adults, long-standing diabetes has a substantial and independent effect on short-term mortality. Older individuals with prediabetes remained at low mortality risk over a median 5.6 years of follow-up.

Low alanine aminotransferase levels predict low muscle strength in older patients with diabetes: A nationwide cross-sectional study in Korea

AIM

Low alanine aminotransferase (ALT) level is associated with frailty in the older adult population. We investigated the usefulness of ALT in predicting low muscle strength among older patients with diabetes.

METHODS

We included 550 men aged ≥50 years and 525 postmenopausal women. All participants had diabetes, and data were based on the 2014-2016 Korea National Health and Nutrition Examination Survey. Participants with ALT levels confounded by hepatic causes or who had a cerebrovascular accident were excluded. The accompanying metabolic disorders and the associated parameters were evaluated. Low muscle strength was defined as handgrip strength below the Korean-specific cut-off value.

RESULTS

In men and women, when ALT level was divided into quartiles (Q1-Q4), a positive correlation between ALT and body mass index, triglycerides, fasting plasma glucose, glycated hemoglobin levels and handgrip strength was observed, whereas a negative correlation was observed with age and duration of diabetes (P < 0.05, all). After adjusting for age, sex, protein intake, aerobic exercise, body mass index, duration of diabetes, glycated hemoglobin and triglycerides, the lower ALT quartiles ([Q1 and Q2) showed a higher risk for low muscle strength compared with Q4 (OR 2.123 and 2.437; P = 0.060 and 0.029). The cut-off ALT level for low muscle strength was 18.5 IU/L.

CONCLUSION

Older patients with diabetes with ALT levels below low-to-normal should not be considered metabolically healthy. Clinicians should pay special attention to the risk of low muscle strength in individuals with ALT levels of ≤18.5 IU/L, independent of any associated metabolic disorders. Geriatr Gerontol Int 2020; 20: 271-276.

Prevalência de fragilidade e fatores associados em idosos pós-acidente vascular cerebral

Resumo Objetivo avaliar a prevalência da fragilidade e fatores associados em idosos acometidos por acidente vascular cerebral (AVC). Método estudo transversal, com pacientes de idade igual ou maior que 60 anos, assistidos em ambulatório de neurologia. A coleta de dados foi realizada por questionário contendo dados sociodemográficos, clínicos, hábitos de vida e assistência na área de reabilitação e pelos instrumentos Mini Exame do Estado Mental e Escala de Fragilidade de Edmonton. Resultados a população do estudo foi composta por 69 pessoas idosas, com média de idade de 72 (±7,4) anos. Entre os frágeis estavam os indivíduos mais longevos (90,9%), do sexo feminino (92,3%), com estado civil que representasse ter tido companheiro em algum momento da vida (separado, divorciado ou viúvo) (94,4%), que não moravam sozinhos (80,3%), sem nenhuma escolaridade (80,6%) e renda (100%), que se declararam da cor negra (100%) e de religião espírita (100%). A maioria não apresentou comorbidades ou hábitos de vida deletérios, a exceção da hipertensão arterial sistêmica. Houve ainda, baixa assistência na área de reabilitação. A avaliação pelo MEEM indicou estado mental alterado para 83,7% dos idosos frágeis. Foram encontradas associações significativas entre a fragilidade e o estado civil (p=0,042), com a presença da diabetes mellitus (p=0,002), e ausência de infarto agudo do miocárdio (p=0,030). Conclusão Sugere-se a realização de estudos que possam acompanhar esse tipo de população acometida pelo AVC, desde a hospitalização até a alta da reabilitação, com vistas a esclarecer o processo de declínio funcional e cognitivo e sua relação com a fragilidade.

Preparation, Reliability, and Validity of a Japanese Version of the "Satisfaction of Treatment among Caregivers of Dependent Type 2 Diabetic Patients" Questionnaire

The aim of this study was to prepare a Japanese version of the "Satisfaction of Treatment among Caregivers of Dependent Type 2 Diabetic Patients" (STCD₂-J) questionnaire, which is used to assess the satisfaction of family caregivers with respect to the treatment for elderly patients with type 2 diabetes mellitus who require support. In addition, the reliability and validity of the STCD₂-J questionnaire were analyzed. A Japanese version of the original STCD₂ questionnaire was prepared, revised, and back-translated; the back-translated version was sent to the authors of the original version for confirmation. Family caregivers of patients with type 2 diabetes mellitus aged ≥65 years who regularly underwent medical examinations at the diabetes mellitus outpatient clinic of Ise Red Cross Hospital were included. Cronbach's α coefficient was calculated to assess internal consistency. Exploratory factor analyses were performed to assess construct validity, and Pearson's correlation coefficients between STCD₂-J score and HbA1c as well as the degree of satisfaction with patients' blood glucose levels, depression, and negative self-assessment of nursing care were calculated to assess criterion-related validity. This study included 208 individuals (55 males and 153 females). Cronbach's α coefficient was 0.88. Factor analyses showed a single-factor structure both with and without rotation. The STCD₂-J scores were significantly inversely correlated with HbA1c (r = -0.27, P < 0.001). Significant correlations were observed between the STCD₂-J scores and degree of satisfaction with patients' blood glucose levels (r = 0.43, P < 0.001), depression (r = -0.20, P = 0.003), and negative self-assessment of nursing care (r = -0.19, P = 0.004). The reliability and validity of the STCD₂-J questionnaire were confirmed. The STCD₂-J questionnaire can be used in Japan as a tool to assess the satisfaction of family caregivers with the treatment of elderly patients with type 2 diabetes mellitus requiring support.

