Diabetes-Multimorbidity Combinations and Disability Among Middle-aged and Older Adults

Association between multiple metals mixture and diabetic retinopathy in older adults with diabetes mellitus: a cross-sectional study in China

Previous studies have linked single metal with diabetic retinopathy (DR), but information about the combined effects of multiple metals mixture was scarce. Thus, we performed this cross-sectional study to investigate the single and joint associations between multiple metals mixture and DR risk among elderly diabetic population in China. A total of 1127 elderly adults (aged ≥ 60) with diabetes mellitus from a large-scale DR screening program in southern China included. Metals (beryllium, magnesium, chromium, manganese, iron, nickel, copper, arsenic, thallium and lead) in serum were quantified by inductively coupled plasma mass spectrometer. DR was diagnosed according to the consensus of the global DR project group. The relationships between metals and DR risks were estimated by logistic regression, Bayesian kernel machine regression (BKMR) and weighted quantile sum (WQS) regression. Of 1127 older adults with diabetes mellitus, there were 324 DR and 803 non-DR participants. Logistic regression models found serum magnesium and iron were negatively related to DR risks. Both BKMR model and WQS regression revealed that higher serum levels of multiple metals mixture were associated with lower risks of DR, with Be contributing the most to the overall effect. Additionally, in subgroup analyses, the interaction between beryllium and blood pressure on DR risk was also observed (Pinteraction = 0.008). Overall, these results provided new evidence of direct association between multiple metals mixture and DR risk among elderly diabetic population in China.

Association of pre-diabetes with the risks of adverse health outcomes and complex multimorbidity: evidence from population-based studies in the NIS and UK Biobank

Abstracts

Introduction

This study aimed to examine the risk of common diseases among people with pre-diabetes and explored the relationship between pre-diabetes and multimorbidity (in this case, two or more comorbid diseases).

Methods

An observational multicohort study using data from the UK Biobank database and the National Inpatient Sample (NIS) database (2016-2018) was conducted. We analysed 461 535 participants and 17 548 442 patients aged 18 years or older from both databases, of whom 14.0% and 0.7% were diagnosed with pre-diabetes, respectively. A total of 76 common diseases of various body systems were selected as adverse health outcomes for analysis.

Results

Among 64 523 individuals with pre-diabetes in the UK Biobank, the mean age was 60 years, 35 304 (54.7%) were female. There were 24 non-overlapping diseases associated with pre-diabetes with significant multiple test results in both databases, and most of them are circulatory system diseases. Compared with normoglycaemia, the confounder-adjusted HR in the UK Biobank for pre-diabetes was 1.46 (95% CI 1.43 to 1.49) for accompanying complex multimorbidity (ie, four or more pre-diabetes-related diseases), the corresponding confounder-adjusted OR in the NIS study was 10.03 (95% CI 9.66 to 10.40).

Conclusion

Pre-diabetes was associated with a significantly higher risk of multimorbidity. Pre-diabetes, thus, might represent an important target for multimorbidity prevention, and stronger emphasis on its management seems necessary to reduce the risk of the development of multiple comorbidities, especially before the onset of overt diabetes.

Classification of longitudinal estimated glomerular filtration rate trajectories in Canadian adults with type 1 diabetes

AIMS

Type 1 diabetes (T1D) increases the risk of chronic kidney disease (CKD) development. The aims of this study were to classify trajectories of estimated glomerular filtration rate (eGFR) in a cohort of Canadian adults with T1D, and to describe the risk factors associated with declining eGFR trajectories.

METHODS

In this retrospective cohort of adults with T1D, data was collected between 1996 and 2020. CKD was defined as eGFR <60 mL/min/1.73 m2. Latent class mixed models were used to categorize eGFR trajectories. Multinomial logistic regression was used to identify factors associated with declining eGFR trajectories.

RESULTS

In this study, 304 adults were analyzed, with baseline measurements at a median duration of T1D of 15.3 (5.4-24.2) years. Eight percent of the cohort developed CKD over a median duration of 24.3 (13.7-34.8) years. Four classes of longitudinal eGFR trajectories were identified, broadly categorized as steeply declining (SD1, SD2) and gradual declining (GD1, GD2). Female sex, poor glycemic control, elevated body mass index, and albuminuria were associated with a steeply declining trajectory.

CONCLUSION

In this cohort, four distinctive eGFR trajectories were identified, including a subtype with steeply declining eGFR. Given the complex nature of CKD progression, further prospective study of this model for identification of individuals at risk for CKD based on their trajectory of kidney function may support clinicians in their decision-making.

Management of older adults with diabetes mellitus: Perspective from geriatric medicine

Advances in diabetes medication and population aging are lengthening the lifespans of people with diabetes mellitus (DM). Older patients with diabetes mellitus often have multimorbidity and tend to have polypharmacy. In addition, diabetes mellitus is associated with frailty, functional decline, cognitive impairment, and geriatric syndrome. Although the numbers of patients with frailty, dementia, disability, and/or multimorbidity are increasing worldwide, the accumulated evidence on the safe and effective treatment of these populations remains insufficient. Older patients, especially those older than 75 years old, are often underrepresented in randomized controlled trials of various treatment effects, resulting in limited clinical evidence for this population. Therefore, a deeper understanding of the characteristics of older patients is essential to tailor management strategies to their needs. The clinical guidelines of several academic societies have begun to recognize the importance of relaxing glycemic control targets to prevent severe hypoglycemia and to maintain quality of life. However, glycemic control levels are thus far based on expert consensus rather than on robust clinical evidence. There is an urgent need for the personalized management of older adults with diabetes mellitus that considers their multimorbidity and function and strives to maintain a high quality of life through safe and effective medical treatment. Older adults with diabetes mellitus accompanied by frailty, functional decline, cognitive impairment, and multimorbidity require special management considerations and liaison with both carers and social resources.

Self-Reported Diabetes in Older Adults: A Comparison of Prevalence and Related Factors in the Mexican Health and Aging Study (2015, 2018, and 2021)

Aim: To estimate the prevalence and factors associated with diabetes among older adults and compare the prevalence rate of a three-round national survey of the Mexican Health and Aging Study (MHAS). Methods: A cross-sectional study was conducted with data obtained from MHAS 2015 (n = 8167), 2018 (n = 7854), and 2021 (n = 8060), which comprised a nationally representative sample of older adults in Mexico. The measures included sociodemographic characteristics and health. A binary logistic regression model was used to identify the association between independent variables and self-reported diabetes. Results: The prevalence of diabetes was 26.3%, 27.7%, and 28.1% in 2015, 2018, and 2021, respectively. This prevalence decreased with age and was higher for female, urban older adults, those with multimorbidity, a lower level of education, and without social security coverage for the three years. Age was associated with a lower possibility of presenting diabetes ([OR = 0.79[0.71-0.89]] and [OR = 0.41[0.33-0.52]] in groups aged 75-84 years and ≥85 years, respectively). Females continue to be more likely to present diabetes than males (OR = 1.39 [95% CI 1.25-1.55]). Older adults living in rural areas are 20% less likely to present diabetes than those living in urban areas (OR = 0.80 [95% CI 0.69-0.93]). Uninsured older adults (OR = 1.35 [95% CI 1.20-1.53]), those who wear glasses (OR = 1.23 [95% CI 1.16-1.30]), those with multimorbidity (OR = 1.13 [95% CI 1.01-1.27]), and those who currently drink alcohol (OR = 1.12 [95% CI 1.00-1.25]) were significantly more likely to have diabetes. Conclusion: An elevated prevalence of diabetes was found in older adults in Mexico, while not having access to social security was associated with a higher possibility of presenting diabetes and living in a rural area was associated with a lower possibility of presenting diabetes. Detection, prevention, and control programs should be implemented to reduce the incidence and severity of the disease in older adults and, thus, prevent its associated complications.

