Geriatric conditions develop in middle-aged adults with diabetes

When Functional Impairment Develops Early: Perspectives from Middle-Aged Adults

BACKGROUND

Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age.

OBJECTIVE

To examine the experiences and needs of adults who developed functional impairment in middle age.

DESIGN

Qualitative study using semi-structured interviews.

PARTICIPANTS

Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco.

APPROACH

Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis.

KEY RESULTS

Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear.

CONCLUSIONS

Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BACKGROUND

Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID.

METHODS

We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization.

RESULTS

Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder.

DISCUSSION

Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Associations of Age at Diagnosis and Duration of Diabetes With Morbidity and Mortality Among Older Adults

Importance

Older adults vary widely in age at diagnosis and duration of type 2 diabetes, but treatment often ignores this heterogeneity.

Objectives

To investigate the associations of diabetes vs no diabetes, age at diagnosis, and diabetes duration with negative health outcomes in people 50 years and older.

Design, Setting, and Participants

This cohort study included participants in the 1995 through 2018 waves of the Health and Retirement Study (HRS), a population-based, biennial longitudinal health interview survey of older adults in the US. The study sample included adults 50 years or older (n = 36 060) without diabetes at entry. Data were analyzed from June 1, 2021, to July 31, 2022.

Exposures

The presence of diabetes, specifically the age at diabetes diagnosis, was the main exposure of the study. Age at diagnosis was defined as the age when the respondent first reported diabetes. Adults who developed diabetes were classified into 3 age-at-diagnosis groups: 50 to 59 years, 60 to 69 years, and 70 years and older.

Main Outcomes and Measures

For each diabetes age-at-diagnosis group, a propensity score-matched control group of respondents who never developed diabetes was constructed. The association of diabetes with the incidence of key outcomes-including heart disease, stroke, disability, cognitive impairment, and all-cause mortality-was estimated and the association of diabetes vs no diabetes among the age-at-diagnosis case and matched control groups was compared.

Results

A total of 7739 HRS respondents developed diabetes and were included in the analysis (4267 women [55.1%]; mean [SD] age at diagnosis, 67.4 [9.9] years). The age-at-diagnosis groups included 1866 respondents at 50 to 59 years, 2834 at 60 to 69 years, and 3039 at 70 years or older; 28 321 HRS respondents never developed diabetes. Age at diagnosis of 50 to 59 years was significantly associated with incident heart disease (hazard ratio [HR], 1.66 [95% CI, 1.40-1.96]), stroke (HR, 1.64 [95% CI, 1.30-2.07]), disability (HR, 2.08 [95% CI, 1.59-2.72]), cognitive impairment (HR, 1.30 [95% CI, 1.05-1.61]), and mortality (HR, 1.49 [95% CI, 1.29-1.71]) compared with matched controls, even when accounting for diabetes duration. These associations significantly decreased with advancing age at diagnosis. Respondents with diabetes diagnosed at 70 years or older only showed a significant association with the outcome of elevated mortality (HR, 1.08 [95% CI, 1.01-1.17]).

Conclusions and Relevance

The findings of this cohort study suggest that age at diabetes diagnosis was differentially associated with outcomes and that younger age groups were at elevated risk of heart disease, stroke, disability, cognitive impairment, and all-cause mortality. These findings reinforce the clinical heterogeneity of diabetes and highlight the importance of improving diabetes management in adults with earlier diagnosis.

Skeletal muscle as a treatment target for older adults with diabetes mellitus: The importance of a multimodal intervention based on functional category

Although the lifespan of people with diabetes has increased in many countries, the age-related increase in comorbidities (sarcopenia, frailty and disabilities) and diabetic complications has become a major issue. Diabetes accelerates the aging of skeletal muscles and blood vessels through mechanisms, such as increased oxidative stress, chronic inflammation, insulin resistance, mitochondrial dysfunction, genetic polymorphism (fat mass and obesity-associated genes) and accumulation of advanced glycation end-products. Diabetes is associated with early onset, and progression of muscle weakness and sarcopenia, thus resulting in diminished daily life function. The type and duration of diabetes, insulin section/resistance, hyperglycemia, diabetic neuropathy, malnutrition and low physical activity might affect muscular loss and weakness. To prevent the decline in daily activities in older adults with diabetes, resistance training or multicomponent exercise should be recommended. To maintain muscle function, optimal energy and sufficient protein intake are necessary. Although no specific drug enhances muscle mass and function, antidiabetic drugs that increase insulin sensitivity or secretion could be candidates for improvement of sarcopenia. The goals of glycemic control for older patients are determined based on three functional categories through an assessment of cognitive function and activities of daily living, and the presence or absence of medications that pose a hypoglycemic risk. As these functional categories are associated with muscle weakness, frailty and mortality risk, providing multimodal interventions (exercise, nutrition, social network or support and optimal medical treatment) is important, starting at the category II stage for maintenance or improvement in daily life functions. Geriatr Gerontol Int 2022; ••: ••-••.

Recruitment of Older Veterans with Diabetes Risk for Alzheimer's Disease for a Randomized Clinical Trial of Computerized Cognitive Training

BACKGROUND

Type 2 diabetes mellitus (T2DM) is prevalent in the general United States population, and in the veteran population. T2DM has consistently been linked to increased risk for cognitive impairment, dementia, and Alzheimer's disease. Computerized cognitive training (CCT) is practical and inexpensive cognitive interventions that is an alternative to medication.

OBJECTIVE

To report the recruitment methods and challenges to date in an ongoing two-site randomized controlled trial (RCT) of CCT on cognitive function and T2DM management in an older non-demented veteran population.

