Guidelines for improving the care of the older person with diabetes mellitus

Impact of COVID-19 Pandemic on Healthcare Utilization in People with Diabetes: A Time-Segmented Longitudinal Study of Alberta's Tomorrow Project

OBJECTIVE

The objective is to characterize the impact of COVID-19 on major healthcare for diabetes, including hospitalization, emergency department (ED) visits and primary care visits in Alberta, Canada.

METHODS

Participants from Alberta's Tomorrow Project (ATP) with pre-existing diabetes prior to 1 April 2018 were included and followed up to 31 March 2021. A time-segmented regression model was used to characterize the impact of COVID-19 on healthcare utilization after adjusting for seasonality, socio-demographic factors, lifestyle behaviors and comorbidity profile of patients.

RESULTS

Among 6099 participants (53.5% females, age at diagnosis 56.1 ± 9.9 y), the overall rate of hospitalization, ED visits and primary care visits was 151.5, 525.9 and 8826.9 per 1000 person-year during the COVID-19 pandemic (up to 31 March 2021), which means they reduced by 12% and 22% and increased by 6%, compared to pre-pandemic rates, respectively. Specifically, the first COVID-19 state of emergency (first wave of the outbreak) was associated with reduced rates of hospitalization, ED visits and primary care visits, by 79.4% (95% CI: 61.3-89.0%), 93.2% (95% CI: 74.6-98.2%) and 65.7% (95% CI: 47.3-77.7%), respectively. During the second state of emergency, healthcare utilization continued to decrease; however, a rebound (increase) of ED visits was observed during the period when the public health state of emergency was relaxed.

CONCLUSION

The declared COVID-19 states of emergency had a negative impact on healthcare utilization for people with diabetes, especially for hospital and ED services, which suggests the importance of enhancing the capacity of these two healthcare sectors during future COVID-19-like public health emergencies.

New horizons in clinical practice guidelines for use with older people

Globally, more people are living into advanced old age, with age-associated frailty, disability and multimorbidity. Achieving equity for all ages necessitates adapting healthcare systems. Clinical practice guidelines (CPGs) have an important place in adapting evidence-based medicine and clinical care to reflect these changing needs. CPGs can facilitate better and more systematic care for older people. But they can also present a challenge to patient-centred care and shared decision-making when clinical and/or socioeconomic heterogeneity or personal priorities are not reflected in recommendations or in their application. Indeed, evidence is often lacking to enable this variability to be reflected in guidance. Evidence is more likely to be lacking about some sections of the population. Many older adults are at the intersection of many factors associated with exclusion from traditional clinical evidence sources with higher incidence of multimorbidity and disability compounded by poorer healthcare access and ultimately worse outcomes. We describe these challenges and illustrate how they can adversely affect CPG scope, the evidence available and its summation, the content of CPG recommendations and their patient-centred implementation. In all of this, we take older adults as our focus, but much of what we say will be applicable to other marginalised groups. Then, using the established process of formulating a CPG as a framework, we consider how these challenges can be mitigated, with particular attention to applicability and implementation. We consider why CPG recommendations on the same clinical areas may be inconsistent and describe approaches to ensuring that CPGs remain up to date.

Caloric restriction mitigates age-associated senescence characteristics in subcutaneous adipose tissue-derived stem cells

Adipose tissue regulates metabolic balance, but aging disrupts it, shifting fat from insulin-sensitive subcutaneous to insulin-resistant visceral depots, impacting overall metabolic health. Adipose-derived stem cells (ASCs) are crucial for tissue regeneration, but aging diminishes their stemness and regeneration potential. Our findings reveal that aging is associated with a decrease in subcutaneous adipose tissue mass and an increase in the visceral fat depots mass. Aging is associated with increase in adipose tissue fibrosis but no significant change in adipocyte size was observed with age. Long term caloric restriction failed to prevent fibrotic changes but resulted in significant decrease in adipocytes size. Aged subcutaneous ASCs displayed an increased production of ROS. Using mitochondrial membrane activity as an indicator of stem cell quiescence and senescence, we observed a significant decrease in quiescence ASCs with age exclusively in subcutaneous adipose depot. In addition, aged subcutaneous adipose tissue accumulated more senescent ASCs having defective autophagy activity. However, long-term caloric restriction leads to a reduction in mitochondrial activity in ASCs. Furthermore, caloric restriction prevents the accumulation of senescent cells and helps retain autophagy activity in aging ASCs. These results suggest that caloric restriction and caloric restriction mimetics hold promise as a potential strategy to rejuvenate the stemness of aged ASCs. Further investigations, including in vivo evaluations using controlled interventions in animals and human studies, will be necessary to validate these findings and establish the clinical potential of this well-established approach for enhancing the stemness of aged stem cells.