The association of cardiometabolic multimorbidity and fear of falling among older adults: Data from the national health and aging trends study

OBJECTIVES

Cardiometabolic diseases (CMDs) have been individually associated with fall-related outcomes, but their combined effect on fear of falling (FOF) has not been investigated. This study aims to examine the association between cardiometabolic multimorbidity and FOF in older adults.

METHODS

Data from the National Health and Aging Trends Study, 4,295 community-dwelling older adults ≥ 65 years were analyzed in this longitudinal study. CMDs were assessed at baseline, including heart disease, diabetes, stroke, and hypertension. FOF was evaluated by asking participants if they worried about falling in the past month. Data were analyzed using multi-adjusted logistic regression.

RESULTS

Cardiometabolic multimorbidity was associated with a higher risk of FOF. The combination of heart disease and diabetes showed the highest risk of FOF (OR = 3.47, 95 % CI: 1.63-7.40).

CONCLUSIONS

These findings underscore the need for targeted interventions to mitigate the combined impact of cardiometabolic multimorbidity on FOF in older adults.

Prevalence and co-prevalence of comorbidities among Chinese adult patients with type 2 diabetes mellitus: a cross-sectional, multicenter, retrospective, observational study based on 3B study database

Purpose

This study aimed to investigate the prevalence and co-prevalence of comorbidities among Chinese individuals with type 2 diabetes (T2DM).

Methods

Medical records were retrospectively retrieved from the 3B Study database, which provided a comprehensive assessment of comorbid conditions in Chinese adult outpatients with T2DM. Patient characteristics, laboratory measures, and comorbidities were summarized via descriptive analyses, overall and by subgroups of age (<65, 65-74, 75 years) and gender.

Results

Among 25,454 eligible patients, 53% were female, and the median age was 63 years. The median time of diabetes duration was 6.18 years. A total of 20,309 (79.8%) patients had at least one comorbid condition alongside T2DM. The prevalence of patients with one, two, three, and four or more comorbid conditions was 28.0%, 24.6%, 15.6%, and 11.6%, respectively. Comorbidity burden increased with longer T2DM duration. Older age groups also exhibited higher comorbidity burden. Females with T2DM had a higher overall percentage of comorbidities compared to males (42.7% vs. 37.1%). The most common comorbid conditions in T2DM patients were hypertension (HTN) in 59.9%, overweight/obesity in 58.3%, hyperlipidemia in 42.0%, retinopathy in 16.5%, neuropathy in 15.2%, cardiovascular disease (CVD) in 14.9%, and renal disease in 14.4%. The highest co-prevalence was observed for overweight/obesity and HTN (37.6%), followed by HTN and hyperlipidemia (29.8%), overweight/obesity and hyperlipidemia (27.3%), HTN and CVD (12.6%), HTN and retinopathy (12.1%), and HTN and renal disease (11.3%).

Conclusion

The majority of T2DM patients exhibit multiple comorbidities. Considering the presence of multimorbidity is crucial in clinical decision-making.

Systematic review registration

https://clinicaltrials.gov/, identifier NCT01128205.

The effect of multimorbidity patterns on physical and cognitive function in diabetes patients: a longitudinal cohort of middle-aged and older adults in China

Background

The prevalence of diabetes has increased rapidly, and comorbid chronic conditions are common among diabetes patients. However, little is known about the pattern of multimorbidity in diabetes patients and the effect on physical and cognitive function. This study aimed to assess the disease clusters and patterns of multimorbidity in diabetes patients using a novel latent class analysis (LCA) approach in middle-aged and older adults and explore the association between different clusters of multimorbidity in diabetes and the effect on physical and cognitive function.

Methods

This national observational study included 1,985 diabetes patients from the four waves of the China Health and Retirement Longitudinal Study (CHARLS) in 2011 to 2018. Thirteen chronic diseases were used in latent class analysis to identify the patterns of multimorbidity in diabetes, which span the cardiovascular, physical, psychological, and metabolic systems. Cognitive function is assessed via a structured questionnaire in three domains: memory, executive function, and orientation. We combined activities of daily living (ADL) with instrumental activities of daily living (IADL) to measure physical function. Linear mixed models and negative binomial regression models were used to analyze the association between patterns of multimorbidity in diabetes and the effect on cognitive function and disability, respectively.

Results

A sample of 1,985 diabetic patients was identified, of which 1,889 (95.2%) had multimorbidity; their average age was 60.6 years (standard deviation (SD) = 9.5), and 53.1% were women. Three clusters were identified: "cardio-metabolic" (n = 972, 51.5%), "mental-dyslipidemia-arthritis" (n = 584, 30.9%), and "multisystem morbidity" (n = 333, 17.6%). Compared with diabetes alone, the "multisystem morbidity" class had an increased association with global cognitive decline. All patterns of multimorbidity were associated with an increased risk of memory decline and disability; however, the "multisystem morbidity" group also had the strongest association and presented a higher ADL-IADL disability (ratio = 4.22, 95% CI = 2.52, 7.08) and decline in memory Z scores (β = -0.322, 95% CI = -0.550, -0.095, p = 0.0058).

Conclusion

Significant longitudinal associations between different patterns of multimorbidity in diabetes patients and memory decline and disability were observed in this study. Future studies are needed to understand the underlying mechanisms and common risk factors for multimorbidity in diabetes patients and to propose treatments that are more effective.

Gender-specific association of the accumulation of chronic conditions and disability in activities of daily living with depressive symptoms

BACKGROUND

In the era of rapid aging with a rising prevalence of multimorbidity, complex interactions between physical and psychological conditions have challenged the health care system. However, little is known about the association of the accumulation of chronic conditions and disability in activities of daily living with depressive symptoms, especially in developed countries.

METHODS

This population-based cohort study used data from the Health and Retirement Study. A total of 22,335 middle-aged and older adults participated in the 2014 (T1), 2016 (T2), and 2018 (T3) waves of the cohort were included. The accumulation of chronic conditions and disability were defined as the number of chronic diseases and the five activities of daily living. Depressive symptoms were measured by the Center for Epidemiologic Studies Depression Scale. A longitudinal mediation model with a cross-lagged panel model was run. As robust check, the models were applied with a longer follow-up period (from 2012 to 2018). Additionally, results were estimated in China.

RESULTS

Bidirectional associations have been found among the accumulation of chronic conditions, disability, and depressive symptoms, especially between disability and depression. Disability (T2) mediated 11.11 % and 16.87 % of the association between the accumulation of chronic conditions (T1) and depression (T3) for men and women in the United States. The results were consistent in robust analysis.

CONCLUSIONS

This study found that men and women routinely experienced disability and depressive symptoms because of the accumulation of chronic conditions. In terms of depressive symptoms, women were more sensitive to the accumulation of chronic conditions through disability.

Are physically disabled people at high risk of coronary heart disease among disabled population - Evidence from 7.5-year retrospective cohort study

OBJECTIVES

Previous cross-sectional studies suggested that people with physical disabilities (one of the subgroups of disabled people) are associated with an increased risk of cardiovascular diseases (CVD) than healthy peers. However, a longitudinal cohort of disabled people exhibited a different trend, in which the study populations were similar in health inequalities. We aimed to examine whether physical disability was associated with an increased risk of coronary heart disease (CHD) among disabled people.