Prevalence of type 2 diabetes and their complications among home health care patients at Al-Kharj military industries corporation hospital

INTRODUCTION

The diabetes mellitus type 2 is a result of hyperglycemia due to insulin resistance caused by insufficient secretion of insulin from the beta cells of pancreas. The detection and controlling of diabetes mellitus type 2 (DMT2) at primary health-care centers in Saudi Arabia is well justified and widely practiced. The knowledge and awareness of DMT2 patients should be increased through the determination of its prevalence which may decrease the rates of comorbidities.

METHODS

A questionnaire of 159 patients registered at Home Care Center at Family and Community Medicine Department, Al-Kharj Military Industries Corporation Hospital, Saudi Arabia was used. Hemoglobin A1C (HbA1C) percentage and blood pressure were measured for all participants. Statistical analysis was performed for all data.

RESULTS

A total of 36.5% of cases were males and 63.5% were females with a mean age of 77.6 years. 94.3% of participants had DMT2 where 3.8% had type 1. 74.2% of cases experienced only one to two complications other than diabetes where 20.8% had more than three diseases. 47.2% of cases had HbA1C% <7.5% where 29 cases had HbA1C% ranged from 7.5% to 8% and about 32.8% of patients had poor glycemic control with HbA1C >8%. 81.1% of cases had hypertension, while 25.8% suffered from Stroke complication, 8.8% of patients had a congestive cardiac failure, 7.5% had ischemic heart disease, and 6.3% suffered from chronic kidney disease. The treatment goals, HbA1C 7.5--8%, have been achieved for about 64% of DMT2 patients where 51 patients still had uncontrolled DMT2 with HbA1C >8%.

CONCLUSION

Despite the majority of cases had good glycemic control, more attention should be paid to those over 65 years as they commonly had more morbidities that definitely affect their treatment regimes. Patients should be involved in different home health care programs to increase their awareness and knowledge of the possible risk factors and diabetes comorbidities.

[Individualising antihypertensive therapy in patients with diabetes. A guideline by the Austrian Diabetes Association (Update 2019)]

Hypertension is one of the most important comorbidities of diabetes, contributing significantly to death and leads to macrovascular and microvascular complications. When assessing the medical priorities for patients with diabetes, treating hypertension should be a primary consideration. In the present review practical approaches to hypertension in diabetes, including individualized targets for preventing specific complications are discussed according to current studies and guidelines. According to recent studies, blood pressure values of about 130/80 mm Hg are associated with the best outcome. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers are the most effective drugs for treating hypertension in diabetes. Calcium antagonists or diuretics are acceptable as second-line agents. Once the target is achieved, antihypertensive drugs should be continued. Newer antidiabetic medications such as SGLT-2-inhibitors or GLP1-receptor agonists have also antihypertensive effects.

Polypharmacy in Type 2 Diabetes Mellitus: Insights from an Internal Medicine Department

BACKGROUND AND OBJECTIVES

Polypharmacy heavily impacts the quality of life of patients worldwide. It is a necessary evil in many disorders, and especially in type 2 diabetes mellitus, as patients require treatment both for this condition and its related or unrelated comorbidities. Thus, we aimed to evaluate the use of polypharmacy in type 2 diabetes mellitus vs. non-diabetes patients.

MATERIALS AND METHODS

A cross-sectional retrospective observational study was conducted. We collected the medical records of patients hospitalized in the Internal Medicine Clinic of the Clinical Emergency Hospital of Bucharest, Romania, for a period of two months (01/01/2018-28/02/2018). Patients diagnosed with type 2 diabetes mellitus were included in the study group, whereas patients who were not diabetic were used as controls.

