Functional status and health outcomes in older americans with diabetes mellitus

The individualisation of glycaemic targets in response to patient characteristics in type 2 diabetes: a scoping review

BACKGROUND

Evidence and guidelines increasingly support an individualised approach to care for people with type 2 diabetes and individualisation of glycaemic targets in response to patient factors.

METHODS

We undertook a scoping review of the literature for evidence of factors impacting upon glycated haemoglobin target individualisation in adults with type 2 diabetes. Data were analysed thematically with the themes inductively derived from article review.

FINDINGS

Evidence suggests that presence of cardiovascular disease, hypoglycaemia unawareness, severe hypoglycaemia, limited life expectancy, advanced age, long diabetes duration, frailty, cognitive impairment, disability, extensive comorbidity, diabetes distress and patient preference should inform the setting of glycaemic targets.

CONCLUSION

The management of people with diabetes is complex. In clinical practice, many patients will have a variety of factors that should be considered when personalising their care. Approaches to personalised care and glycaemic treatment targets should be undertaken as part of a shared decision-making process between physician and patient. Use of electronic records might enable greater efficiency and more widespread use of personalised care plans for people with diabetes.

Does undiagnosed diabetes mitigate the association between diabetes and cognitive impairment? Findings from the ELSI-Brazil study

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with cognitive impairment. However, most of the evidence has been based on self-reported T2DM, and undiagnosed diabetes has not been considered as a separate category. We aimed to examine the extent to which undiagnosed diabetes modifies the association between diabetes and cognitive impairment in a representative sample of Brazilian adults aged 50 years and older.

METHODS

We analyzed baseline data from 1944 participants of the Brazilian Longitudinal Study of Aging (ELSI-Brazil) conducted from 2015 to 2016. Diabetes was evaluated based on self-reported doctor diagnosis and glycosylated hemoglobin levels. Participants were classified as diabetics (D), undiagnosed diabetics (UDD), or nondiabetics (ND). Cognitive function was assessed by word list learning and verbal fluency tests. Three multiple logistic regression models were used to evaluate the changes in the strength of the associations.

RESULTS

Participants with diabetes had 49% greater odds of exhibiting impaired memory than nondiabetics (odds ratio [OR] = 1.49; 95% CI: 1.01-2.20). By combining UDD and ND, the association between diabetes and impaired memory was attenuated by 2.0%, losing its statistical significance (OR = 1.46; 95% CI: 0.98-2.17). By combining UDD and D, the association was attenuated by 7.4% (OR = 1.38; 95% CI: 1.01-1.90). No significant association was found between T2DM and impaired verbal fluency.

CONCLUSION

This study found an association between T2DM and impaired memory but not with impaired verbal fluency. When UDD individuals are considered diabetics, this association is attenuated; when UDD individuals are considered as ND, this association is attenuated to the extent that it loses its statistical significance, affecting thus the clinical interpretation.

Diabetes and Risk of Post-Fragility Hip Fracture Outcomes in Elderly Patients

OBJECTIVE

To explore the effect of diabetes on short-term (30 days after fracture) and 1-year outcomes for fragility hip fracture patients.

METHODS

We conducted a retrospective cohort study involving 161 diabetic hip fracture patients (older than 60 years) and 483 nondiabetic hip fracture patients. Patients were followed up on day 30 and 1 year after fracture. The short-term outcome was complications that occurred within 30 days after hip fracture and length of stay. The 1-year outcomes were postfracture functional outcomes and reduced activity level and mortality rate within 1 year after fracture. The clinical characteristics and outcomes of patients were analyzed.

RESULTS

Compared with nondiabetic patients, diabetic patients had a longer length of awaiting surgery (6.0 vs. 5.0 days, P=0.031) and a longer length of total hospital stay (17 vs. 15 days, P < 0.001). Furthermore, compared with nondiabetic patients, diabetic patients have higher costs (P=0.011), in addition to being more prone to developing urinary tract infections (6.2% vs. 1.7%, P=0.002) and deep vein thrombosis (4.3% vs. 1.4%, P=0.029) complications. However, at one-year follow-up, no differences in recovery of function and mortality were observed between the two groups.

CONCLUSIONS

Diabetic patients are at an increased risk of urinary tract infections and deep vein thrombosis complications but have similar recovery of function and 1-year mortality compared to nondiabetic patients.

Relationship between frailty and mortality, hospitalization, and cardiovascular diseases in diabetes: a systematic review and meta-analysis

Background

In patients with diabetes, death and cardiovascular diseases are attributed to classical risk factors such as hypertension, dyslipidemia, and smoking habit, whereas these events are attributed to frailty in the remaining patients. In this meta-analysis, we examined the relationship between frailty and mortality, hospitalization, and cardiovascular diseases in patients with diabetes.

Methods

Literature search was conducted using databases such as MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. Studies that examined the relationship between frailty and mortality, hospitalization, and cardiovascular disease and included hazard ratios (HRs), odds ratios (ORs), and 95% confidence intervals (CIs) were included. Statistical analysis was performed using a random effects model, and pooled HRs, pooled ORs, and 95% CIs were calculated.

Results

The literature search extracted 8 studies (565,039 patients) that met our inclusion criteria, which were included in this meta-analysis. The pooled HR of prefrailty and frailty related to mortality was 1.09 (95% CI 1.01–1.17; P = 0.02) and 1.35 (95% CI 1.05–1.74; P = 0.02), respectively, indicating a significant relationship between them. The pooled OR of prefrailty and frailty related to hospitalization was 2.15 (95% CI 1.30–3.54; P = 0.003) and 5.18 (95% CI 2.68–9.99; P < 0.001), respectively, indicating a significant relationship. Although a significant relationship was found between frailty and cardiovascular diseases, we found only few related studies; thus, robust results could not be obtained.

Conclusions

In patients with diabetes, a significant relationship was observed between frailty and mortality and hospitalization. However, only few heterogeneous studies were included, warranting further examination.