STUDY DESIGN AND SETTING

This retrospective cohort study from the Shanghai Health Examination Program included a total of 6419 disabled adults (50.77 [9.88] age) with complete electronic health records and were free of CHD at baseline (2012) were followed-up for a 7.5-year period until 2019. The physical disability and non-physical disability subgroups were characterized based on the Disability Classification and Grading Standard (GB/T 26341-2010). Multivariable Cox regression analyses were used to evaluate adjusted hazard ratios (HR) for subsequent CHD, while Kaplan-Meier curves was used to assess the proportional hazards assumption. We conducted subgroup analyses based on gender, levels of disability, and baseline blood pressure.

RESULTS

Kaplan-Meier analysis revealed a higher incidence of CHD in the physical disability group compared to the non-physical disability group during the 7.5-year follow-up period (P < 0.05). Subjects with physical disabilities exhibited an increased risk for subsequent CHD occurrence (HR: 1.12; 95% CI: 1.03-1.31), compared to the non-physical subgroup after adjustments for confounders. The sensitivity analysis conducted on subgroups according to gender and disability severity indicated that moderate physical disability and female physical disability were associated with a higher prevalence of CHD, which was confirmed by multi-adjusted regression analysis. The spline curves of BP and CHD indicated that the physical disability group displayed lower SBP and DBP thresholds of 120 mmHg and SBP, respectively.

CONCLUSION

Within the disabled population, individuals with physical disability are at higher risk of developing CHD, and it is plausible that their optimal BP threshold for CHD prevention may need to be set at a lower level. Further research is essential to investigate BP management among individuals with physical disabilities and its influence on cardiovascular-related adverse events.

Letter to the editor: alarming prevalence of comorbid conditions in adults with type 2 diabetes in Iran

One of the key challenges that healthcare continues to face is the ongoing epidemiological transition from communicable diseases to non-communicable diseases. In Iran, it is expected that the number of patients with non-communicable diseases will increase because of the growing prevalence of the Western lifestyle, nutritional transition, and the aging of society. As the elderly population continues to grow, cardiovascular diseases have progressively replaced communicable diseases as the leading cause of mortality. In 2016, ischemic heart diseases, cerebrovascular accidents, hypertension, and diabetes were the first, second, fourth, and sixth leading causes of mortality respectively. Like many patients with a chronic disease, most Iranians with diabetes have at least one comorbid condition. Diabetes-related comorbidities increase the healthcare demands, cost, and risk of poor patient outcomes. Although a growing body of evidence indicates that the type and severity of the comorbid conditions matter, less attention has been paid to studying how they influence diabetes care. Further research should continue to focus on furthering our understanding of management strategies to enhance the quality of care for diabetes patients having comorbidities.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01254-w.

Behavioral and Psychological Factors in Buffering Diabetes-related Disability Development

BACKGROUND

Diabetes is associated with disability development. Healthy behaviors and psychosocial support can help patients manage their disease.

PURPOSE

To examine the role of various behavioral and psychological factors in buffering the effect of diabetes on disability development over time in Taiwanese adults.

METHODS

Data on 5,131 adults aged ≥50 years were obtained from the Taiwan Longitudinal Study on Aging. A cohort sequential multilevel design was employed to analyze the association between behavioral and psychosocial factors and the risk of disability over a 11-year period.

RESULTS

In patients with diabetes, having social support and exercising more than six times a week were associated with 4% and 49% reductions in the risk of disability, respectively (βdiabetes*socialsupport = -0.285, p = .006; βdiabetes*exercise3 = -2.612, p = .007). Exercising more than six times a week had an additional significant protective effect against disability development per year (βdiabetes*exercises3*age = -0.241, p = .038). Depression did not significantly interact with diabetes. However, a trajectory analysis revealed that individuals who had both diabetes and depression had the highest disability score from middle age among all participants.

CONCLUSIONS

Engaging in frequent exercise is the most influential factor for reducing the risk of disability in patients with diabetes. Social support provides an additional benefit for disability prevention in individuals with diabetes.

A network-based study reveals multimorbidity patterns in people with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) are at a heightened risk of living with multiple comorbidities. However, the comprehension of the multimorbidity characteristics of T2DM is still scarce. This study aims to illuminate T2DM's prevalent comorbidities and their interrelationships using network analysis. Using electronic medical records (EMRs) from 496,408 Chinese patients with T2DM, we constructed male and female global multimorbidity networks and age- and sex-specific networks. Employing diverse network metrics, we assessed the structural properties of these networks. Furthermore, we identified hub, root, and burst diseases within these networks while scrutinizing their temporal trends. Our findings uncover interconnected T2DM comorbidities manifesting as emergence in clusters or age-specific outbreaks and core diseases in each sex that necessitate timely detection and intervention. This data-driven methodology offers a comprehensive comprehension of T2DM's multimorbidity, providing hypotheses for clinical considerations in the prevention and therapeutic strategies.

Segmenting Patients With Diabetes With the Navigator Service in Primary Care and a Description of the Self-Acting Patient Group: Cross-Sectional Study

BACKGROUND

The aim of patient segmentation is to recognize patients with similar health care needs. The Finnish patient segmentation service Navigator segregates patients into 4 groups, including a self-acting group, who presumably manages their everyday life and coordinates their health care. Digital services could support their self-care. Knowledge on self-acting patients' characteristics is lacking.

OBJECTIVE

The study aims are to describe how Navigator assigns patients with diabetes to the 4 groups at nurses' appointments at a health center, the self-acting patient group's characteristics compared with other patient groups, and the concordance between the nurse's evaluation of the patient's group and the actual group assigned by Navigator (criterion validity).

METHODS

Patients with diabetes ≥18 years old visiting primary care were invited to participate in this cross-sectional study. Patients with disability preventing informed consent for participation were excluded. Nurses estimated the patients' upcoming group results before the appointment. We describe the concordance (%) between the evaluation and actual groups. Nurses used Navigator patients with diabetes (n=304) at their annual follow-up visits. The self-acting patients' diabetes care values (glycated hemoglobin [HbA1c], urine albumin to creatinine ratio, low-density lipoprotein cholesterol, blood pressure, BMI), chronic conditions, medication, smoking status, self-rated health, disability (World Health Organization Disability Assessment Schedule [WHODAS] 2.0), health-related quality of life (EQ-5D-5L), and well-being (Well-being Questionnaire [WBQ-12]) and the patients' responses to Navigator's question concerning their digital skills as outcome variables were compared with those of the other patients. We used descriptive statistics for the patients' distribution into the 4 groups and demographic data. We used the Mann-Whitney U test with nonnormally distributed variables, independent samples t test with normally distributed variables, and Pearson chi-square tests with categorized variables to compare the groups.

RESULTS

Most patients (259/304, 85.2%) were in the self-acting group. Hypertension, hyperlipidemia, and joint ailments were the most prevalent comorbidities among all patients. Self-acting patients had less ischemic cardiac disease (P=.001), depression or anxiety (P=.03), asthma or chronic obstructive pulmonary disease (P<.001), long-term pain (P<.001), and related medication. Self-acting patients had better self-rated health (P<.001), functional ability (P<.001), health-related quality of life (P<.001), and general well-being (P<.001). All patients considered their skills at using electronic services to be good.

CONCLUSIONS

The patients in the self-acting group had several comorbidities. However, their functional ability was not yet diminished compared with patients in the other groups. Therefore, to prevent diabetic complications and disabilities, support for patients' self-management should be emphasized in their integrated care services. Digital services could be involved in the care of patients willing to use them. The study was performed in 1 health center, the participants were volunteers, and most patients were assigned to self-acting patient group. These facts limit the generalizability of our results.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/20570.

Spousal concordance in adverse childhood experiences and the association with depressive symptoms in middle-aged and older adults: findings across China, the US, and Europe

Background

Adverse childhood experiences (ACEs) are associated with higher depressive risks in adulthood. Whether respondents' ACEs are associated with their own depressive symptoms in adulthood and whether this association extends to their spouses' depressive symptoms remain unexplored.