METHODS

Veterans are recruited primarily by targeted mailings or by direct contact at clinics and presentations.

RESULTS

From 1,459 original contacts, 437 expressed initial interest, 111 provided informed consent, and 97 completed baseline assessments. Participants from the two VA Medical Centers differed in demographics and baseline characteristics. Comparing recruitment methods, the proportion of individuals contacted who were ultimately consented was significantly less from mailings (5%) than other sources (20%), primarily face- to-face clinic visits (χ2 (1) = 38.331, p < 0.001).

CONCLUSIONS

Mailings are cost-effective, but direct contact improved recruitment. Not using or lacking access to computers and ineligibility were major reasons for non-participation. Within-site comparisons of demographically diverse sites can address confounding of demographic and other site differences.

Factors influencing safe glucose-lowering in older adults with type 2 diabetes: A PeRsOn-centred ApproaCh To IndiVidualisEd (PROACTIVE) Glycemic Goals for older people: A position statement of Primary Care Diabetes Europe

Diabetes in later life is associated with a range of factors increasing the complexity of glycaemic management. This position statement, developed from an extensive literature review of the subject area, represents a consensus opinion of primary care clinicians and diabetes specialists. It highlights many challenges facing older people living with type 2 diabetes and aims to support primary care clinicians in advocating a comprehensive, holistic approach. It emphasises the importance of the wishes of the individual and their carers when determining glycaemic goals, as well as the need to balance intended benefits of treatment against the risk of adverse treatment effects. Its ultimate aim is to promote consistent high-quality care for older people with diabetes.

Frailty and geriatric conditions in older patients with idiopathic pulmonary fibrosis

BACKGROUND

Functional status, an important predictor of health outcomes in older patients, has not been studied in an IPF population. This study aimed to determine the prevalence of frailty and geriatric conditions in older patients with IPF.

METHODS

IPF patients age ≥65 years were identified prospectively at the University of Michigan. Frailty was assessed using the Fried frailty phenotype. Questionnaires addressing functional status, geriatric conditions and symptoms were administered. Quantitative measurement of pectoralis muscle area was performed. Patient variables were compared among different frailty groups.

RESULTS

Of the 50 participants, 48% were found to be frail and 40% had ≥2 geriatric conditions. Frailty was associated with increased age, lower lung function, shorter 6-min walk distance, higher symptom scores and a greater number of comorbidities, geriatric conditions and functional limitations (p < 0.05). Pectoralis muscle area was nearly significant (p = 0.08). Self-reported fatigue score (odds ratio [OR] = 2.13, confidence interval [CI] 95% 1.23-3.70, p = 0.0068) and diffusion capacity (OR = 0.54 CI 95% 0.35-0.85, p = 0.0071) were independent predictors of frailty.

CONCLUSIONS

Frailty and geriatric conditions are common in older patients with IPF. The presence of frailty was associated with objective (diffusion capacity) and subjective (self-reported fatigue score) data. Longitudinal evaluation is necessary to determine impact of frailty on disease-related outcomes in IPF.

Geriatric Syndromes in People Living with HIV Associated with Ageing and Increasing Comorbidities: Implications for Neurocognitive Complications of HIV Infection

Long-term survival of treated people living with HIV (PLWH) currently approaches that of the general population. The average age of PLWH is currently in the mid-50s in resource-rich countries and is predicted that over 40% of PLWH will be older than 60 within a decade. Similar trends have been confirmed in all communities of PLWH with access to antiretroviral therapies. However, the positive impact on survival has been challenged by several developments. Ageing PLWH have clinical features similar to the general population about 5-10 years older. In addition to the earlier occurrence of common age-related conditions common geriatric syndromes have also impacted this population prematurely. These are often difficult to evaluate and manage conditions usually of multifactorial aetiology. They include polypharmacy, frailty, impaired mobility and falls, sarcopenia, sensory impairment, and increasingly, non-dementing cognitive decline. Cognitive decline is of particular concern to PLWH and their care providers. In the general geriatric population cognitive impairment increases with age and occurs in all populations with a prevalence of over 25% in people over 80. Effective treatments are lacking and therefore minimizing risk factors plays an important role in maintaining healthspan. In the general population geriatric syndromes may increase the risk of cognitive decline. The corollary is that decreasing the risk of their development may limit cognitive impairment. Whether a similar status holds in PLWH is uncertain. This chapter will address the question of whether common geriatric syndromes in PLWH contribute to cognitive impairment. Common risk factors may provide clues to limit or delay cognitive decline.

Characteristics of Elderly Patients Initiating Sitagliptin or Non-DPP-4-Inhibitor Oral Antihyperglycemic Agents: Analysis of a Cross-Sectional US Claims Database

INTRODUCTION

Previous analyses concluded that patients initiating treatment with sitagliptin are older and have more comorbidities than patients initiating treatment with other oral antihyperglycemic agents (OAHAs). However, these studies focused on the general population or subjects ≤ 65 years of age. We sought to compare differences in baseline characteristics of elderly patients (≥ 65 years of age) with T2DM initiating sitagliptin vs. non-DPP-4 inhibitor (non-DPP-4i) OAHA in the MarketScan^® Medicare Supplemental Database.

METHODS

Relevant patients were identified in the MarketScan^® Medicare Supplemental Database and categorized according to the complexity of their antihyperglycemic treatment: initiating monotherapy, escalating to dual combination therapy, or escalating to triple combination therapy. Within each category, the comparison between patients initiating use of sitagliptin or non-DPP-4i OAHA was made within three age groups: 65-74, 75-84, and ≥ 85 years. Gender and comorbidity recorded within the 12 months prior to the index date (date of initiation/escalation of treatment) were assessed as baseline characteristics in each group. Between-treatment group differences in each covariate were compared using standardized differences.