Functional Exercise Improves Mobility Performance in Older Adults With Type 2 Diabetes: A Randomized Controlled Trial

Background: Diabetes-related disability occurs in approximately two-thirds of older adults with diabetes and is associated with loss of independence, increased health care resource utilization, and sedentary lifestyle. The objective of this randomized controlled trial was to determine the effect of a center-based functional circuit exercise training intervention followed by a 10-week customized home-based program in improving mobility function in sedentary older adults with diabetes. Methods: Participants (n = 111; mean age 70.5 [7.1] y; mean body mass index 32.7 [5.9] kg/m²) were randomized to either a moderate-intensity functional circuit training (FCT) plus 10-week home program to optimize physical activity (FCT-PA) primary intervention or one of 2 comparison groups (FCT plus health education [FCT-HE] or flexibility and toning plus health education [FT-HE]). Results: Compared with FT-HE, FCT-PA improvements in comfortable gait speed of 0.1 m/s (P < .05) and 6-minute walk of 80 ft were consistent with estimates of clinically meaningful change. At 20 weeks, controlling for 10-week outcomes, improvements were found between groups for comfortable gait speed (FCT-PA vs FT-HE and FCT-HE vs FT-HE) and 6-minute walk (FCT-PA vs FCT-HE). Conclusions: Functional exercise training can improve mobility in overweight/obese older adults with diabetes and related comorbidities. Future studies should evaluate intervention sustainability and adaptations for those with more severe mobility impairments.

Evidence-Based Management of Diabetes in Older Adults

The number of older adults with diabetes is rapidly increasing worldwide. A variety of factors contribute to the age-related increase in the incidence of diabetes. The lack of empiric evidence in the field has limited the management guidelines to mostly expert opinion. Given uncertainty over the rate at which to lower blood glucose levels and the optimal method of doing so, the goals of diabetes control in older people must be individualized. If the patient requires insulin therapy, the newer insulins, with their improved pharmacodynamic consistency and reduced risk of hypoglycemia, should be preferred. Several oral agents are preferable for people with sufficient endogenous insulin because they do not cause hypoglycemia when used as monotherapy. Some of these oral agents have been found to have cardioprotective effects. Older people with diabetes also require management of the other risk factors for cardiovascular disease, with antihypertensive drugs, cholesterol-lowering agents and low-dose aspirin. However, the precise targets for blood pressure control and low-density lipoprotein (LDL) cholesterol levels continue to evolve as more data become available. Diabetes care in older adults should focus on enhancing the individual's quality of life rather than trying to normalize blood glucose levels or reach predetermined blood pressure and LDL cholesterol targets.

Using the Centers for Disease Control and Prevention's Stay Independent Checklist to Engage a Community of American Indians and Raise Awareness About Risk of Falls, 2016

Background

The unintentional death rate from falls is higher among American Indians from the US Southwest than from other regions in the country. The Zuni Pueblo is a geographically isolated, rural American Indian community located in western New Mexico. Education and screening for falls risk is lacking in this community and may be needed to reduce falls and falls-related illness and death.

Community Context

Building on a 17-year relationship with the Zuni Health Initiative, meetings were held with Zuni tribal leadership, staff from the Zuni Senior Center and Zuni Home Health Services, members of the Zuni Comprehensive Community Health Center, Indian Health Service, and Zuni community health representatives (CHRs) to discuss elder falls in the community. Existing infrastructure, including CHRs who were already trained and certified in diabetes education and prevention, provided support for the study.

Methods

Tribal leadership agreed that CHRs would be trained to administer the Centers for Disease Control and Prevention’s (CDC’s) Stay Independent checklist to assess falls risk. They administered the checklist during one-on-one interviews in Shiwi (Zuni native language), English, or both to a convenience sample of 50 Zuni elders.

Outcomes

Mean age of participants was 72 (standard deviation, 7.4) years, and 78% were women. Fifty-two percent reported at least 1 fall during the past year; 66% scored 4 or more on the CDC Stay Independent checklist, indicating elevated risk for falls. CHRs reported that the checklist was easy to administer and culturally accepted by the elder participants.

Interpretation

This study broadened the Zuni Health Initiative to include falls risk screening. Self-reported falls were common in this small sample, and the incidence was significantly higher than the national rate. These results highlight the need for community engagement, using culturally acceptable falls screening, to promote falls education and implement falls prevention programs.

Diabetes Nurse Educators' Prioritized Elder Foot Care Behaviors

Purpose

The purpose of this study was to identify diabetes nurse educators' perceptions of the most important foot care behaviors for elderly people to enact in daily care.

Methods

A structured, open-ended questionnaire was mailed to a regionally stratified random sample of 90 diabetes nurse educators. Subjects were asked to identify and rank order 8 foot care behaviors perceived important for elderly people with diabetes to enact daily. Data were transcribed and coded into categories and domains using descriptive content analysis.

Results

Forty-seven diabetes nurse educators responded with a total of 346 foot care behaviors perceived important for elders. Twenty-one major foot care behavior content categories were grouped into 4 domains of descending importance: foot/nail care, footwear/shoes, general health, and foot emergencies.

Conclusions

Diabetes nurse educators generated a range of baseline data for developing a reliable, valid, and patient foot care knowledge outcome measure to support national diabetes patient education and self-management program guidelines.

Primary care-public health linkages: Older primary care patients with prediabetes & type 2 diabetes encouraged to attend community-based senior centers

The Institute of Medicine (IOM) suggests that primary care-public health integration can improve health outcomes for vulnerable patients, but the extent to which formal linkages may enhance patients' use of community resources, or the factors that may influence providers to encourage their patients to use these resources, remain unclear. We conducted baseline assessments in 2014-2015 with 149 older adults with prediabetes or diabetes who had recently joined three senior centers linked to a network of primary care clinics in San Antonio, Texas. In addition to collecting sociodemographic and clinical characteristics, we asked members to identify their source of primary care and whether a health care provider had encouraged them to go to the senior center. We also asked members why they had joined the senior centers and which programs interested them the most. Members' source of primary care was not associated with being encouraged to attend the senior centers by a health care professional. Multivariable analysis indicated that participants with total annual household incomes of $20,000 or less [OR = 2.78; 95% CI = (1.05, 7.14)] and those reporting 12 years of education or less [OR = 3.57; 95% CI = (1.11, 11.11)] were significantly more likely to report being encouraged to attend the senior center by a health care provider. Providers who are aware of community-based resources to support patient self-management may be just as likely to encourage their socioeconomically vulnerable patients with prediabetes or diabetes to use them as providers who have a more formal partnership with the senior centers.