Methods

Data were from China Health and Retirement Longitudinal Study (CHARLS), the Health and Retirement Study (HRS), and the Survey of Health, Ageing and Retirement in Europe (SHARE). ACEs were categorized into overall, intra-familial, and extra-familial ACEs. Correlations of couples' ACEs were calculated using Cramer's V and partial Spearman's correlation. Associations of respondents' ACEs with spousal depressive symptoms were assessed using logistic regression, and mediation analyses were conducted to explore the mediating role of respondents' depressive symptoms.

Results

Significant associations between husbands' ACEs and wives' depressive symptoms, with odds ratios (ORs) and 95% confidence intervals (CIs) of 2.09 (1.36-3.22) for 4 or more ACEs in CHARLS, and 1.25 (1.06-1.48) and 1.38 (1.06-1.79) for 2 or more ACEs in HRS and SHARE. However, wives' ACEs were associated with husbands' depressive symptoms only in CHARLS and SHARE. Findings in intra-familial and extra-familial ACEs were consistent with our main results. Additionally, respondents' depressive symptoms mediated more than 20% of the effect of respondents' ACEs on spousal depressive symptoms.

Conclusion

We found that ACEs were significantly correlated between couples. Respondents' ACEs were associated with spousal depressive symptoms, with respondents' depressive symptoms mediating the association. The bidirectional implications of ACEs on depressive symptoms should be considered within household and effective interventions are warranted.

Social exclusion in people with diabetes: cross-sectional and longitudinal results from the German Ageing Survey (DEAS)

As social exclusion can be linked to worse health and overall reduced quality of life, we describe social exclusion in people with diabetes and assess whether diabetes can be considered as a risk factor for social exclusion. We analyzed two waves (2014, 2017, N = 6604) from a survey of community-dwelling people aged > 40 using linear regression, group comparison and generalized estimating equations to explore the association between diabetes, social exclusion, socioeconomic, physical and psychosocial variables. In the entire cohort, diabetes was cross-sectionally associated with social exclusion after adjusting for covariates (p = 0.001). In people with diabetes, social exclusion was further associated with self-esteem (p < 0.001), loneliness (p =  < 0.001), income (p = 0.017), depression (p = 0.001), physical diseases (p = 0.04), and network size (p = 0.043). Longitudinal data revealed that higher levels of social exclusion were already present before the diagnosis of diabetes, and future social exclusion was predicted by self-esteem, loneliness, depression, and income, but not by diabetes (p = .221). We conclude that diabetes is not a driver of social exclusion. Instead, both seem to co-occur as a consequence of health-related and psychosocial variables.

Multimorbidity and Functional Disability among Older Adults: The Role of Inflammation and Glycemic Status - An Observational Longitudinal Study

INTRODUCTION

Specific multimorbidity combinations, in particular those including arthritis, stroke, and cognitive impairment, have been associated with high burden of activities of daily living (ADL)-instrumental activities of daily living (IADL) disability in older adults. The biologic underpinnings of these associations are still unclear.

METHODS

Observational longitudinal study using data from the Health and Retirement Study (N = 8,618, mean age = 74 years, 58% female, 25% non-white) and negative binomial regression models stratified by sex to evaluate the role of inflammatory and glycemic biomarkers (high-sensitivity C-reactive protein (hs-CRP) and HbA1c) in the association between specific multimorbidity combinations (grouped around one of eight index diseases: arthritis, cancer, cognitive impairment, diabetes, heart disease, hypertension, lung disease, and stroke; assessed between 2006 and 2014) and prospective ADL-IADL disability (2 years later, 2008-2016). Results were adjusted for sociodemographic characteristics, body mass index, number of coexisting diseases, and baseline ADL-IADL score.

RESULTS

Multimorbidity combinations indexed by arthritis (IRR = 1.1, 95% CI = 1.01-1.20), diabetes (IRR = 1.19, 95% CI = 1.09-1.30), and cognitive impairment (IRR = 1.11, 95% CI = 1.01-1.23) among men and diabetes-indexed multimorbidity combinations (IRR = 1.07, 95% CI = 1.01-1.14) among women were associated with higher ADL-IADL scores at increasing levels of HbA1c. Across higher levels of hs-CRP, multimorbidity combinations indexed by arthritis (IRR = 1.06, 95% CI = 1.02-1.11), hypertension (IRR = 1.06, 95% CI = 1.02-1.11), heart disease (IRR = 1.06, 95% CI = 1.01-1.12), and lung disease (IRR = 1.14, 95% CI = 1.07-1.23) were associated with higher ADL-IADL scores among women, while there were no significant associations among men.

CONCLUSION

The findings suggest potential for anti-inflammatory management among older women and optimal glycemic control among older men with these particular multimorbidity combinations as focus for therapeutic/preventive options for maintaining functional health.

Cumulative muscle strength and risk of diabetes: A prospective cohort study with mediation analysis

AIMS

Previous studies assessing the association of muscle strength with risk of diabetes have seldomly accounted for the cumulative exposure over time. This study examined the association of 4-year cumulative muscle strength with risk of diabetes in middle-aged and older adults.

METHODS

We included participants without diabetes, who had 3 repeated measurements of muscle strength, which was assessed by grip strength (normalized by body-weight) and chair-rising time, over 4 years. Cumulative muscle strength was calculated based on trapezoid rule. Logistic regression analysis and mediation analysis for cumulative blood pressure were performed.

RESULTS

We included 3731 and 3799 participants with data on cumulative grip strength and cumulative chair-rising time, respectively. The odds of diabetes were gradually reduced with increments in cumulative grip strength or decrements in cumulative chair-rising time, with the corresponding odds ratio being 0.79 and 0.89 per 1 standard deviation change after multivariable-adjustment. Cumulative systolic blood pressure mediated 10.8% and 14.2% of the associations of diabetes with cumulative grip strength and cumulative chair-rising time, respectively. Cumulative grip strength also correlated inversely with blood pressure, glycemia, and inflammation.

CONCLUSIONS

Higher cumulative muscle strength was associated with lower risk of diabetes and better cardiometabolic health in middle-aged and older Chinese adults.

Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention

BACKGROUND

Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care.

METHODS

Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation.

RESULTS

We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users.

CONCLUSIONS

We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Depressive Multimorbidity and Trajectories of Functional Status among Older Americans: Differences by Racial/Ethnic Group

OBJECTIVE

This study aims to evaluate the impact of depressive multimorbidity (ie, including depressive symptoms) on the long-term development of activities of daily living (ADL) and instrumental activities of daily living (IADL) limitations according to racial/ethnic group in a representative sample of US older adults.

DESIGN

Prospective, observational, population-based 16-year follow-up study of nationally representative sample.

SETTING AND PARTICIPANTS

Sample of older non-Hispanic Black, Hispanic, and nonHispanic White Americans from the Health and Retirement Study (2000‒2016, N = 16,364, community-dwelling adults ≥65 years of age).

METHODS

Data from 9 biennial assessments were used to evaluate the accumulation of ADL-IADL limitations (range 0‒11) among participants with depressive (8-item Center for Epidemiologic Studies Depression score≥4) vs somatic (ie, physical conditions only) multimorbidity vs those without multimorbidity (no or 1 condition). Generalized estimating equations included race/ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White), baseline age, sex, body mass index, education, partnered, and net worth.