RESULTS

Patients with T2DM who initiated treatment with sitagliptin tended to be older and were more likely to have a pre-treatment history of arrhythmia, congestive heart failure, peripheral vascular disease, renal failure, and stroke than those initiating non-DPP-4i OAHAs, with the most pronounced differences observed between patients initiating monotherapy in all three age groups. As treatment complexity advanced to dual combination therapy, the differences were attenuated and mostly observed in the 75-84 and ≥ 85 age groups. In patients aged 65-74 years initiating triple therapy, no differences were observed between groups.

CONCLUSION

Patients ≥ 65 years with T2DM initiating sitagliptin tend to be older and have more comorbidities than those prescribed other classes of OAHA. Appropriate adjustment is required to minimize the impact of potential confounding and channeling bias in any comparative analyses including users of sitagliptin.

FUNDING

Merck & Co., Inc., Kenilworth, NJ, USA.

Higher prevalence and earlier appearance of geriatric phenotypes in old adults with type 2 diabetes mellitus

AIMS

To compare the prevalence of cognitive dysfunction, depression, lower mobility performance, disability and falls in older community-dwelling individuals with type 2 diabetes mellitus (T2DM) and in controls of similar age.

METHODS

We conducted a cross-sectional study in primary health care settings in 3 semi-urban regions in Greece. Were assessed 403 community-dwelling older persons (age ≥65 years, median: 73), 198 with and 205 without diabetes. Common geriatric syndromes were studied using structured individual interviews and widely-used screening scales. An ensuing secondary analysis per age group was performed.

RESULTS

After adjusting for several confounding factors, the diabetes group presented a 2-fold greater odds of having abnormal scores in Mini Mental State Examination (95%CI: 1.2-3.4, p = 0.006), a 1.5-fold greater odds of abnormal performance in the Clock Drawing Test (95%CI: 1.0-2.4, p = 0.05) and a 2-fold greater odds of slower performance in Timed-Up-And-Go test (95%CI: 1.1-3.4, p = 0.022). In the analysis per age group, impaired cognitive and mobility performances were observed in individuals with diabetes of the younger subgroup (65-74 years), while in the older subgroup (≥75 years), those differences disappeared.

CONCLUSIONS

In a community-dwelling population aged ≥65 years, cognitive and physical fragilisation is more frequent and is observed at an earlier age in individuals with T2DM than in those without.

Major health impact of accelerated aging in young HIV-infected individuals on antiretroviral therapy

BACKGROUND

Aging among HIV-infected individuals on antiretroviral therapy (ART) is a significant clinical challenge; however, studies assessing multidimensional aspects of aging are lacking. We characterized 10 geriatric conditions encompassing multiple functional domains, its health impact and associated risk factors in HIV-infected and age-matched uninfected controls.

METHODS

HIV-infected individuals were recruited from the outpatient clinic in University Malaya Medical Centre, Malaysia and controls from the community. All participants were aged at least 25 years of age with no acute illness, and HIV-infected individuals were on stable ART. Geriatric conditions were assessed and the burden scored as a composite of geriatric conditions present in an individual (total score = 10). Multivariate regression analysis was performed to determine the risk factors and health impact associated with the burden of geriatric conditions.

RESULTS

We analyzed data from 336 HIV-infected individuals (total HIV+), of whom 172 were matched for age, sex, and ethnicity with 172 HIV-uninfected controls (matched subset). In the total HIV-positive cohort, median (interquartile range) age was 44 (38-51) years and CD4 T-cell count was 562 (398-737) cells/μl. The burden of geriatric conditions was significantly higher in the HIV-infected group compared with controls (P < 0.001). With an increasing geriatric condition burden, quality-of-life scores were 2.2-times poorer, healthcare use five times greater, and mortality risk scores four times higher in the HIV-infected group compared with matched controls. Both sociobehavioural and HIV-related clinical factors were independently associated with an increasing burden of geriatric condition in HIV.

CONCLUSIONS

A high burden of geriatric conditions with significant impact on health outcomes, including mortality risk scores are observed among HIV-infected individuals on ART in a resource-limited setting.

Multimorbidity: constellations of conditions across subgroups of midlife and older individuals, and related Medicare expenditures

INTRODUCTION

The Department of Health and Human Services' 2010 Strategic Framework on Multiple Chronic Conditions called for the identification of common constellations of conditions in older adults.

OBJECTIVES

To analyze patterns of conditions constituting multimorbidity (CCMM) and expenditures in a US representative sample of midlife and older adults (50-64 and ≥65 years of age, respectively).

DESIGN

A cross-sectional study of the 2010 Health and Retirement Study (HRS; n=17,912). The following measures were used: (1) count and combinations of CCMM, including (i) chronic conditions (hypertension, arthritis, heart disease, lung disease, stroke, diabetes, cancer, and psychiatric conditions), (ii) functional limitations (upper body limitations, lower body limitations, strength limitations, limitations in activities of daily living, and limitations in instrumental activities of daily living), and (iii) geriatric syndromes (cognitive impairment, depressive symptoms, incontinence, visual impairment, hearing impairment, severe pain, and dizziness); and (2) annualized 2011 Medicare expenditures for HRS participants who were Medicare fee-for-service beneficiaries (n=5,677). Medicaid beneficiaries were also identified based on their self-reported insurance status.