Pioglitazone is equally effective for diabetes prevention in older versus younger adults with impaired glucose tolerance

To determine the efficacy of pioglitazone to prevent type 2 diabetes in older compared to younger adults with pre-diabetes. Six hundred two participants with impaired glucose tolerance (IGT) were randomized in double blind fashion to placebo or pioglitazone for diabetes prevention in the ACT NOW study (NEJM 364:1104-1115, 2011). Cox proportional hazard regression was used to compare time to development of diabetes over a mean of 2 years between older (≥61 years) and younger participants. We compared effects of pioglitazone versus placebo on metabolic profiles, inflammatory markers, adipokines, β cell function (disposition index), insulin sensitivity (Matsuda index), and body composition by ANOVA. Diabetes incidence was reduced by 85 % in older and 69 % in younger subjects (p = 0.41). β cell function (disposition index) increased by 35.0 % in the older and 26.7 % in younger subjects (p = 0.83). Insulin sensitivity (Matsuda index) increased by 3.07 (5.2-fold) in older and by 2.54 (3.8-fold) in younger participants (p = 0.58). Pioglitazone more effectively increased adiponectin in older versus younger subjects (22.9 ± 3.2 μg/mL [2.7-fold] vs. 12.7 ± 1.4 μg/mL [2.2-fold], respectively; p = 0.04). Younger subjects tended to have a greater increase in whole body fat mass compared to older subjects (3.6 vs. 3.1 kg; p = 0.061). Younger and older subjects had similar decreases in bone mineral density (0.018 ± 0.0071 vs. 0.0138 ± 0.021 g/cm2). Younger and older pre-diabetic adults taking pioglitazone had similar reductions in conversion to diabetes and older adults had similar or greater improvements in metabolic risk factors, demonstrating that pioglitazone is useful in preventing diabetes in older adults.

Review: Cardiovascular risk and diabetes in old people

he transitions that took place during the second half of the 20th century produced an increase in the prevalence of cardiovascular diseases and demographic changes have brought the focus to older people. The necessity to improve the control of cardiovascular diseases and the unsatisfactory performance of available therapeutic approaches moved some of the attention to cardiovascular risk factors. Among them, one of the most outstanding is diabetes which many consider to be a cardiovascular disease equivalent. It became evident that cardiovascular risk factors act jointly, and the way to tackle them must follow a global strategy. At the end of the last century several cardiovascular risk factor tables were produced with the focus being on middle-age people, who formed the main database for studies in cardiovascular disease. However, an increasing proportion of patients are older and in this group current approaches to cardiovascular risk estimation may not be the most suitable.

A real-world study of the effect of timing of insulin initiation on outcomes in older medicare beneficiaries with type 2 diabetes mellitus

OBJECTIVES

To compare clinical and economic outcomes of early insulin initiation with those of delayed initiation in older adults with type 2 diabetes mellitus (T2DM).

DESIGN

Retrospective cohort study.

SETTING

Humana Medicare Advantage health insurance plan.

PARTICIPANTS

Older (≥65) Medicare beneficiaries with T2DM.

MEASUREMENTS

Subjects were grouped according to number of classes of oral antidiabetes drugs (OADs) they had taken before initiation of insulin: one (early insulin initiators), two, or three or more (delayed insulin initiators). One-year follow-up outcomes included change in glycosylated hemoglobin (HbA1c), percentage of older adults with HbA1c less than 8.0%, hypoglycemic events, and total healthcare costs.

RESULTS

Overall, 14,669 individuals were included in the analysis. Baseline and 1-year follow-up HbA1c levels were available for 4,028 (27.5%) individuals. Insulin was initiated early in 32% and delayed in 20%. At follow-up, unadjusted reduction in HbA1c was 0.9±3.7% for the group with one OAD, 0.7±2.4% for those with two, and 0.5±3.6% for those with three or more. Early insulin initiation was associated with significantly greater reduction in HbA1c (0.4%; adjusted P<.001), 30% greater likelihood of achieving HbA1c less than 8.0% (adjusted odds ratio=1.30, 95% confidence interval=1.18-1.43), and no significant differences in total costs or hypoglycemia events (11.5% of early initiators vs 10.2% of delayed initiators; P=.32).

CONCLUSION

This study suggests beneficial effects of early insulin initiation in older adults with T2DM who do not have adequate glycemic control, without increasing the risk of hypoglycemia or greater total direct healthcare costs.

Diabetes in older people: new insights and remaining challenges

Diabetes in ageing communities imposes a substantial personal and public health burden by virtue of its high prevalence, its capacity to cause disabling vascular complications, the emergence of new non-vascular complications, and the effects of frailty. In this Review, we examine the current state of knowledge about diabetes in older people (aged ≥ 75 years) and discuss how recognition of the effect of frailty and disability is beginning to lead to new management approaches. A multidimensional and multidisciplinary assessment process is essential to obtain information on medical, psychosocial, and functional capabilities, and also on how impairments of these functions could limit activities. Major aims of diabetes care include maintenance of independence, functional status, and quality of life by reduction of symptom and medicine burden, and active identification of risks. Linking of therapeutic targets to individual functional status is mandatory and very tight glucose control is often not necessary. Hypoglycaemia remains an important avoidable iatrogenic event. Quality diabetes care in older people remains an important challenge for health professionals.

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.

Assessment of an Expanded Functional Disability Scale for Older Adults With Diabetes

Although prior literature has shown the plausibility of combining the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) items to form an expanded scale for measuring the degree of functional decline, this has not been shown in older adults with diabetes who are disproportionately affected by functional disability. Using the 2009 Medicare Current Beneficiary Survey data, we evaluated the factor structure of the pooled ADL and IADL items. Based on our study comprising 2,158 community-dwelling older adults (≥65 years) with diabetes, the unidimensional model exhibited good fit. Despite well-fitting indices, high correlations were observed between the latent constructs (>.70) of the multi-factor models, suggesting a lack of discriminant validity. These findings provide empirical support for a combined scale that can comprehensively and efficiently characterize the extent of functional disability in older adults with diabetes for research, risk adjustment, and evaluation in patient-centered medical homes.

Avaliação da capacidade funcional dos idosos e fatores associados à incapacidade

O objetivo deste estudo foi avaliar a capacidade funcional e analisar as características associadas à incapacidade dos idosos atendidos em uma Estratégia da Saúde da Família em Montes Claros-MG. Utilizou-se a escala de Lawton e Brody e a escala de Katz, analisadas pela regressão logística multinomial. Foram entrevistados 286 idosos cuja idade variou de 60 a 103 anos, média de 71,2 anos (DP ± 8,3). Destes, 61,9% autorreferiram independentes quanto à capacidade funcional. A dependência apenas na AIVD foi positivamente associada à faixa etária ≥ 75 anos (OR = 8,38), ao sexo feminino (OR = 3,64) e com doença cardíaca (OR = 3,24). A dependência tanto nas AIVD como nas ABVD foi positivamente associada à faixa etária ≥ 75 anos (OR = 6,40), sem companheiro (OR = 3,26), aos que apresentavam AVE (OR = 51,85), doença cardíaca (OR = 4,18) e aos com diabetes (OR = 3,35). A maior proporção de idosos foi considerada independente para a realização de atividades básicas e instrumentais de vida diária. Contudo, uma parcela expressiva ainda apresenta comprometimento do estado funcional. É essencial que as equipes da Estratégia da Saúde da Família busquem a promoção da saúde e a prevenção de doenças, além de intervenções terapêuticas que possam minimizar os fatores que interferem na capacidade funcional.