RESULTS

Depressive and somatic multimorbidity were associated with 5.18 and 2.95 times greater accumulation of functional limitations, respectively, relative to no disease [incidence rate ratio (IRR) = 5.18, 95% confidence interval, CI (4.38,6.13), IRR = 2.95, 95% CI (2.51,3.48)]. Hispanic and Black respondents experienced greater accumulation of ADL-IADL limitations than White respondents [IRR = 1.27, 95% CI (1.14, 1.41), IRR = 1.31, 95% CI (1.20, 1.43), respectively].

CONCLUSIONS AND IMPLICATIONS

Combinations of somatic diseases and high depressive symptoms are associated with greatest accumulation of functional limitations over time in adults ages 65 and older. There is a more rapid growth in functional limitations among individuals from racial/ethnic minority groups. Given the high prevalence of multimorbidity and depressive symptomatology among older adults and the availability of treatment options for depression, these results highlight the importance of screening/treatment for depression, particularly among older adults with socioeconomic vulnerabilities, to slow the progression of functional decline in later life.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework

Objectives

Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM.

Design

We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines.

Results

Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences).

Conclusions

We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework

Objectives

Symptomatic knee osteoarthritis (OA) frequently co-occurs in individuals with type 2 diabetes mellitus (T2DM). In the context of T2DM, OA is often underdiagnosed and undertreated. To elucidate strategies to improve OA care in persons with T2DM, we assessed their perceptions of the barriers and enablers to seeking and engaging in OA care.

Design

We conducted semi-structured interviews with 18 individuals with T2DM and symptomatic knee OA in Ontario, Canada. Transcripts were deductively coded using the Theoretical Domains Framework (TDF), an implementation science framework that incorporates theoretical domains of behaviour determinants, which can be linked to behaviour change techniques. Within each of the relevant domains, data were thematically analyzed to generate belief statements.

Results

Seven of the TDF domains prominently influenced the behaviour to seek and engage in OA care. Participants described insufficient receipt of OA knowledge to fully engage in care (knowledge), feeling incapable of participating in physical activity due to joint pain (beliefs about capabilities), uncertainty about effectiveness of therapies (optimism) and lack of guidance from health care providers and insufficient access to community programs/supports (environmental context and resources). Key enablers were strong social support (social influences), sources of accountability (behavioural regulation) and experiencing benefit from treatment (reinforcement). Participants did not see concomitant T2DM as limiting the desire to seek OA care.

Conclusions

Among individuals with symptomatic knee OA and T2DM, we identified behavioural determinants of seeking and engaging in OA care. These will be mapped to behavioural change techniques to inform development of a complex intervention.

Multimorbidity, Frailty and Diabetes in Older People-Identifying Interrelationships and Outcomes

Multimorbidity and frailty are highly prevalent in older people with diabetes. This high prevalence is likely due to a combination of ageing and diabetes-related complications and other diabetes-associated comorbidities. Both multimorbidity and frailty are associated with a wide range of adverse outcomes in older people with diabetes, which are proportionally related to the number of morbidities and to the severity of frailty. Although, the multimorbidity pattern or cluster of morbidities that have the most adverse effect are not yet well defined, it appears that mental health disorders enhance the multimorbidity-related adverse outcomes. Therefore, comprehensive diabetes guidelines that incorporate a holistic approach that includes screening and management of mental health disorders such as depression is required. The adverse outcomes predicted by multimorbidity and frailty appear to be similar and include an increased risk of health care utilisation, disability and mortality. The differential effect of one condition on outcomes, independent of the other, still needs future exploration. In addition, prospective clinical trials are required to investigate whether interventions to reduce multimorbidity and frailty both separately and in combination would improve clinical outcomes.

Predictors associated with prefrailty in older Taiwanese individuals with type 2 diabetes

Type 2 diabetes (T2DM) is one of the most well-studied and important factors that increase the risk of prefrailty in older people in Taiwan. This study was conducted to examine whether metabolic biomarkers, lifestyle behaviors, body composition, and chronic diseases are associated with frailty in older people with T2DM. We also observed how people manage their T2DM related to prefrailty. This study investigated a total of 201 participants diagnosed with T2DM who received care in our hospital from September 2018 to February 2019. Patients were divided into 3 groups (not frail, prefrail, and frail), and frailty was measured with the 5-item FRAIL scale. Socioeconomic characteristics, metabolic biomarkers, lifestyle behaviors, body composition, and chronic diseases were assessed at enrollment. No participants who we tested met the criteria for frailty. Based on the results of chi-square tests, prefrailty was associated with female sex, middle school education, unemployment, alcohol use, high body fat percentage, above-normal waist circumference, obesity, cardiovascular disease, and hypertension. Logistic regression analyses identified a significant correlation of prefrailty with the type of job from which they retired, cardiovascular disease, and hypertension. An important and surprising finding of this study was that the unemployed group was at high risk for prefrailty, which was not observed in previous research. The groups engaged in manual and professional jobs had better hand grip strength, a slower walking speed, and less risk of prefrailty than the unemployed group.

Prevalence and patterns of multimorbidity in chronic diseases in Guangzhou, China: a data mining study in the residents' health records system among 31 708 community-dwelling elderly people

OBJECTIVES

Examination of the prevalence, influence factors and patterns of multimorbidity among the elderly people in Guangzhou, China.

DESIGN

Cross-sectional study.

PARTICIPANTS

31 708 community-dwelling elderly people aged 65 and over.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence, influence factors and patterns of multimorbidity in seven chronic conditions among the participants. A multistage, stratified random sampling was adopted for selection of health records in the residents' health records system of Guangzhou. Data mining by association rule mining analysis was used to explore the correlations and multimorbidity patterns between seven chronic diseases.

RESULTS

The prevalence of morbidity was 55.0% (95% CI 40.1% to 60.1%) and the multimorbidity was 15.2% (95% CI 12.4% to 18.4%) among the participants. Elderly, women, higher education level, being single, living in urban areas and having medical insurance were more likely to have chronic diseases and multimorbidity. Data mining by association rule mining analysis reveals patterns of multimorbidity among the participants, including coexistence of hypertension and diabetes (support: 12.5%, confidence: 17.6%), hypertension and coronary heart disease (support: 4.4%, confidence: 5.7%), diabetes and coronary heart disease (support: 1.6%, confidence: 5.7%), diabetes, coronary heart disease and hypertension (support: 1.4%, confidence: 4.4%).

CONCLUSIONS

A high prevalence of morbidity (especially on hypertension and diabetes) and a relatively low multimorbidity of chronic diseases exist in elderly people. Data mining of residents' health records will help for strengthening the management of residents' health records in community health service centres of Guangzhou, China.

Patterns of cardiometabolic multimorbidity and the risk of depressive symptoms in a longitudinal cohort of middle-aged and older Chinese

BACKGROUND

Cardiometabolic diseases (CMDs) are associated with depression. However, it is unclear whether coexisting CMDs may increase the risk of depression. We examined associations between cardiometabolic multimorbidity and depressive symptoms among middle-aged and older Chinese.

METHODS

Participants aged ≥45 years were enrolled from the China Health and Retirement Longitudinal Study 2011-2018 (N = 18,002). Cardiometabolic multimorbidity was defined as the coexistence of ≥2 CMDs, including stroke, heart disease, diabetes, hypertension, and dyslipidemia. Depressive symptoms were assessed by the Center for Epidemiological Studies Depression Scale. We used generalized estimating equation models to examine associations between cardiometabolic multimorbidity and depressive symptoms, including the dose effect of disease count and prevalent disease combinations, as well as individual and additive effects of specific CMDs.

RESULTS

The prevalence of cardiometabolic multimorbidity was 24.5%. A higher number of CMDs had an additive dose effect on depressive symptoms that persisted consistently in specific CMDs. Stroke only, heart disease only, and diabetes only were each associated with a higher risk of depressive symptoms compared with no CMDs. CMD combinations involving stroke, heart disease, or diabetes were each associated with an increased risk of depressive symptoms compared with the absence of stroke, heart disease, or diabetes.