Adherence to the Mediterranean diet and risk of gestational diabetes: a prospective cohort study

BACKGROUND

Limited data is available on the association between adherence to the Mediterranean diet during early pregnancy and risk of gestational diabetes (GDM) in countries located in the Middle East, one of the regions with the highest prevalence of GDM.

METHODS

A total of 647 pregnant mothers were included in the present prospective birth cohort study in Iran. Dietary intake was assessed by a 90-item food frequency questionnaire during the first trimester of pregnancy. Cases of GDM were ascertained by a two-step approach with a 50-g screen followed by a 100-g oral glucose tolerance for those who tested positive. Cox proportional hazard model was used to calculate the hazard ratio and 95%CI of GDM across tertiles of the Mediterranean diet score, while controlling for a wide range of potential confounders.

RESULTS

A total of 647 pregnant mothers were included, of whom 77 mothers were diagnosed with GDM during their pregnancy. The average age of the mothers was 28.8 ± 5.1 years. In the multivariable analysis, being in the third tertile of the score of adherence to the Mediterranean diet was associated with a 41% lower risk of developing GDM as compared to those in the first tertile (adjusted hazard ratio: 0.59, 95%CI: 0.35, 0.99).

CONCLUSIONS

Based on our findings, greater adherence to the Mediterranean diet during early pregnancy may be associated with a lower risk of developing GDM in Iranian women. Larger cohort studies are needed to confirm the findings.

Nicotinamide Riboside Improves Stemness of Human Adipose-Derived Stem Cells and Inhibits Terminal Adipocyte Differentiation

Adipose tissue plays a crucial role in maintaining metabolic homeostasis by serving as a storage site for excess fat and protecting other organs from the detrimental effects of lipotoxicity. However, the aging process is accompanied by a redistribution of fat, characterized by a decrease in insulin-sensitive subcutaneous adipose depot and an increase in insulin-resistant visceral adipose depot. This age-related alteration in adipose tissue distribution has implications for metabolic health. Adipose-derived stem cells (ASCs) play a vital role in the regeneration of adipose tissue. However, aging negatively impacts the stemness and regenerative potential of ASCs. The accumulation of oxidative stress and mitochondrial dysfunction-associated cellular damage contributes to the decline in stemness observed in aged ASCs. Nicotinamide adenine dinucleotide (NAD+) is a crucial metabolite that is involved in maintaining cellular homeostasis and stemness. The dysregulation of NAD+ levels with age has been associated with metabolic disorders and the loss of stemness. In this study, we aimed to investigate the effects of nicotinamide riboside (NR), a precursor of NAD+, on the stemness of human ASCs in cell culture. Our findings reveal that adipogenesis is accompanied by an increase in mitochondrial activity and the production of reactive oxygen species (ROS). However, treatment with NR leads to a reduction in mitochondrial activity and ROS production in ASCs. Furthermore, NR administration improves the stemness-related genes expression in ASCs and mitigates their propensity for adipocyte differentiation. These results suggest that NR treatment holds promise as a potential strategy to rejuvenate the stemness of aged ASCs. Further investigations, including in vivo evaluations using animal models and human studies, will be necessary to validate these findings and establish the clinical potential of this well-established drug for enhancing the stemness of aged stem cells.

Prediabetes, diabetes and loss of disability-free survival in a community-based older cohort: a post-hoc analysis of the ASPirin in Reducing Events in the Elderly trial

BACKGROUND

Evidence for the prognostic implications of hyperglycaemia in older adults is inconsistent.

OBJECTIVE

To evaluate disability-free survival (DFS) in older individuals by glycaemic status.

METHODS

This analysis used data from a randomised trial recruiting 19,114 community-based participants aged ≥70 years, who had no prior cardiovascular events, dementia and physical disability. Participants with sufficient information to ascertain their baseline diabetes status were categorised as having normoglycaemia (fasting plasma glucose [FPG] < 5.6 mmol/l, 64%), prediabetes (FPG 5.6 to <7.0 mmol/l, 26%) and diabetes (self-report or FPG ≥ 7.0 mmol/l or use of glucose-lowering agents, 11%). The primary outcome was loss of disability-free survival (DFS), a composite of all-cause mortality, persistent physical disability or dementia. Other outcomes included the three individual components of the DFS loss, as well as cognitive impairment-no dementia (CIND), major adverse cardiovascular events (MACE) and any cardiovascular event. Cox models were used for outcome analyses, with covariate adjustment using inverse-probability weighting.

RESULTS

We included 18,816 participants (median follow-up: 6.9 years). Compared to normoglycaemia, participants with diabetes had greater risks of DFS loss (weighted HR: 1.39, 95% CI 1.21-1.60), all-cause mortality (1.45, 1.23-1.72), persistent physical disability (1.73, 1.35-2.22), CIND (1.22, 1.08-1.38), MACE (1.30, 1.04-1.63) and cardiovascular events (1.25, 1.02-1.54) but not dementia (1.13, 0.87-1.47). The prediabetes group did not have an excess risk for DFS loss (1.02, 0.93-1.12) or other outcomes.