RESULTS

No large representations of participants within specific CCMM categories were observed; however, functional limitations and geriatric syndromes were prominently present with higher CCMM counts. Among fee-for-service Medicare beneficiaries aged 50-64 years, 26.7% of the participants presented with ≥10 CCMM, but incurred 48% of the expenditure. In those aged ≥65 years, these percentages were 16.9% and 34.4%, respectively.

CONCLUSION

Functional limitations and geriatric syndromes considerably add to the MM burden in midlife and older adults. This burden is much higher than previously reported.

Implementation of integrated geriatric care at a German hospital: a case study to understand when and why beneficial outcomes can be achieved

BACKGROUND

Many health systems have implemented integrated care as an alternative approach to health care delivery that is more appropriate for patients with complex, long-term needs. The objective of this article was to analyse the implementation of integrated care at a German geriatric hospital and explore whether the use of a "context-mechanisms-outcomes"-based model provides insights into when and why beneficial outcomes can be achieved.

METHODS

We conducted 15 semi-structured interviews with health professionals employed at the hospital. The data were qualitatively analysed using a "context-mechanisms-outcomes"-based model. Specifically, mechanisms were defined as the different components of the integrated care intervention and categorised according to Wagner's Chronic Care Model (CCM). Context was understood as the setting in which the mechanisms are brought into practice and described by the barriers and facilitators encountered in the implementation process. These were categorised according to the six levels of Grol and Wensing's Implementation Model (IM): innovation, individual professional, patient, social context, organisational context and economic and political context. Outcomes were defined as the effects triggered by mechanisms and context, and categorised according to the six dimensions of quality of care as defined by the World Health Organization, namely effectiveness, efficiency, accessibility, patient-centeredness, equity and safety.

RESULTS

The integrated care intervention consisted of three main components: a specific reimbursement system ("early complex geriatric rehabilitation"), multidisciplinary cooperation, and comprehensive geriatric assessments. The inflexibility of the reimbursement system regarding the obligatory number of treatment sessions contributed to over-, under- and misuse of services. Multidisciplinary cooperation was impeded by a high workload, which contributed to waste in workflows. The comprehensive geriatric assessments were complemented with information provided by family members, which contributed to decreased likelihood of adverse events.

CONCLUSIONS

We recommend an increased focus on trying to understand how intervention components interact with context factors and, combined, lead to positive and/or negative outcomes.

Preclinical models of overwhelming sepsis implicate the neural system that encodes contextual fear memory

Long-term sepsis survivors sustain cryptic brain injury that leads to cognitive impairment, emotional imbalance, and increased disability burden. Suitable animal models of sepsis, such as cecal ligation and puncture (CLP), have permitted the analysis of abnormal brain circuits that underlie post-septic behavioral phenotypes. For instance, we have previously shown that CLP-exposed mice exhibit impaired spatial memory together with depleted dendritic arbors and decreased spines in the apical dendrites of pyramidal neurons in the CA1 region of the hippocampus. Here we show that contextual fear conditioning, a form of associative memory for fear, is chronically disrupted in CLP mice when compared to SHAM-operated animals. We also find that the excitatory neurons in the basolateral nucleus of the amygdala (BLA) and the granule cells in the dentate gyrus (DG) display significantly fewer dendritic spines in the CLP group relative to the SHAM mice, although the dendritic arbors and gross morphology of the BLA and DG are comparable between the two groups. Moreover, the basal dendrites of CA1 pyramidal neurons are unaffected in the CLP mice. Taken together, our data indicate that the structural damage in the amygdalar-hippocampal network represents the neural substrate for impaired contextual fear memory in long-term sepsis survivors. Further, our data suggest that the brain injury caused by overwhelming sepsis alters the stability of the synaptic connections involved in associative fear. These results likely have implications for the emotional imbalance observed in human sepsis survivors.

Clustering of geriatric deficits emerges to be an essential feature of ageing - results of a cross-sectional study in Poland

The majority of old people suffer from various clinical conditions that affect health, functioning and quality of life. This research is a part of a cross-sectional, nationwide PolSenior Study that provides a comprehensive assessment of eight geriatric impairments and their co-occurrence in a representative sample (3471 participant aged 65-104 years, mean age 78.3 years) of the old adults living in the community in Poland. The participants were recruited randomly from all administrative regions of Poland by a three-stage, proportional, stratified-by-age group selection process. Eight geriatric conditions were assessed: falls, incontinences, cognitive impairment, mood disorders, vision and hearing impairments, malnutrition, and functional dependence. We showed that the most common deficits causing disability were vision and hearing impairments, and mood disorders, with more than two thirds of the participants presented at least one geriatric deficit. We showed that presence any of the analyzed conditions significantly increased the risk for co-occurrence of other examined weaknesses. The highest prevalence odds ratios were for functional dependence and, respectively: malnutrition (8.61, 95%CI:4.70-15.80), incontinences (8.0, 95%CI:5.93-10.70), and cognitive impairment (7.22; 95%CI:5.91-8.83). We concluded that the majority of the old people living in the community present various clinical conditions that prompt disability.

Assessment of geriatric syndromes and physical function in people living with HIV

As the number of older adults living with HIV continues to increase, understanding how to incorporate geriatric assessments within HIV care will be critical. Assessment of geriatric syndromes and physical function can be useful tools for HIV clinicians and researchers to help identify the most vulnerable older adults and to better understand the aging process in people living with HIV (PLWH). This review focuses on the assessment of falls, frailty, and physical function, first in the general population of older adults, and includes a specific focus on use of these assessments in older adults living with HIV.