LIMITATION

Self-reported chronic conditions.

CONCLUSION

Stroke, heart disease, and diabetes showed individual and additive effects on CMD combinations, whereas hypertension and dyslipidemia only showed associations with depressive symptoms in combinations with other CMDs. These results suggest person-centered healthcare of mental health prevention and treatment for middle-aged and older adults with individual or multiple CMDs.

Multimorbidity Accumulation Among Middle-Aged Americans: Differences by Race/Ethnicity and Body Mass Index

BACKGROUND

Obesity and multimorbidity are more prevalent among U.S. racial/ethnic minority groups. Evaluating racial/ethnic disparities in disease accumulation according to body mass index (BMI) may guide interventions to reduce multimorbidity burden in vulnerable racial/ethnic groups.

METHOD

We used data from the 1998-2016 Health and Retirement Study on 8 106 participants aged 51-55 at baseline. Disease burden and multimorbidity (≥2 co-occurring diseases) were assessed using 7 chronic diseases: arthritis, cancer, heart disease, diabetes, hypertension, lung disease, and stroke. Four BMI categories were defined per convention: normal, overweight, obese class 1, and obese class 2/3. Generalized estimating equations models with inverse probability weights estimated the accumulation of chronic diseases.

RESULTS

Overweight and obesity were more prevalent in non-Hispanic Black (82.3%) and Hispanic (78.9%) than non-Hispanic White (70.9 %) participants at baseline. The baseline burden of disease was similar across BMI categories, but disease accumulation was faster in the obese class 2/3 and marginally in the obese class 1 categories compared with normal BMI. Black participants across BMI categories had a higher initial burden and faster accumulation of disease over time, while Hispanics had a lower initial burden and similar rate of accumulation, compared with Whites. Black participants, including those with normal BMI, reach the multimorbidity threshold 5-6 years earlier compared with White participants.

CONCLUSIONS

Controlling weight and reducing obesity early in the lifecourse may slow the progression of multimorbidity in later life. Further investigations are needed to identify the factors responsible for the early and progressing nature of multimorbidity in Blacks of nonobese weight.

Muscle-to-fat ratio identifies functional impairments and cardiometabolic risk and predicts outcomes: biomarkers of sarcopenic obesity

BACKGROUND

Sarcopenic obesity aims to capture the risk of functional decline and cardiometabolic diseases, but its operational definition and associated clinical outcomes remain unclear. Using data from the Longitudinal Aging Study of Taipei, this study explored the roles of the muscle-to-fat ratio (MFR) with different definitions and its associations with clinical characteristics, functional performance, cardiometabolic risk and outcomes.

METHODS

(1) Appendicular muscle mass divided by total body fat mass (aMFR), (2) total body muscle mass divided by total body fat mass (tMFR) and (3) relative appendicular skeletal muscle mass (RASM) were measured. Each measurement was categorized by the sex-specific lowest quintiles for all study participants. Clinical outcomes included all-cause mortality and fracture.

RESULTS

Data from 1060 community-dwelling older adults (mean age: 71.0 ± 4.8 years) were retrieved for the study. Overall, 196 (34.2% male participants) participants had low RASM, but none was sarcopenic. Compared with those with high aMFR, participants with low aMFR were older (72 ± 5.6 vs. 70.7 ± 4.6 years, P = 0.005); used more medications (2.9 ± 3.3 vs. 2.1 ± 2.5, P = 0.002); had a higher body fat percentage (38 ± 4.8% vs. 28 ± 6.4%, P < 0.001), RASM (6.7 ± 1.0 vs. 6.5 ± 1.1 kg/m² , P = 0.001), and cardiometabolic risk [fasting glucose: 105 ± 27.5 vs. 96.8 ± 18.7 mg/dL, P < 0.001; glycated haemoglobin (HbA1c): 6.0 ± 0.8 vs. 5.8 ± 0.6%, P < 0.001; triglyceride: 122.5 ± 56.9 vs. 108.6 ± 67.5 mg/dL, P < 0.001; high-density lipoprotein cholesterol (HDL-C): 56.2 ± 14.6 vs. 59.8 ± 16 mg/dL, P = 0.010]; and had worse functional performance [Montreal Cognitive Assessment (MoCA): 25.7 ± 4.2 vs. 26.4 ± 3.0, P = 0.143, handgrip strength: 24.7 ± 6.7 vs. 26.1 ± 7.9 kg, P = 0.047; gait speed: 1.8 ± 0.6 vs. 1.9 ± 0.6 m/s, P < 0.001]. Multivariate linear regression showed that age (β = 0.093, P = 0.001), body mass index (β = 0.151, P = 0.046), total percentage of body fat (β = 0.579, P < 0001) and RASM (β = 0.181, P = 0.016) were associated with low aMFR. Compared with those with high tMFR, participants with low tMFR were older (71.7 ± 5.5 vs. 70.8 ± 4.7 years, P = 0.075); used more medications (2.8 ± 3.3 vs. 2.1 ± 2.5, P = 0.006); had a higher body fat percentage (38.1 ± 4.7 vs. 28 ± 6.3%, P < 0.001), RASM (6.8 ± 1.0 vs. 6.5 ± 1.1 kg/m² , P < 0.001), and cardiometabolic risk (fasting glucose: 104.8 ± 27.6 vs. 96.9 ± 18.7 mg/dL, P < 0.001; HbA1c: 6.1 ± 0.9 vs. 5.8 ± 0.6%, P < 0.001; triglyceride: 121.4 ± 55.5 vs. 108.8 ± 67.8 mg/dL, P < 0.001; HDL-C: 56.4 ± 14.9 vs. 59.7 ± 15.9 mg/dL, P = 0.021); and had worse functional performance (MoCA: 25.6 ± 4.2 vs. 26.5 ± 3.0, P = 0.056; handgrip strength: 24.6 ± 6.7 vs. 26.2 ± 7.9 kg, P = 0.017; gait speed: 1.8 ± 0.6 vs. 1.9 ± 0.6 m/s, P < 0.001). Low tMFR was associated with body fat percentage (β = 0.766, P < 0.001), RASM (β = 0.476, P < 0.001) and Mini-Nutritional Assessment (β = -0.119, P < 0.001). Gait speed, MoCA score, fasting glucose, HbA1c and tMFR were significantly associated with adverse outcomes, and the effects of aMFR were marginal (P = 0.074).

CONCLUSIONS

Older adults identified with low MFR had unfavourable body composition, poor functional performance, high cardiometabolic risk and a high risk for the clinical outcome.

Spatiotemporal Analysis of the Prevalence and Pattern of Multimorbidity in Older Chinese Adults

Background

Multimorbidity presents an enormous problem to societal and healthcare utilization under the context of aging population in low- and middle-income countries (LMICs). Currently, systematic studies on the profile of multimorbidity and its characteristics among Chinese elderly are lacking. We described the temporal and spatial trends in the prevalence of multimorbidity and explored chronological changes of comorbidity patterns in a large elderly population survey.

Methods

Data were extracted from the Chinese Longitudinal Healthy Longevity Study (CLHLS) conducted between 1998 and 2018 in a random selection of half of the counties and city districts. All the elderly aged 65 and older were included in the survey of eight waves. We used 13 investigated chronic diseases to measure the prevalence of multimorbidity by means of geography, subpopulation, and chronological changes. The patterns of multimorbidity were assessed by computing the value of relative risk (RR indicates the likelihood of certain diseases to be associated with multimorbidity) and the observed-to-expected ratio (O/E indicates the likelihood of the coexistence of a multimorbidity combination).