Management of diabetes mellitus type-2 in the geriatric population: Current perspectives

The prevalence of diabetes mellitus (DM) has increased exponentially throughout the world and there is rapid increase in elderly diabetics. DM is associated with increased mortality and considerable morbidity including stroke, heart disease, and diminished quality of life in the elderly. However, the unique features of geriatric diabetes have not been given due a prominence in medical literature. Hypoglycemia remains the biggest complicating factor and needs to be avoided in the elderly. Most people in the geriatric age group have some degree of renal insufficiency and medications need to be adjusted wisely with changing renal profile. Because safer and more effective pharmacological therapy is available, an individual approach to DM in the elderly is essential.

Genetic ablation of tau mitigates cognitive impairment induced by type 1 diabetes

Patients affected by diabetes show an increased risk of developing Alzheimer disease (AD). Similarly, patients with AD show impaired insulin function and glucose metabolism. However, the underlying molecular mechanisms connecting these two disorders are still not well understood. Herein, we investigated the microtubule-associated protein tau as a new link between AD and diabetes. To determine whether diabetes causes cognitive decline by a tau-dependent mechanism, we treated non-transgenic (Ntg) and tau-knockout mice with streptozotocin, causing type 1 diabetes-like disease (T1D). Interestingly, although induction of T1D in Ntg mice led to cellular and behavioral deficits, it did not do so in tau-knockout mice. Thus, data suggest that tau is a fundamental mediator of the induction of cognitive impairments in T1D. Tau dysregulation, which causes a reduction in synaptic protein levels, may be responsible for the cognitive decline observed in Ntg streptozotocin-treated mice. Concomitantly, we demonstrate the novel finding that depletion of endogenous tau mitigates behavioral impairment and synaptic deficits induced in T1D-like mice. Overall, our data reveal that tau is a key molecular factor responsible for the induction of cognitive deficits observed in T1D and represents a potential therapeutic target for diabetes and patients with AD.

Direct social support and long-term health among middle-aged and older adults with type 2 diabetes mellitus

OBJECTIVES

This study examined whether or not direct social support is associated with long-term health among middle-aged and older adults with diabetes mellitus.

METHOD

Direct social support was assessed at baseline (2003) for 1,099 adults with type 2 diabetes mellitus from the Health and Retirement Study. Self-reported health status was examined at baseline and in 4 biennial survey waves (2003-2010). A series of ordinal logistic regression models examined whether or not the 7-item Diabetes Care Profile scale was associated with a subsequent change in health status over time. Additional analyses examined whether or not individual components of direct social support were associated with health status change.

RESULTS

After adjusting for baseline covariates, greater direct social support as measured by the Diabetes Care Profile was associated with improved health outcomes over time; however, this trend was not significant (p = .06). The direct social support measures that were associated with improved health over follow-up were support for taking medicines (odds ratio [OR] = 1.22), physical activity (OR = 1.26), and going to health care providers (OR = 1.22; all p < .05).

DISCUSSION

Interventions that specifically target improving specific aspects of diabetes social support may be more effective in improving long-term health than less targeted efforts.

Observational study of once-daily insulin detemir in people with type 2 diabetes aged 75 years or older: a sub-analysis of data from the Study of Once daily LeVEmir (SOLVE)

OBJECTIVES

Older patients are particularly vulnerable to hypoglycaemia. The aim of this study was to evaluate the response to initiation of once-daily insulin detemir in patients aged ≥75 years with type 2 diabetes mellitus (T2DM) treated with one or more oral antidiabetic drugs (OADs).

METHODS

A sub-analysis was conducted using data from SOLVE (Study of Once daily LeVEmir), a 24-week observational study involving 3,219 investigators and 2,817 project sites from ten countries. Routine clinical practice was followed; there were no study-prescribed procedures. The total cohort comprised 17,374 participants, of whom 2,398 (14 %) were aged ≥75 years. The physicians collected information from patient recall, the patients' medical records and their self-monitored blood glucose diaries (if kept).

RESULTS

Pre-insulin glycated haemoglobin (HbA(1c)) was similar between participants aged ≥75 years and those aged <75 years (HbA(1c) 8.8 ± 1.5 % vs. 8.9 ± 1.6 % [mean ± SD], respectively). After 24 weeks of treatment, similar reductions in HbA(1c) were observed in the two subgroups: 7.6 ± 1.1 % and 7.5 ± 1.2 % in participants aged ≥75 years and those aged <75 years, respectively. The incidence of severe hypoglycaemia (episodes per patient-year) decreased during the study in both age groups (from 0.057 to 0.007 in patients aged ≥75 years; from 0.042 to 0.005 in patients aged <75 years), while minor hypoglycaemia increased from 1.1 to 2.0 and from 1.7 to 1.8 episodes per patient-year in the older and younger age groups, respectively. Average weight reduction was similar in both groups: -0.5 kg (≥75 years) and -0.6 kg (<75 years).

CONCLUSION

In both the older and younger age groups, the addition of once-daily insulin detemir to existing OAD regimens was effective and safe. In older patients, an improvement in HbA(1c) of 1.2 % was not associated with an increased risk of severe hypoglycaemia or weight gain.

Evaluation of an intra-institutional diabetes disease management program for the glycemic control of elderly long-term care diabetic patients

AIM

Increasing numbers of nursing home elderly patients suffer from diabetes requiring individually optimized glycemic control. This is a complicated challenge because of their high comorbidity level, and heterogeneous and changing eating status varying from independent to dysphagia and enteral feeding. In order to cope with these complex needs, we developed and implemented a diabetes disease management program. The purpose of the present study was to evaluate this program.

METHODS

We used the point prevalence approach by checking for fasting blood glucose, glycated hemoglobin and other routine biochemical tests. Eating status was evaluated by the Functional Outcome Swallowing Scale. Details about the diabetes disease management program are given in the text.

RESULTS

A total of 86 (36%) of the 234 patients on the study day were diabetics. Of these, 80 were eligible for the study. Their mean fasting blood glucose was 143.1 ± 60.6 mg/dL. The mean glycated hemoglobin level was 7.23 ± 1.39%.

CONCLUSION

No case of hypoglycemia was detected on the examination day, or during the preceding 3 weeks. No significant difference was found among the different Functional Outcome Swallowing Scale categories. These results are within satisfactory range for this category of patients suggesting that our diabetes disease management program contributes to a better glycemic control.