Healthspan and longevity can be extended by suppression of growth hormone signaling

Average and maximal lifespan are important biological characteristics of every species, but can be modified by mutations and by a variety of genetic, dietary, environmental, and pharmacological interventions. Mutations or disruption of genes required for biosynthesis or action of growth hormone (GH) produce remarkable extension of longevity in laboratory mice. Importantly, the long-lived GH-related mutants exhibit many symptoms of delayed and/or slower aging, including preservation of physical and cognitive functions and resistance to stress and age-related disease. These characteristics could be collectively described as "healthy aging" or extension of the healthspan. Extension of both the healthspan and lifespan in GH-deficient and GH-resistant mice appears to be due to multiple interrelated mechanisms. Some of these mechanisms have been linked to healthy aging and genetic predisposition to extended longevity in humans. Enhanced insulin sensitivity combined with reduced insulin levels, reduced adipose tissue, central nervous system inflammation, and increased levels of adiponectin represent such mechanisms. Further progress in elucidation of mechanisms that link reduced GH action to delayed and healthy aging should identify targets for lifestyle and pharmacological interventions that could benefit individuals as well as society.

Frailty, Diabetes, and Mortality in Middle-Aged African Americans

BACKGROUND

Older adult frail diabetics have high mortality risk, but data are limited regarding frail late middle-aged diabetics, especially for African-Americans. The aim of this study is to examine the association of diabetes with health outcomes and frailty in the African American Health (AAH) study.

METHODS

AAH is a population-based longitudinal cohort study. Participants were African Americans (N=998) ages 49 to 65 years at baseline. Cross-sectional comparisons for diabetes included disability, function, physical performance, cytokines, and frailty. Frailty measures included the International Academy of Nutrition and Aging [FRAIL] frailty scale, Study of Osteoporotic Fractures [SOF] frailty scale, Cardiovascular Health Study [CHS] frailty scale, and Frailty Index [FI]). Longitudinal associations for diabetes included new ADLs ≥ 1 and mortality at 9-year follow-up.

RESULTS

Diabetics were more likely to be frail using any of the 4 frailty scales than were non-diabetics. Frail diabetics, compared to nonfrail diabetics, reported significantly increased falls in last 1 year, higher IADLs and higher LBFLs. They demonstrated worse performance on the SPPB, one-leg stand, and grip strength; and higher Tumor Necrosis Factor receptors (sTNFR1 and sTNFR2). Mortality and 1 or more new ADLs also were increased among frail compared to nonfrail diabetics when followed for 9 years.

CONCLUSIONS

Frailty in middle-aged African American persons with diabetes is associated with having more disability and functional limitations, worse physical performance, and higher cytokines (sTNFR1 and sTNFR2 only). Middle-aged African Americans with diabetes have an increased risk of mortality and frail diabetics have an even higher risk of death, compared to nonfrail diabetics.

Geriatric Syndromes in Older HIV-Infected Adults

BACKGROUND

Geriatric syndromes such as falls, frailty, and functional impairment are multifactorial conditions used to identify vulnerable older adults. Limited data exist on these conditions in older HIV-infected adults, and no studies have comprehensively examined these conditions.

METHODS

Geriatric syndromes including falls, urinary incontinence, functional impairment, frailty, sensory impairment, depression, and cognitive impairment were measured in a cross-sectional study of HIV-infected adults aged 50 years and older who had an undetectable viral load on antiretroviral therapy. We examined both HIV and non-HIV-related predictors of geriatric syndromes including sociodemographics, number of comorbidities and nonantiretroviral medications, and HIV-specific variables in multivariate analyses.

RESULTS

We studied 155 participants with a median age of 57 (interquartile range: 54-62) and 94% were men. Prefrailty (56%), difficulty with instrumental activities of daily living (46%), and cognitive impairment (47%) were the most frequent geriatric syndromes. Lower CD4 nadir incidence rate ratio [IRR: 1.16, 95% (confidence interval) CI: 1.06 to 1.26], non-white race (IRR: 1.38, 95% CI: 1.10 to 1.74), and increasing number of comorbidities (IRR: 1.09, 95% CI: 1.03 to 1.15) were associated with increased risk of having more geriatric syndromes.

CONCLUSIONS

Geriatric syndromes are common in older HIV-infected adults. Treatment of comorbidities and early initiation of antiretroviral therapy may help to prevent development of these age-related complications. Clinical care of older HIV-infected adults should consider incorporation of geriatric principles.

Menopause, obesity and inflammation: interactive risk factors for Alzheimer's disease

Alzheimer’s disease (AD) is a multifactorial neurodegenerative disorder, the development of which is regulated by several environmental and genetic risk factors. Two factors theorized to contribute to the initiation and/or progression of AD pathogenesis are age-related increases in inflammation and obesity. These factors may be particularly problematic in women. The onset of menopause in mid-life elevates the vulnerability of women to AD, an increased risk that is likely associated with the depletion of estrogens. Menopause is also linked with an abundance of additional changes, including increased central adiposity and inflammation. Here, we review the current literature to explore the interactions between obesity, inflammation, menopause and AD.

Importance of Geriatric Syndromes in Older Patients with Diabetes with de novo Insulin Treatment: The VEGAS Study

Aims

The VEGAS study was conducted to evaluate representative data of de novo insulin-treated older patients with type 2 diabetes in the outpatient setting in Germany.

Methods

In this prospective, multicenter, non-interventional observational study, a nationwide written survey was carried out among practitioners (02/2011–06/2011). Older patients, aged ≥70 years, starting de novo insulin therapy, were documented.