RESULTS

The study group consisted of 63 patients with type 2 diabetes mellitus (mean age 69.19 ± 9.67 years, range 46-89 years; 52.38% males). The control group included 63 non-diabetes patients (mean age 67.05 ± 14.40 years, range 42-93 years, 39.68% males). Diabetic patients had more comorbidities (10.35 ± 3.09 vs. 7.48 ± 3.59, p = 0.0001) and received more drugs (7.81 ± 2.23 vs. 5.33 ± 2.63, p = 0.0001) vs. non-diabetic counterparts. The mean number of drug-drug and food-drug interactions was higher in type 2 diabetes mellitus patients vs. controls: 8.86 ± 5.76 vs. 4.98 ± 5.04, p = 0.0003 (minor: 1.22 ± 1.42 vs. 1.27 ± 1.89; moderate: 7.08 ± 4.08 vs. 3.54 ± 3.77; major: 0.56 ± 0.74 vs. 0.37 ± 0.77) and 2.63 ± 1.08 vs. 2.19 ± 1.42 (p = 0.0457), respectively.

CONCLUSIONS

Polypharmacy should be an area of serious concern also in type 2 diabetes mellitus, especially in the elderly. In our study, type 2 diabetes mellitus patients received more drugs than their non-diabetes counterparts and were exposed to more drug-drug and food-drug interactions.

Racial and Ethnic Disparities in the Burden and Cost of Diabetes for US Medicare Beneficiaries

Purpose: To examine the burden and cost of diabetes among fee-for-service Medicare beneficiaries. Methods: Medicare 5% File data for type 1 diabetes (T1D) and type 2 diabetes (T2D) consisting of 1,397,933 enrollees in fee-for-service without Medicare Advantage during the period 2012-2013 were analyzed by race and ethnicity. Results: Although non-Hispanic whites (nHWs) comprised most of this population (86%), prevalence of T1D and T2D was higher for Hispanics than nHWs (3.4% vs. 1.8%, p=0.0006, for T1D and 33.4% vs. 21.9%, p<0.0001, for T2D). Hispanics also had more acute hospital admissions (p=0.0235 for T1D and p=0.0009 for T2D) and longer lengths of stay (7.5 vs. 6.9 days for T1D, p=0.0105, and 6.7 vs. 6.2 days for T2D, p<0.0001) compared with nHWs. Allowed and paid costs per member per month adjusted for confounding were higher for Hispanics than nHWs for T2D (both p<0.0001) and lower for those with T1D (both p<0.0001). Mean number of chronic diseases in patients with diabetes was higher in Hispanics than nHWs (both T1D and T2D, p<0.0000). For T2D, Hispanics were more likely to have glycated hemoglobin (HbA_1c) and lipid testing as well as nephropathy screening (all p<0.0001). Hispanics with T1D were also more likely to have HbA_1c and lipid tests (p=0.0014 and p=0.0011, respectively); retinopathy and nephropathy screening rates did not differ significantly from rates among nHWs. Conclusion: Diabetes disproportionately impacts US seniors, with Hispanics almost twice as likely as nHWs to be diagnosed. Racial and ethnic disparities exist in the burden and cost of diabetes care for Medicare recipients.

Evidence-based diabetes care for older people with Type 2 diabetes: a critical review

In our ageing society diabetes imposes a significant burden in terms of the numbers of people with the condition, diabetes-related complications including disability, and health and social care expenditure. Older people with diabetes can represent some of the more complex and difficult challenges facing the clinician working in different settings, and the recognition that we have only a relatively small (but increasing) evidence base to guide us in diabetes management is a limitation of our current approaches. Nevertheless, in this review we attempt to explore what evidence there is to guide us in a comprehensive scheme of treatment for older adults, often in a high-risk clinical state, in terms of glucose lowering, blood pressure and lipid management, frailty care and lifestyle interventions. We strive towards individualized care and make a call for action for more high-quality research using different trial designs.

Diabetes and frailty

PURPOSE OF REVIEW

Disability and its preceding condition, frailty, are outstanding issues for achieving healthy aging. Diabetes is a very prevalent chronic disease among older patients that favours frailty status. This review will analyse the relationship between diabetes and frailty in the elderly and summarize the current strategies to improve physical function in diabetic older patients.

RECENT FINDINGS

We have analyzed the current knowledge providing insight on the relationship between frailty and diabetes in older people. Epidemiological evidences and potential mechanisms connecting diabetes with frailty in the aging process have been examined. Finally, the strategies to reduce frailty in aged population with diabetes were discussed.

SUMMARY

Current evidence reveals the high prevalence of diabetes in frail older patients, producing an additional impairment of physical performance in this population. Insulin resistance seems to contribute to this clinical manifestation which is related to the impact of diabetes on skeletal muscle function, on vascular function, and on the hormonal milieu. Exercise, nutritional and educational interventions, and less strict glycaemic control appear as the most effective strategies to reduce frailty in diabetic older people.