Clinical frailty and long-term mortality in elderly subjects with diabetes

Elderly subjects are characterized by a high prevalence of diabetes and clinical frailty. This study aimed to examine the predictive role of clinical frailty on long-term mortality in elderly subjects with and without diabetes. The study evaluated mortality after 12-year follow-up in 188 subjects with diabetes and 1,100 subjects without diabetes selected in 1992. Clinical frailty was assessed according to the "Frailty Staging System" and stratified in tertiles. After 12-year follow-up, mortality was 50.5 % in subjects without and 66.5 % in subjects with diabetes (p < 0.001). With increasing frailty, mortality increases from 57.9 to 79.0 % (p for trend <0.01) in subjects without and from 75.9 to 87.0 % in subjects with diabetes (p for trend <0.001). Multivariate analysis shows that both diabetes (hazard ratio = 1.38; 95 % confidence interval = 1.12-1.95; p = 0.02) and frailty score (hazard ratio = 1.58 for each unit of increase; 95 % confidence interval = 1.41-2.35; p = 0.04) are predictive of long-term mortality. Moreover, when Cox regression analysis was performed by selecting sex, frailty increases the risk of long-term mortality for each unit of increase by 14 % (hazard ratio = 1.14; 95 % confidence interval = 1.10-1.18; p < 0.01) in women and by 60 % in men (hazard ratio = 1.60; 95 % confidence interval = 1.21-2.12; p < 0.001) in the absence and by 31 % (Hazard ratio = 1.31, 95 % confidence interval = 1.03-1.85, p = 0.03) in women and by 60 % in men (hazard ratio = 1.99, 95 % confidence interval = 1.75-3.05, p < 0.001) in the presence of diabetes, respectively. We concluded that diabetes predicts long-term mortality in elderly subjects. Moreover, clinical frailty significantly predicts mortality in subjects without and even more in those with diabetes. This phenomenon is particularly evident in men. Thus, clinical frailty may be considered a new prognostic factor to identify subjects with diabetes at high risk of mortality.

Treatment of type 2 diabetes in the elderly

As the number of older adults increases in the United States and worldwide, management of patients with multiple coexisting chronic diseases has become a critical component in health care. Management of diabetes is particularly challenging in this population due to significant risks of microvascular and macrovascular diseases on the one hand, and complications of the treatment strategies (e.g., hypoglycemia) with intensive control on the other hand. To provide a balanced approach to diabetes in the elderly, a comprehensive and holistic strategy, with consideration of overall health, functional status, psychosocial environment, financial resources and, finally but most importantly, quality of life is needed. Understanding the unique challenges faced by older adults with diabetes and issues pertaining to antidiabetes medications with aging is an important first step in the direction of better and tailored care of this burgeoning population.

Special considerations with insulin therapy in older adults with diabetes mellitus

Aging is associated with alterations in insulin secretion and action. However, aging per se does not alter the pharmacokinetics of commercially available insulin and its analogues. Insulin therapy in older adults is complicated by psychosocial and physiological changes of aging. Several new insulin and insulin analogue preparations are now available for clinical use. Used as prandial (e.g. insulin lispro, insulin aspart or insulin glulisine) and basal insulin (e.g. insulin glargine, insulin detemir), these analogues simulate physiological insulin profiles more closely than the older conventional insulins. The availability of multiple insulin products provides new opportunities to achieve control of diabetes mellitus. The choice of initial insulin therapy can be made based on blood glucose profiles. Overall, these profiles can be divided into three general patterns that include: (i) round-the-clock hyperglycaemia; (ii) fasting hyperglycaemia with daytime euglycaemia; and (iii) daytime hyperglycaemia with normal fasting blood glucose levels. The prescription of insulin is a dynamic process, and the insulin regimen should be adjusted based on individual response. The goal of diabetes care in older adults is to enhance quality of life without subjecting individuals to complicated treatment regimens that may interfere with their independence in carrying out daily activities.

The excess mortality risk of diabetes associated with functional decline in older adults: results from a 7-year follow-up of a nationwide cohort in Taiwan

BACKGROUND

Diabetes is associated with an increased risk of functional decline in older adults. Few studies have investigated the contribution of functional decline to excess mortality risk in older people with diabetes. The aim of this study was to examine how diabetes in combination with different levels of functional decline affects 7-year mortality in older adults.

METHODS

We analyzed data from a nationally representative sample of people aged 65 years and over, participating in the 2001 National Health Interview Survey in Taiwan. A total of 1873 participants were followed through 2002-2008, of whom 286 (15.3%) had a history of diabetes confirmed by a medical professional. Participants were divided into three functional status groups: (1) high functioning-no limitations involving activities of daily living (ADLs), instrumental activities of daily living (IADLs), or physical functioning; (2) low functioning-limitations in one or more ADLs; (3) middle functioning-all participants in between groups 1 and 2.

RESULTS

The crude mortality rate was 52.7 per 1,000 person-years in those with diabetes and 34.1 per 1,000 person-years in those without diabetes. After adjustment for other factors, diabetes alone was not associated with an increased mortality risk in those with high functioning. However, diabetes alone had a hazard ratio (HR) for mortality of 1.90 (95%CI = [1.02-3.53]) in those with middle functioning and 3.67 (95%CI = [1.55-8.69]) in those with low functioning. The presence of diabetes and one or more other chronic conditions was associated with a HR for mortality of 2.46 (95%CI = [1.61-3.77]) in those with middle functioning and 4.03 (95%CI = [2.31-7.03]) in those with low functioning.

CONCLUSIONS

Our results indicate that diabetes is not associated with increased mortality in those with high functioning. There was a gradient effect of functional decline on mortality in individuals with diabetes. Additionally, among participants with other chronic conditions, functional decline was associated with a greater burden of mortality in older adults with diabetes. These findings highlight the critical importance of the prevention of cardiovascular disease morbidity and the maintenance of functional abilities in order to reduce mortality risk in older adults with diabetes.

Sarcopenia and diabetes: pathogenesis and consequences

Sarcopenia, loss of muscle mass with age, is considered as a major cause of frailty and decreased independence in the elderly population. On the other hand, ageing is associated with an increase in prevalence of diabetes. In this review, we discuss the pathophysiological basis of sarcopenia and its relationship to oxidative stress and insulin resistance state, which contribute to development of glucose intolerance and type 2 diabetes. We will also discuss some ideas on the consequences and treatment of sarcopenia.