Results

Data from 4,858 patients from about 500 centers (mean age: 78.2 ± 5.4 years; mean glycosylated hemoglobin [HbA_1c]: 70 ± 14.2 mmol/mol [8.6 ± 1.3 %]) were collected. The mean target HbA_1c value was 55 ± 6.6 mmol/mol (7.2 ± 0.6 %). 91.1 % of geriatric patients were multi-morbid. 96.2 % showed at least one physical or psychological geriatric syndrome. Most of the patients were notably impaired according to their age. Conventional insulin therapy and basal-supported oral therapy were the most frequently planned treatment regimens (39.1 and 31.1 %). Important factors in the selection of the insulin treatment regimen were an efficient HbA_1c decrease (65.6 %), easy administration (55.7 %), and also a patient’s ability to self-administer insulin (38.5 %). De novo insulin treatment increased care requirements (22.7 %). 22.3 % of the relatives were scheduled to receive special training. Specific training programs for older patients with diabetes were planned in only 7.3 % of cases.

Conclusions

The data demonstrate the high prevalence of geriatric syndromes during de novo insulin treatment. Individual therapeutic goals and regimes are based on practicability, in particular, the receipt of autonomy and the care requirement. Diabetes education with adapted programs is currently under-represented. Important factors for the choice of an insulin treatment regimen were an efficient HbA_1c decrease, easy administration, and a patient’s ability for self-administration.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-015-0014-9) contains supplementary material, which is available to authorized users.

The association between diabetes and depression: a very disabling condition

Rates of depression are significantly increased in diabetic patients, and even more in the elderly. About 20-30% of patients with diabetes suffer from clinically relevant depressive disorders, 10% of which being affected by the major depression disorder. Moreover, people with depression seem to be more prone to develop an associated diabetes mellitus, and depression can worsen glycemic control in diabetes, with higher risk to develop complications and adverse outcomes, whereas improving depressive symptoms is generally associated with a better glycemic control. Thus, the coexistence of depression and diabetes has a negative impact on both lifestyle and quality of life, with a reduction of physical activity and an increase in the request for medical care and prescriptions, possibly increasing the healthcare costs and the susceptibility to further diseases. These negative aspects are particularly evident in the elderly, with further decrease in the mobility, worsening of disability, frailty, geriatric syndromes and increased mortality. Healthcare providers should be aware of the possible coexistence of depression and diabetes and of the related consequences, to better manage the patients affected by these two pathological conditions.

Poor lower extremity function was associated with pre-diabetes and diabetes in older chinese people

OBJECTIVE

To determine whether a relationship exists between performance-based physical assessments and pre-diabetes/diabetes in an older Chinese population.

METHODS

Our study population comprised 976 subjects (mean ± SD age: 67.6±6.0 years; 44.5% men) from the Hangu area of Tianjin, China. Diabetes was defined by self-reporting of a physician's diagnosis, or a fasting plasma glucose level ≥126 mg/dL; and pre-diabetes was defined as a fasting plasma glucose level ≥100 mg/dL and <126 mg/dL.

RESULTS

When all other variables were adjusted for, men needing longer to finish a Timed Up and Go Test and a decreased usual walking speed had higher odds of pre-diabetes (P for trend = 0.007 and 0.008, respectively) and diabetes (P for trend = 0.012 and 0.014, respectively). However, women needing longer to finish the test and a decreased usual walking speed had a higher odds of diabetes (P for trend = 0.020 and 0.034, respectively) but not of pre-diabetes. There was no apparent association between grip strength and pre-diabetes/diabetes in both sexes.

CONCLUSIONS

In this study, poor lower extremity function was associated with pre-diabetes/diabetes in older people.

Incident Diabetes and Mobility Limitations: Reducing Bias Through Risk-set Matching

BACKGROUND

Increased prevalence of diabetes in the U.S. population could contribute substantially to increases in disability at older ages. Previous studies have examined the association between prevalent diabetes and various impairments and disabilities. Methods considering incident, rather than prevalent, diabetes as the exposure of interest can reduce bias in estimates of these associations.

METHODS

Risk-set matching, a type of propensity score matching meant to handle time-varying exposures, was used to estimate the relationship between incident diabetes and mobility limitations among adults in the Health and Retirement Study. This approach ensures that covariates precede diabetes onset rather than follow it.

RESULTS

Individuals who were diagnosed with diabetes during the study period accumulated more subsequent mobility limitations than were accumulated by matched controls. Among observationally similar pairs of individuals, those who developed diabetes reported an average of 24.9% more mobility limitations at study exit than those who did not.

CONCLUSIONS

The magnitude of the relationship between diabetes and limitations estimated in this article is smaller than that presented in previous studies, but the method presented here is likely to provide a less-biased estimate of the association between diabetes and accumulation of mobility limitations.

Diabetes and cardiovascular disease in older adults: current status and future directions

The prevalence of diabetes increases with age, driven in part by an absolute increase in incidence among adults aged 65 years and older. Individuals with diabetes are at higher risk for cardiovascular disease, and age strongly predicts cardiovascular complications. Inflammation and oxidative stress appear to play some role in the mechanisms underlying aging, diabetes, cardiovascular disease, and other complications of diabetes. However, the mechanisms underlying the age-associated increase in risk for diabetes and diabetes-related cardiovascular disease remain poorly understood. Moreover, because of the heterogeneity of the older population, a lack of understanding of the biology of aging, and inadequate study of the effects of treatments on traditional complications and geriatric conditions associated with diabetes, no consensus exists on the optimal interventions for older diabetic adults. The Association of Specialty Professors, along with the National Institute on Aging, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Heart, Lung, and Blood Institute, and the American Diabetes Association, held a workshop, summarized in this Perspective, to discuss current knowledge regarding diabetes and cardiovascular disease in older adults, identify gaps, and propose questions to guide future research.