Results

From 1998 to 2018, the prevalence of multimorbidity went from 15.60 to 30.76%, increasing in the fluctuation across the survey of eight waves (p_{for trend} = 0.020). Increasing trends were observed similarly in a different gender group (p_male = 0.009; p_female = 0.004) and age groups among female participants (p_~80 = 0.009; p₈₁₋₉₀ = 0.004; p₉₁₋₁₀₀ = 0.035; p_101~ = 0.018). The gap in the prevalence of multimorbidity between the north and the south was getting narrow across the survey of eight waves. Hypertension was the highest prevalent chronic condition while diabetes was most likely to coexist with other chronic conditions in the CLHLS survey. The most frequently occurring clusters were hypertension and heart disease, hypertension and cataract, and hypertension and chronic lung disease. And, the cancer, TB, and Parkinson's disease cluster took the domination of O/E rankings over time, which had a higher probability of coexistence in all the multimorbidity combinations.

Conclusions

The prevalence of multimorbidity has been increasing nationwide, and more attention should be paid to a rapid growth in the southern part of China. It demands the effective diagnosis and treatment adopted to the highly prevalent comorbidities, and strategies and measures were adjusted to strongly relevant clusters.

Are racial/ethnic minorities recently diagnosed with diabetes less likely than white individuals to receive guideline-directed diabetes preventive care?

BACKGROUND

Diabetes mellitus has reached epidemic proportions in the United States. As the prevalence of diabetes continues to rise, the burden of disease is divided unevenly among different populations. Racial/ethnic disparities in diabetes care are pervasive, including the provision of care for prevention of complications. Prevention efforts should be focused on the time that immediately follows a diagnosis of diabetes. The aim of this study was to assess racial/ethnic differences in the receipt of guideline-directed diabetes care for complication prevention by individuals recently diagnosed with diabetes.

METHODS

We used repeated cross-sections of individuals recently diagnosed with diabetes (within the past 5 years) from the National Health Interview Survey from 2011 to 2017. Multivariate regression was used to estimate the associations between race/ethnicity (non-Hispanic White, non-Hispanic Black and Hispanic) and guideline-directed process measures for prevention of diabetes complications (visits to an eye and foot specialist, and blood pressure and cholesterol checks by a health professional - each in the prior year). We assessed effect modification of these associations by socioeconomic status (SES).

RESULTS

In a sample of 7,341 participants, Hispanics had lower rates of having any insurance coverage (75.9 %) than Non-Hispanic Whites (93.2 %) and Blacks (88.1 %; p<0.001). After adjustment for demographics, total comorbidities, SES, and health insurance status, Hispanics were less likely to have an eye exam in the prior year (OR 0.80; (95 % CI 0.65-0.99); p=0.04) and a blood pressure check (OR 0.42; (95 % CI 0.28-0.65); p<0.001) compared to Non-Hispanic Whites. There was no significant effect modification of race/ethnicity by SES.

CONCLUSIONS

Hispanics recently diagnosed with diabetes were less likely to receive some indicators of guideline-directed care for the prevention of complications. Lack of insurance and SES may partially explain those differences. Future work should consider policy change and providers' behaviors linked to racial/ethnic disparities in diabetes care.

Type 2 diabetes mellitus in older adults: clinical considerations and management

The past 50 years have seen a growing ageing population with an increasing prevalence of type 2 diabetes mellitus (T2DM); now, nearly half of all individuals with diabetes mellitus are older adults (aged ≥65 years). Older adults with T2DM present particularly difficult challenges. For example, the accentuated heterogeneity of these patients, the potential presence of multiple comorbidities, the increased susceptibility to hypoglycaemia, the increased dependence on care and the effect of frailty all add to the complexity of managing diabetes mellitus in this age group. In this Review, we offer an update on the key pathophysiological mechanisms associated with T2DM in older people. We then evaluate new evidence relating particularly to the effects of frailty and sarcopenia, the clinical difficulties of age-associated comorbidities, and the implications for existing guidelines and therapeutic options. Our conclusions will focus on the effect of T2DM on an ageing society.

The activity of daily living (ADL) subgroups and health impairment among Chinese elderly: a latent profile analysis

Background

Disability in aged people became one of the major challenges in China due to the acceleration of population aging. Nevertheless, there were limited methods to appropriately discriminate the degree of combined basic activity of daily living (BADL) and instrumental activity of daily living (IADL). The present study explored an empirical typology of the activity of daily living (ADL) and its association with health status among the elderly in China.

Methods

Data throughout the Chinese Longitudinal Healthy Longevity Survey (CLHLS) was retrieved and Latent profile analysis (LPA) was conducted to identify the subgroups of ADL for included elderly subjects. Multinomial regression was performed to detect the effect of identified characteristics with ADL subgroups, and the restricted cubic spine was drawn to show the changes in the relationship between age-specific ADL disability and BMI.

Results

The overall participants (n=8108) were divided into three ADL classes by LPA - ‘no BADL limitation-no IADL limitation’ (Class one, n=6062, 75%), ‘no BADL limitation- IADL impairment’ (Class two, n=1526, 19%), and ‘BADL impairment- IADL impairment’ (Class three, n=520, 6%). Compared with the participants in Class one, the oldest-old, living without spouse, lacking of exercise, short in social activities, having experience of falls, having comorbidity of diabetes, heart disease, stroke, decreased cognitive function, depression symptom were highly associated with Class two and Class three. Additionally, malnutrition and asthma were associated with combined BADL/IADL impairment (Class three), while illiteracy was only associated with IADL impairment (Class two). Furthermore, a statistically significant U-shape association was detected between age and BADL/IADL disability (Class three vs. Class two) as well as BMI and BADL/IADL disability (Class three vs. Class one). The elderly aged 80–90 with IADL impairment were less likely to evolve into combined BADL/IADL impairment, and the elderly who were underweight or obese may have higher risk of combined BADL/IADL impairment.

Conclusion

A novel functional assessment was explored based on LPA, by which elderly people could be classified into three distinct classes of combined BADL/IADL. The predictors identified with particular IADL/BADL classes could draw early attention to the onset of functional disability and enlighten targeted interventions to address consequent problems of aged people.

The rising complexity and burden of multimorbidity in a middle-income country

BACKGROUND

The limited knowledge on aetiology, epidemiology and risk factors for multimorbidity especially evident from low and middle-income countries curtail the development and implementation of sustainable healthcare models. Sri Lanka, boasting for one of South Asia's most efficient public health systems that is accessible free-of-charge by the citizens is presently transitioning from lower-middle to upper-middle-income tier. Faced with the triple burden of disease, it is imperative for Sri Lanka to incorporate an integrated model to manage multimorbidity.

METHODS

A descriptive cross-sectional study was carried out in medical clinics of a tertiary care hospital and a University primary care department. Data were extracted on to a form from the clinical records of patients over the age of 20 years with at least one non-communicable disease (NCD) and analysed.

RESULTS

Multimorbidity was present among 64.1% of patients (n = 1600). Nearly 44.44% of the patients aged 20-35 years have a minimum of two disorders, and by the time they reach 50 years, nearly 64% of the patients have two or more non-communicable diseases. Nearly 7% of those aged over 65 years were diagnosed with four or more disorders. A fourth of the sample was affected by co-morbid diabetes mellitus and hypertension, whereas the combinations of coronary heart disease with hypertension and diabetes mellitus were also found to be significantly prevalent. A salient revelation of the binomial logistic regression analysis was that the number of disorders was positively correlated to the presence of mental disorders 7.25 (95% CI = 5.82-8.68).