Factors influencing the outcomes of patients with both coronary artery disease and diabetes enrolled in standard cardiac rehabilitation programs: a literature review

Currently 23.5 million working-age adults 20 years or older have had a diagnosis of both coronary artery disease (CAD) and type 2 diabetes mellitus (T2DM), with estimates that an additional 9% of the total US population will have a diagnosis of this chronic disease combination by the year 2025. Current annual health care costs for this working-age population including medical costs, functional disability, work loss, and premature mortality currently exceed $620 billion. Prior research efforts have shown that 25% to 32% of patients requiring a coronary revascularization procedure have both CAD and T2DM. The primary intervention prescribed for these patients to regain functional ability after revascularization is enrollment in a standard outpatient cardiac rehabilitation (CR) program. These standard programs, ranging in duration from 6 to 12 weeks, have been shown to improve the physical function of CAD patients by up to 15%, but patients diagnosed with both chronic conditions of CAD and T2DM (T2DM+CAD) attending these same programs exhibit only an 8% improvement. Moreover, T2DM+CAD patients experience much lower rates of rehabilitation program appointment adherence as well as greater program attrition (T2DM+CAD: 45%-62% vs CAD: 92%). Current medical literature regarding the relationship between CAD, T2DM, and cardiac rehabilitation will be examined to identify specific factors that could influence the functional outcomes achieved by the T2DM+CAD population when enrolled in a standard CR program and help increase understanding of why the adherence and attrition differences exist.

Biodemography: new approaches to understanding trends and differences in population health and mortality

The incorporation of biological information in large population surveys has expanded demographic analysis to clarify the meaning of observed trends and differences in population health and mortality. Levels of measured biological risk in the population were reduced in recent years largely because of the expanded use of prescription drugs. The increased use of antihypertensives and, to a lesser extent, lipid-lowering drugs was a likely cause of significant mortality reduction. Blacks and persons with lower educational attainment experience higher levels of biological risk factors, more diseases, and more frailty; these differences are the sources of higher mortality for these groups. Hispanics are less likely to have a higher prevalence of risk factors and diseases than the non-Hispanic population, providing further understanding of the "Hispanic paradox." Almost every examined indicator of biological risk, disease, and frailty is related to higher mortality, indicating how incorporation of this information provides a fuller understanding of the morbidity process.

Physical disability trajectories in older Americans with and without diabetes: the role of age, gender, race or ethnicity, and education

PURPOSE

This research combined cross-sectional and longitudinal data to characterize age-related trajectories in physical disability for adults with and without diabetes in the United States and to investigate if those patterns differ by age, gender, race or ethnicity, and education.

DESIGN AND METHODS

Data were examined on 20,433 adults aged 51 and older from the 1998 to 2006 Health and Retirement Study. Multilevel models and a cohort-sequential design were applied to quantitatively depict the age norm of physical disability after age 50.

RESULTS

Adults with diabetes not only experience greater levels of physical disability but also faster rates of deterioration over time. This pattern is net of attrition, time-invariant sociodemographic factors, and time-varying chronic disease conditions. Differences in physical disability between adults with and without diabetes were more pronounced in women, non-White, and those of lower education. The moderating effects of gender and education remained robust even after controlling for selected covariates in the model.

IMPLICATIONS

This study highlighted the consistently greater development of disability over time in adults with diabetes and particularly in those who are women, non-White, or adults of lower education. Future studies are recommended to examine the mechanisms underlying the differential effects of diabetes on physical disability by gender and education.

Assessment of cognitive status in patients with type 2 diabetes through the Mini-Mental Status Examination: a cross-sectional study

BACKGROUND

Diabetes is considered an independent risk factor for cognitive impairment and some studies observed through neuropsychological tests that cognitive disfunction affects both elderly and younger patients with diabetes. The aims of this study were to evaluate the cognitive status of outpatients with type 2 diabetes and to evaluate factors associated with impaired function.

METHODS

A cross-sectional study was conducted in a group of type 2 diabetic outpatients. They were asked to undergo the Mini-Mental State Examination (MMSE) during routine ambulatory visits between April 2006 and January 2007, with the highest pontuation of the test being 30 points. Patients were classified as having possible dementia according to years of study. Exclusion criteria were blindness, illiteracy, stroke, Alzheimer disease and psychiatric disorder. Results are presented as median (interquartile range) or mean +/- SD.

RESULTS

The study group was composed of 346 type 2 diabetic outpatients (216 females), aged 58,6 +/- 12,1 years and with duration of diabetes of 12,3 +/- 9,1 years. Hypertension was present in 77,2%. The total MMSE score achieved was 26 points (16 - 30) and was correlated with years of study (R2 = 0,39, p < 0,001) and 'per capita' income (R2 = 0,22, p < 0,0001) and duration of diabetes (R2 = - 0,13, p = 0,01). Patients who needed help to take their medications obtained worst performance in the MMSE (23,16 +/- 3,55 vs 25,7 +/- 2,84, p < 0,01) and were more likely to present possible dementia (p < 0,01). Forty two subjects (12.1%) had diagnosis of possible dementia and this was also associated with years of study (p = 0,045). No association was observed between possible dementia and total MMSE scores with A1C levels.

CONCLUSIONS

We conclude that patients with type 2 diabetes should be regularly evaluated for their cognitive function, because duration of disease could be associated with decline in cognition. The early implementation of mini mental which is a simple method of execution can be done to detect early stages of dementia. This test could be an important tool to access the ability of patient to understand their disease and treatment.

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

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

Diabetes-related support, regimen adherence, and health decline among older adults

OBJECTIVES. Social support is generally conceptualized as health promoting; however, there is little consensus regarding the mechanisms through which support is protective. Illness support has been proposed to promote regimen adherence and subsequent prevention of health decline. We hypothesize that (a) support for regimen adherence is negatively associated with self-reported health decline among older diabetic adults and that (b) regimen adherence is negatively associated with health decline among older diabetic adults.

METHODS

We used the Health and Retirement Study data on individuals over the age of 60 years with type 2 diabetes mellitus (n = 1,788), examining change in self-reported health status over a 2-year period using binomial and cumulative ordinal logistic regression models.

RESULTS

Diabetic support is not significantly associated with health decline, but it is strongly associated with adherence to health-promoting activities consisting of a diabetic regimen. Therefore, the extent to which one receives illness support for a given regimen component is highly positively associated with adhering to that component, although this adherence does not necessarily translate into protection against perceived decline in health.

CONCLUSIONS

Illness-related support appears to be a mechanism through which social support matters in the diabetic population. Although this relationship did not extend to prevention of health status decline among diabetics, the relationship between support and illness management is promising.

Is hyperglycemia associated with frailty status in older women?

OBJECTIVES

To determine whether hyperglycemia is related to prevalent frailty status in older women.