Optimizing health for complex adults in primary care: current challenges and a way forward

As the population ages, the quantity and complexity of comorbidities only increases in the primary care setting. Health systems strive to improve quality of care and enhance cost savings, but current administrative and payment systems do not easily support the implementation of existing evidence and best practices for multimorbid adults in most primary care offices. This perspectives piece sets forth a research agenda in the area of implementation science at the intersection of geriatrics and general internal medicine. We challenge academic medical centers, medical societies, journals, and funders to actively value and support investigation in this area as much as traditional research pathways.

Factors associated with geriatric syndromes in older homeless adults

Although older homeless adults have high rates of geriatric syndromes, risk factors for these syndromes are not known. We used multivariable regression models to estimate the association of subject characteristics with the total number of geriatric syndromes in 250 homeless adults aged 50 years and older. Geriatric syndromes included falls, cognitive impairment, frailty, major depression, sensory impairment, and urinary incontinence. A higher total number of geriatric syndromes was associated with having less than a high school education, medical comorbidities (diabetes and arthritis), alcohol and drug use problems, and difficulty performing one or more activities of daily living. Clinicians who care for older homeless patients with these characteristics should consider screening them for geriatric syndromes. Moreover, this study identifies potentially modifiable risk factors associated with the total number of geriatric syndromes in older homeless adults. This knowledge may provide targets for clinical interventions to improve the health of older homeless patients.

Physical function limitations among middle-aged and older adults with prediabetes: one exercise prescription may not fit all

OBJECTIVE

To describe the prevalence of physical function limitations among a nationally representative sample of adults with prediabetes.

RESEARCH DESIGN AND METHODS

We performed a cross-sectional analysis of 5,991 respondents≥53 years of age from the 2006 wave of the Health and Retirement Study. All respondents self-reported physical function limitations and comorbidities (chronic diseases and geriatric conditions). Respondents with prediabetes reported no diabetes and had a measured glycosylated hemoglobin (HbA1c) of 5.7-6.4%. Descriptive analyses and logistic regressions were used to compare respondents with prediabetes versus diabetes (diabetes history or HbA1c≥6.5%) or normoglycemia (no diabetes history and HbA1c<5.7%).

RESULTS

Twenty-eight percent of respondents≥53 years of age had prediabetes; 32% had mobility limitations (walking several blocks and/or climbing a flight of stairs); 56% had lower-extremity limitations (getting up from a chair and/or stooping, kneeling, or crouching); and 33% had upper-extremity limitations (pushing or pulling heavy objects and/or lifting>10 lb). Respondents with diabetes had the highest prevalence of comorbidities and physical function limitations, followed by those with prediabetes, and then normoglycemia (P<0.05). Compared with respondents with normoglycemia, respondents with prediabetes had a higher odds of having functional limitations that affected mobility (odds ratio [OR] 1.48), the lower extremities (OR 1.35), and the upper extremities (OR 1.37) (all P<0.01). The higher odds of having lower-extremity limitations remained after adjusting for age, sex, and body mass index (OR 1.21, P<0.05).

CONCLUSIONS

Comorbidities and physical function limitations are prevalent among middle-aged and older adults with prediabetes. Effective lifestyle interventions to prevent diabetes must accommodate physical function limitations.

Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors in patients with type 2 diabetes mellitus

Providing effective medical care for older patients with type 2 diabetes mellitus (T2D) that may contribute to their active aging has always been challenging. We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications in patients with T2D in Malaysia. This was a cross-sectional study using secondary data from the electronic diabetes registry database Adult Diabetes Control and Management (ADCM). A total of 303 centers participated and contributed a total of 70,889 patients from May 2008 to the end of 2009. Demographic data, details on diabetes, hypertension, dyslipidemia and their treatment modalities, various risk factors and complications were updated annually. Independent associated risk factors were identified using multivariate regression analyses. Fifty-nine percent were female. Malay comprised 61.9%, Chinese 19% and Indian 18%. There were more Chinese, men, longer duration of diabetes and subjects that were leaner or had lower BMI in the older age group. Patients aged ≥ 60 years achieved glycemic and lipid targets but not the desired blood pressure. After adjusting for duration of diabetes, gender, ethnicity, body mass index, disease control and treatment, a significantly higher proportion of patients ≥ 60 years suffered from reported diabetes-related complications. Age ≥ 60 years was an independent risk factor for diabetes-related complications despite good control of cardiovascular risk factors. Our findings caution against the currently recommended control of targets in older T2D patients with more longstanding diseases and complications.

Association of geriatric conditions and cardiovascular diseases with disability in older adults with diabetes: findings from a nationally representative survey

AIM

To examine how diabetes in combination with cardiovascular diseases (hypertension, heart disease and stroke) and geriatric conditions (cognitive impairment and depressive symptoms) affects the odds of disability in older adults.

METHODS

We analyzed data from a nationally representative sample of people aged 65 years and over (n=2727) participating in the 2005 National Health Interview Survey in Taiwan. A total of 473 participants had a history of self-reported physician diagnosed diabetes. Disability was defined as reporting limitations in one or more tasks of activities of daily living (ADL), instrumental activities of daily living (IADL) or general physical activities (GPA). The Mini-Mental State Examination was used to assess cognitive function. The Center for Epidemiologic Studies Depression Scale was used to assess depressive symptoms.