CONCLUSION

Multimorbidity is highly prevalent among this population and seemingly has a detrimental effect on the psychological wellbeing of those affected. Therefore, the need for horizontal integration of all primary to tertiary care disciplines, including mental health, to manage multimorbidity by policymakers is emphasized as a priority task.

Is polypharmacy beneficial or detrimental for older adults with cardiometabolic multimorbidity? Pooled analysis of studies from Hong Kong and Europe

BACKGROUND

Physicians often prescribe high numbers of medications for managing multiple cardiometabolic diseases. It is questionable whether polypharmacy (concurrent use of five or more medications) is beneficial or detrimental for older adults with cardiometabolic multimorbidity (co-occurrence of two or more diseases).

OBJECTIVE

To examine combined effects of multimorbidity and polypharmacy on hospitalization and frailty and to determine whether effect sizes of polypharmacy vary with numbers of cardiometabolic diseases.

METHODS

We pooled longitudinal data of community-dwelling older adults in Hong Kong, Israel, and 17 European countries. They completed questionnaires for baseline assessment from 2015 to 2018 and reassessment at 1-2-year follow-up. We performed regression analyses to address the objective.

RESULTS

Among 44 818 participants (mean age: 69.6 years), 28.3% had polypharmacy and 34.8% suffered from cardiometabolic multimorbidity. Increased risks of hospitalization and worsening frailty were found in participants with 'multimorbidity alone' [adjusted odds ratio (AOR) 1.10 and 1.26] and 'polypharmacy alone' (AOR 1.57 and 1.68). With 'multimorbidity and 'polypharmacy' combined, participants were not at additive risks (AOR 1.53 and 1.47). In stratified analysis, with increasing numbers of cardiometabolic diseases, associations of polypharmacy with hospitalization and frailty were attenuated but remained statistically significant.

CONCLUSION

Polypharmacy is less detrimental, yet still detrimental, for older adults living with cardiometabolic multimorbidity. Physicians should optimize prescription regardless of the number of diseases. Health policymakers and researchers need to consider their interrelationship in hospitalization risk predictions and in developing frailty scales.

Diabetes multimorbidity combinations and disability in the Mexican Health and Aging Study, 2012-2015

PURPOSE

The aim of this study was to investigate the relationship between specific combinations of chronic conditions and disability in Mexican older adults with diabetes.

METHODS

This was a prospective cohort study of Mexican adults (n = 2558) with diabetes and aged 51 or older that used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. The main outcome was an index that measured ability to perform activities of daily living and instrumental activities of daily living. The main independent variables were diabetes multimorbidity combinations, defined as diabetes and at least one other chronic condition. The authors calculated the prevalence of each multimorbidity combination present in the sample in 2012 and used negative binomial regression models to estimate the association of the most prevalent of these combinations with disability incidence in 2015.

RESULTS

The three most prevalent combinations were: 1) diabetes-hypertension (n = 637, 31.9%) 2) diabetes-hypertension-depression (n = 388, 19.4%) and 3) diabetes-depression (n = 211, 10.6%). In fully adjusted models comparing participants with specific multimorbidity combinations to participants with diabetes alone, the combinations that had an increased association with disability were diabetes-hypertension-depression, diabetes-depression and diabetes-hypertension-arthritis-depression. In nested models, the addition of arthritis to combinations including depression increased this association.

CONCLUSIONS

Consistent with prior studies, multimorbidity combinations including depression were associated with increased risk of disability. However, the effect size of this relationship was lower than what had been previously been reported internationally. This highlights the need for globally oriented multimorbidity research.

Severity Levels of Disability Among Older Adults in Low- and Middle-Income Countries: Results From the Study on Global Ageing and Adult Health (SAGE)

Background: Recent studies suggest the importance of distinguishing the severity levels of disability in the older adult population. However, there is still no consensus regarding an optimal classification. Few studies have estimated the prevalence of severe disability, and the results have been confined to high-income countries. There is no evidence for low- and middle-income countries (LMICs). Therefore, the aim of this study was to provide estimates of the levels of severity associated with disability in older adult populations in LMICs and to examine their relationship with health and socioeconomic factors. Methods: We used data from the Study on global AGEing and adult health (SAGE), wave 1 (2007-2010). Nationally representative samples of adults over 50 years from China, Ghana, India, Mexico, Russian Federation, and South Africa were analyzed (n = 33,641). We measured disability using the World Health Organization Disability Assessment Instrument version 2.0 (WHODAS 2.0). Disability levels according to severity were identified through the use of latent class analysis. Socioeconomic and health factors associated with severe disability were estimated using ordinal logistic regression models. Results: We identified four groups of older adult: (1) without disability, 43.4%; (2) mild disability, 33.3%; (3) moderate disability, 15.3%; and (4) severe disability, 8.0%. These results were heterogeneous for the six countries analyzed. Education and socioeconomic status were significantly associated with severe disability along with the following chronic conditions: angina, arthritis, asthma, cataracts, chronic obstructive pulmonary disease, depression, diabetes, and stroke. Severe disability was also associated with the frailty status, sarcopenia, and mild cognitive impairment. Conclusions: In this study, we estimated severity levels of disability for the older adult population in LMICs. Our results show that severe disability affects 8% of older adult, and that there are important socioeconomic and health factors associated with this condition. Measuring the severity of disability is a critical element to study the causes and consequences of aging. Moreover, the identification of older adult with severe disability is vital to design prevention programs, modify interventions, or develop enabling environments.

Multimorbidity, Function, and Cognition in Aging

Multimorbidity is a global health challenge. Here, we define multimorbidity, describe ways multimorbidity is measured, discuss the prevalence of multimorbidity and how it differs across different populations, examine mechanisms of disease and disability, and discuss the effects of multimorbidity on outcomes such as survival and function.

Type 2 Diabetes Correlates with Comorbidity and Nutritional Status but Not with Functional Health in Geriatric Ward Patients: A Cross-Sectional Study in Poland

PURPOSE

The study aimed to assess the comorbidity profile, functional, and nutritional health in geriatric ward patients depending on their type 2 diabetes (DM) status.

PATIENTS AND METHODS

We performed a cross-sectional study of 416 patients - median age 82 years (IQR 77-86), 77.4% female, 96.9% community-dwelling - consecutively admitted to the geriatric ward at the turn of 2014 and 2015. Comprehensive geriatric assessment results were analyzed (including self-care and instrumental activities of daily living, cognitive abilities, emotional health, risk of falls, frailty status, dynapenia, nutritional health, morbidity, biochemical parameters, and pharmacotherapy).

RESULTS

DM was observed in 126 (30.3%) patients hospitalized in the study period; 4% of DM cases were newly diagnosed. In comparison to patients without DM, older adults with type 2 DM were significantly more frequently burdened with multimorbidity (61.1% versus 39.7%, P<0.001), polypharmacy (88.9% versus 74.7%, P=0.001), obesity (59.8% versus 34.5%, P<0.001), abdominal obesity (94.4% versus 75.5%, P<001), chronic kidney disease (61.1% versus 48.6%, P=0.02) and cardiovascular diseases: ischemic heart disease (66.7% versus 47.9%, P<0.001), congestive heart failure (50.0% versus 34.1%, P=0.002), atrial fibrillation (30.2% versus 20.7%, P=0.04) and peripheral arterial disease (24.6% versus 11.4%, p<0.001). There were no significant differences in all functional parameters evaluated.

CONCLUSION

Type 2 DM patients were significantly more often burdened with multimorbidity, polypharmacy, obesity, and had an unfavorable profile of cardiovascular diseases than patients without DM, but - contrary to our expectations - they did not differ in any functional characteristic assessed. However, this may be due to the geriatric ward patients' specificity of health problems in the advanced, more complex disablement process phases.