DESIGN

Secondary data analysis of baseline data of a prospective cohort study.

SETTING

Baltimore, Maryland.

PARTICIPANTS

Five hundred forty-three women aged 70 to 79.

METHODS

Research used baseline data from 543 participants in the Women's Health and Aging Studies I and II aged 70 to 79 who had all variables needed for analyses. The dependent variable was baseline frailty status (not frail, prefrail, frail), measured using an empirically derived model defining frailty according to weight loss, slow walking speed, weakness, exhaustion, and low activity (1-2 characteristics present=prefrail, > OR =3 =frail). Covariates included body mass index (BMI), interleukin-6 (IL-6), age, race, and several chronic diseases. Analyses included descriptive methods and multinomial logistic regression to adjust for key covariates.

RESULTS

A hemoglobin A1c (HbA1c) level of 6.5% or greater in older women was significantly associated with higher likelihood of prefrail and frail status (normal HbA1c <6.0% was reference). The association between HbA1C levels of 6.0% to 6.5% and frailty status was not different from that of normal HbA1c, but HbA1c levels of 6.5% to 6.9% had nearly twice the likelihood of frailty (odds ratio (OR)=1.96, 95% confidence interval (CI)=1.47-2.59) as normal HbA1c. A HbA1c level of 9.0% or greater was also strongly associated (OR=2.57, 95% CI=1.99,3.32). Significant associations were also seen between baseline prefrail and frail status and low (18.5-20.0 kg/m2) and high (430.0 kg/m2) body mass index (BMI), interleukin-6, and all chronic diseases evaluated, but controlling for these covariates only minimally attenuated the independent association between HbA1c and frailty status.

CONCLUSION

Hyperglycemia is associated with greater prevalence of prefrail and frail status; BMI, inflammation, and comorbidities do not explain the association. Longitudinal research and study of alternative pathways are needed.

Are health-related quality-of-life and self-rated health associated with mortality? Insights from Translating Research Into Action for Diabetes (TRIAD)

AIMS

To determine if health-related quality-of-life and self-rated health are associated with mortality in persons with diabetes.

METHODS

Survey and medical record data were obtained from 7892 patients with diabetes in Translating Research Into Action for Diabetes (TRIAD), a multicenter prospective observational study of diabetes care in managed care. Vital status at follow-up was determined from the National Death Index. Multivariable proportional hazard models were used to determine if a generic measure of health-related quality-of-life (EQ-5D) and self-rated health measured at baseline were associated with 4-year all-cause, cardiovascular, and noncardiovascular mortality.

RESULTS

At baseline, the mean EQ-5D score for decedents was 0.73 (S.D.=0.20) and for survivors was 0.81 (S.D.=0.18) (p<0.0001). Fifty-five percent of decedents and 36% of survivors (p<0.0001) rated their health as fair or poor. Lower EQ-5D scores and fair or poor self-rated health were associated with higher rates of mortality after adjusting for the demographic, socioeconomic, and clinical risk factors for mortality.

CONCLUSIONS

Health-related quality-of-life and self-rated health predict mortality in persons with diabetes. Health-related quality-of-life and self-rated health may provide additional information on patient risk independent of demographic, socioeconomic, and clinical risk factors for mortality.

[The concept and measurement of functional disability in the elderly population: a literature review]

This article aims to review the main concepts and measures of functional disability currently used in studies focusing on this subject. According to this review, functional disability can be defined as a difficulty or the need for help for performing basic or more complex daily activities necessary for keeping an independent life in the community. As refers to measurement criteria, the studies do not follow a clear-cut standard, varying substantially in relation to scales, dimensions and classifications besides depending directly or indirectly on the kind of available information. A correct method for rating functional disability does not exist at yet. For this reason it is essential that the researchers clearly indicate the concept of functional disability used in the studies and detail, which measures or tools were applied.

Occupational therapy in diabetic care-areas of need perceived by older adults with diabetes

This study explored the perception of older adults with diabetes regarding the areas of service considered helpful to their daily activities and routines. A survey questionnaire was designed and given to 52 community-dwelling older adults with diabetes. Results showed that cholesterol control, managing blood sugar, foot care, fatigue management and pacing, and pain management/reduction were the areas of most concern that deserve services. The findings suggest that, in providing holistic client-centered interventions to individuals with diabetes, occupational therapists need to be able to prioritize clients' concerns and help them incorporate diabetes management into their routines and lifestyle.

A tale of two countries--the United States and Japan: are differences in health due to differences in overweight?

Background

Despite similar standards of living and health care systems for older persons, there are marked differences in the relative health of the elderly populations in the United States (US) and Japan. We explore the association of overweight and obesity with these health disparities.

Methods

Data on older adults from the US National Health Interview Survey (1994) and the Longitudinal Study of Aging II (1994) were compared to similar data from the 1999-2001 Nihon University Japanese Longitudinal Study of Aging. Regression analyses for the 2 countries were conducted to examine the correlates of being overweight and obese, and the relationships of overweight and obesity with activities of daily living functioning, heart disease, arthritis, and diabetes.

Results

The prevalence of overweight and obesity is higher in the US than in Japan, as is the prevalence of heart disease, diabetes, arthritis, and functioning problems. Education level and marital status are predictors of overweight for older Americans but not for older Japanese people. Health behaviors affect weight in all groups. The prevalence of functioning problems and disease are more likely to be associated with being overweight in US men and women than in Japanese women, and are not associated with being overweight in Japanese men.

Conclusion

Despite similar standards of living and health care systems for older persons, the conditions associated with poor health differ in the US and Japan. Being overweight or obese appears to be related to more functioning problems and arthritis in the US than in Japan.

Outcomes of an intervention to reduce uncertainty among African American women with diabetes

Poor adjustment to diabetes in older African American women may result from uncertainty, stemming from a lack of information about self-care activities, a complexity of self-care activities, comorbid conditions, and a lack of resources. This study evaluated a telephone intervention to reduce uncertainty (through problem-solving strategies, information, cognitive reframing, and improved patient-provider communication)--namely, to measure its effects on diabetes self-care and psychosocial adjustment. Sixty-eight older African American women were randomly assigned to an experimental group and a control group. The experimental group received the intervention for 4 weeks, and the control group received usual care. Psychosocial adjustment and self-care were measured in all participants at baseline and 6 weeks postbaseline. The experimental group reported increased participation in exercise (self-care component; p < .001) and improvement in psychosocial adjustment (p < .001). Thus, reducing the uncertainty related to diabetes self-care improves self-care exercise, as well as psychosocial adjustment.