RESULTS

After adjustment for other factors, cardiovascular diseases and geriatric conditions independently contributed to the excess odds of disability among participants with diabetes. Participants who had diabetes combined with cardiovascular diseases and geriatric conditions had odds ratios for ADL, IADL and GPA disability of 18.02 (95% CI 5.13-63.34), 7.95 (95% CI 4.07-15.50) and 5.89 (95% CI 3.19-10.90), respectively.

CONCLUSION

Our results highlight the high prevalence of co-occurrence of cardiovascular diseases with geriatric conditions in people with diabetes. Furthermore, the combined presence of these diseases and conditions is strongly associated with an excess odds of disability. These findings highlight the critical importance of preventing cardiovascular disease morbidity, and improving depressed mood and cognitive function in order to reduce disability risk in older adults with diabetes.

Diabetes differentially affects depression and self-rated health by age in the U.S

OBJECTIVE

To determine whether the relationship between age and physical and mental health varies by diabetes status in older U.S. adults.

RESEARCH DESIGN AND METHODS

Using data from the National Social Life, Health, and Aging Project, a national sample of 3,005 adults aged 57-85 years, we tested the significance of the interaction between age and diabetes in association with health states.

RESULTS

Respondents with diabetes in the youngest age cohort had more medical conditions than those without diabetes, a difference that narrowed with age (P for interaction <0.01). The youngest cohort with diabetes had a higher rate of depression compared to those without diabetes (14 vs. 8%). Depression declined with age and did not differ by diabetes status in the oldest respondents (P = 0.01 for age-diabetes interaction).

CONCLUSIONS

Diabetes differentially affects self-rated overall health and depression by age, with convergence in the oldest age-group with and without diabetes.

Geriatric Syndromes and Depressed Mood in Lower-income Singaporeans with Diabetes: Implications for Diabetes Management and Health Promotion

Introduction: This study aims to determine the association of geriatric syndromes and depressed mood among respondents with diabetes in a lower income community; and their association with self-management, lifestyle behaviour, and healthcare utilisation. This paper focuses primarily on the 114 respondents with diabetes aged 50+ to inform policy formulation at the community level. Materials and Methods: A pilot community health assessment was conducted in 4 blocks of 1- and 2-room apartments in Toa Payoh district from July to November 2009. Using a standard questionnaire, interviewers conducted face-to-face interviews with household members on chronic diseases, geriatric syndromes and health-related behaviour. Data were analysed using SPSSv15. Results: A total of 795 respondents were assessed with a response rate of 61.8%. Of 515 (64.8%) aged 50+ analysed in this study, 22.1% reported having diabetes, of whom 31.6% reported being depressed. Respondents with diabetes who reported being depressed had a higher prevalence of geriatric syndromes compared with those non-depressed; i.e. functional decline (30.6% vs 5.1%, P <0.001); falls (33.3% vs 10.3%, P = 0.003); stumbling (30.6% vs 10.3%, P = 0.007); urinary incontinence (33.3% vs 5.1%, P <0.001), progressive forgetfulness (27.8% vs 6.4%, P = 0.002) and poor eyesight (22.2% vs 6.4%, P = 0.014). They were less likely to comply with medications (86.1% vs 97.3%, P = 0.026) and performed exercise (13.9% vs 53.8%, P <0.001). More had hospital admissions (13.9% vs 7.7%); and they had more outpatient visits per person (2.4 visits vs 0.9 visits, P = 0.03) at Specialist Outpatient Clinics. Conclusion: Geriatric syndromes were associated with the presence of depressed mood among persons with diabetes in the lower income group. As those with depressed mood had more unfavourable self-management and lifestyle behaviour, and utilise higher healthcare services, diabetes management must take these findings into consideration. Key words: Depressed mood, Diabetes mellitus, Geriatric syndromes, Low income

Spurious inferences about long-term outcomes: the case of severe sepsis and geriatric conditions

RATIONALE

Survivors of critical illness suffer significant limitations and disabilities.

OBJECTIVES

Ascertain whether severe sepsis is associated with increased risk of so-called geriatric conditions (injurious falls, low body mass index [BMI], incontinence, vision loss, hearing loss, and chronic pain) and whether this association is measured consistently across three different study designs.

METHODS

Patients with severe sepsis were identified in the Health and Retirement Study, a nationally representative cohort interviewed every 2 years, 1998 to 2006, and in linked Medicare claims. Three comparators were used to assess an association of severe sepsis with geriatric conditions in survivors: the prevalence in the United States population aged 65 years and older, survivors' own pre-sepsis levels assessed before hospitalization, or survivors' own pre-sepsis trajectory.

MEASUREMENTS AND MAIN RESULTS

Six hundred twenty-three severe sepsis hospitalizations were followed a median of 0.92 years. When compared with the 65 years and older population, surviving severe sepsis was associated with increased rates of low BMI, injurious falls, incontinence, and vision loss. Results were similar when comparing survivors to their own pre-sepsis levels. The association of low BMI and severe sepsis persisted when controlling for patients' pre-sepsis trajectories, but there was no association of severe sepsis with injurious falls, incontinence, vision loss, hearing loss, and chronic pain after such controls.

CONCLUSIONS

Geriatric conditions are common after severe sepsis. However, severe sepsis is associated with increased rates of only a subset of geriatric conditions, not all. In studying outcomes after acute illness, failing to measure and control for both preillness levels and trajectories may result in erroneous conclusions.