Health-related quality of life in low-income older African Americans

This study examined the relationships among comorbid conditions, symptom stress, depression, functional status and health-related quality of life (HRQOL) in low-income older African Americans with chronic diseases. A convenience sample of 83 older African American adults living in subsidized housing for elders participated in the study. Data were collected in face-to-face interviews. Participants reported lower scores on HRQOL than the SF-36 norms for age 60 or older in the general U.S. population. Comorbid conditions, symptom distress, depression, and functional status significantly predicted both the physical (F = 38.92, p < .001) and mental (F = 23.21, p < .001) health components of HRQOL, accounting for 63% of variance in the SF-36 physical health score and 55% of the variance in the SF-36 mental health score. The findings suggested that developing interventions to assist older African Americans to better manage their symptoms and depression are of prime importance for improving HRQOL.

Biomarkers related to aging in human populations

Biomarkers are increasingly employed in empirical studies of human populations to understand physiological processes that change with age, diseases whose onset appears linked to age, and the aging process itself. In this chapter, we describe some of the most commonly used biomarkers in population aging research, including their collection, associations with other markers, and relationships to health outcomes. We discuss biomarkers of the cardiovascular system, metabolic processes, inflammation, activity in the hypothalamic-pituitary axis (HPA) and sympathetic nervous system (SNS), and organ functioning (including kidney, lung, and heart). In addition, we note that markers of functioning of the central nervous system and genetic markers are now becoming part of population measurement. Where possible, we detail interrelationships between these markers by providing correlations between high risk levels of each marker from three population-based surveys: the National Health and Nutrition Examination Survey (NHANES) III, NHANES 1999-2002, and the MacArthur Study of Successful Aging. NHANES III is used instead of NHANES 1999-2002 when specific markers of interest are available only in NHANES III and when we examine the relationship of biomarkers to mortality which is only known for NHANES III. We also describe summary measures combining biomarkers across systems. Finally, we examine associations between individual markers and mortality and provide information about biomarkers of growing interest for future research in population aging and health.

Insulin use in elderly diabetic patients

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

Variation in antidiabetic medication intensity among Medicare beneficiaries with diabetes mellitus

BACKGROUND

Recent guidelines for treating older patients with diabetes mellitus (DM) and significant disease burden place less emphasis on glycemic control and stress the potential harms that may arise from adherence to strict regimens with antidiabetic medications. However, there are few empirical benchmarks against which clinicians can compare their prescribing practices for patients who have DM and varying levels of comorbidity.

OBJECTIVE

The current study had 2 goals: (1) to provide national estimates showing how the intensity of antidiabetic medication regimens for Medicare beneficiaries with DM varies by level of medical spending (a proxy for overall disease burden); and (2) to identify potential predictive factors associated with the observed differences.

METHODS

This study analyzed 2002 Medicare Current Beneficiary Survey (MCBS) data to benchmark intensity of antidiabetic medication regimens for Medicare beneficiaries with DM arrayed by decile of cumulative medical care spending. The study involved 3 steps: (1) stratification of the study population into 10 mutually exclusive deciles by cumulative all-source annual medical spending; (2) assessment of the unconditional association between decile assignment and intensity of antidiabetic medication use; and (3) identification of mediating factors that differentially explain medication intensity across the spectrum of disease burden. We evaluated 3 outcomes: (1) prevalence of any antidiabetic agent in 2002; (2) annual utilization rates for 5 different classes of oral hypoglycemic agents (sulfonylurea, metformin, thiazolidinedione, alpha-glucosidase inhibitors, and meglitinides) plus insulins; and (3) counts of annual prescription fills.

RESULTS

The final study sample comprised 1956 Medicare beneficiaries representing 23.1% of the MCBS sample after exclusions. We found a pronounced inverted U-shaped pattern in intensity of antidiabetic treatment. Compared with individuals in the group with the highest prevalence of antidiabetic use (decile 7), the unadjusted treatment odds ratios were 0.40 in decile 1 (95% CI, 0.26-0.60) and 0.54 in decile 10 (95% CI, 0.36-0.81). We found similar patterns in the complexity of drug regimens and numbers of antidiabetic prescriptions filled among users. Controlling for disease severity and other factors eliminated the inverted U-shaped pattern among higher cost beneficiaries but not for those in the lower spending deciles.

CONCLUSIONS

This national study found that high-cost Medicare beneficiaries with DM received substantially less intensive antidiabetic regimens compared with those incurring more modest medical expenditures in 2002. Longitudinal analysis is necessary to determine whether this finding indicates suboptimal therapy or has a more benign explanation. However, the magnitude of the association warrants the attention of clinicians who treat elderly and disabled diabetic patients with high disease burden.

Diabetes care in extended-care facilities: appropriate intensity of care?

OBJECTIVE

The American Diabetes Association (ADA) does not recognize different treatment goals for the institutionalized adult compared with the outpatient adult with diabetes, nor has it outlined specific recommendations for this population. The purpose of this study was to examine physician management of patients with type 1 and type 2 diabetes residing in extended-care facilities and to compare this management with ADA standards of care for the outpatient adult.

RESEARCH DESIGN AND METHODS

This retrospective chart review included data from 108 residents with type 1 or type 2 diabetes at 11 extended health care facilities in the Midwestern U.S. and included a review of the medical problem list, medication list, laboratory reports, and all physician and consultation notes during the study period.

RESULTS

Blood glucose was monitored in 98% of the subjects, and 38% met glucose goals. A1C goal was achieved in 67% of patients. Blood pressure was monitored in 94% of patients, with 55% meeting goal. Thirty-one percent of patients had yearly lipids checked, 37% had annual electrocardiograms, 7% had urine analyzed for microalbuminuria, 42% were on aspirin, 87% received foot exams, 42% received dilated eye exams, 89% received influenza vaccinations, and 46% received pneumoccocal vaccinations.

CONCLUSIONS

Care of the institutionalized elderly with diabetes fails to meet ADA standards of care for the outpatient adult. Separate practice guidelines are needed for people with diabetes who reside in extended care facilities in order to improve quality and consistency of care.

The relationships among health functioning indicators and depression in older adults with diabetes

A common health problem among the elderly with diabetes is the onset of depressive symptoms that can adversely affect self-care and control of diabetes. The study examined the relationships of gender, race, comorbid conditions, symptom distress, and functional status with depression in a sample (N = 55) of older adults with diabetes. Most participants were female and black; mean age was 73 years. Gender and symptom distress were the strongest predictors of depression, accounting for 53% of the variance in depression. Although the sample was reasonably high functioning with only moderate levels of symptom distress, these findings serve as an important reminder for nurses that even moderate levels of symptom distress may be an indicator of depressive symptomatology among older diabetic adults.