CONCLUSIONS

Among older people, diabetes was associated with reduced DFS, and higher risk of CIND and cardiovascular outcomes, whereas prediabetes was not. The impact of preventing or treating diabetes in this age group deserves closer attention.

Social Care Recommendations in National Diabetes Treatment Guidelines

PURPOSE OF REVIEW

An expanding body of research documents associations between socioeconomic circumstances and health outcomes, which has led health care institutions to invest in new activities to identify and address patients' social circumstances in the context of care delivery. Despite growing national investment in these "social care" initiatives, the extent to which social care activities are routinely incorporated into care for patients with type II diabetes mellitus (T2D), specifically, is unknown. We conducted a scoping review of existing T2D treatment and management guidelines to explore whether and how these guidelines incorporate recommendations that reflect social care practice categories.

RECENT FINDINGS

We applied search terms to locate all T2D treatment and management guidelines for adults published in the US from 1977 to 2021. The search captured 158 national guidelines. We subsequently applied the National Academies of Science, Engineering, and Medicine framework to search each guideline for recommendations related to five social care activities: Awareness, Adjustment, Assistance, Advocacy, and Alignment. The majority of guidelines (122; 77%) did not recommend any social care activities. The remainder (36; 23%) referred to one or more social care activities. In the guidelines that referred to at least one type of social care activity, adjustments to medical treatment based on social risk were most common [34/36 (94%)]. Recommended adjustments included decreasing medication costs to accommodate financial strain, changing literacy level or language of handouts, and providing virtual visits to accommodate transportation insecurity. Ensuring that practice guidelines more consistently reflect social care best practices may improve outcomes for patients living with T2D.

Update on the management of diabetes in long-term care facilities

The number of patients with diabetes is increasing among older adults in the USA, and it is expected to reach 26.7 million by 2050. In parallel, the percentage of older patients with diabetes in long-term care facilities (LTCFs) will also rise. Currently, the majority of LTCF residents are older adults and one-third of them have diabetes. Management of diabetes in LTCF is challenging due to multiple comorbidities and altered nutrition. Few randomized clinical trials have been conducted to determine optimal treatment for diabetes management in older adults in LTCF. The geriatric populations are at risk of hypoglycemia since the majority are treated with insulin and have different levels of functionality and nutritional needs. Effective approaches to avoid hypoglycemia should be implemented in these settings to improve outcome and reduce the economic burden. Newer medication classes might carry less risk of developing hypoglycemia along with the appropriate use of technology, such as the use of continuous glucose monitoring. Practical clinical guidelines for diabetes management including recommendations for prevention and treatment of hypoglycemia are needed to appropriately implement resources in the transition of care plans in this vulnerable population.

Adherence to the American Diabetes Association's Glycemic Goals in the Treatment of Diabetes Among Older Americans, 2001-2018

OBJECTIVE

To assess trends in HbA1c and appropriateness of diabetes medication use by patient health status.

RESEARCH DESIGN AND METHODS

We conducted cross-sectional analysis of 2001-2018 National Health and Nutrition Examination Survey (NHANES). We included older adults age ≥65 years who had ever been told they had diabetes, had HbA1c >6.4%, or had fasting plasma glucose >125 mg/dL. Health status was categorized as good, intermediate, or poor. Being below goal was defined as taking medication despite having HbA1c ≥1% below the glycemic goals of the American Diabetes Association (ADA), which varied by patient health status and time period. Drugs associated with hypoglycemia included sulfonylureas, insulin, and meglitinides.

RESULTS

We included 3,539 patients. Mean HbA1c increased over time and did not differ by health status. Medication use increased from 59% to 74% with metformin being the most common drug in patients with good or intermediate health and sulfonylureas and insulin most often prescribed to patients with poor health. Among patients taking medications, prevalence of patients below goal increased while prevalence of those above goal decreased from 2001 to 2018. One-half of patients with poor health and taking medications had below-goal HbA1c; two-thirds received drugs associated with hypoglycemia. Patients with poor health who were below goal had 4.9 (95% CI 2.3-10.4) times the adjusted odds of receiving drugs associated with hypoglycemia than healthy patients.

CONCLUSIONS

In accordance with ADA's newer Standards of Medical Care in Diabetes, HbA1c goals were relaxed but did not differ by health status. Below-goal HbA1c was common among patients with poor health; many were prescribed medications associated with a higher risk of hypoglycemia.

Shared Care Practices in Community Addiction and Mental Health Services: A Qualitative Study on the Experiences and Perspectives of Stakeholders

Shared care involves collaboration between primary care, secondary and tertiary care that enables the allocation of responsibilities of care according to the treatment needs of patients over the course of a mental illness. This study aims to determine stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs in Edmonton, Canada. This is a qualitative cross-sectional study with data collected through focus group discussions. Participants included patients, general practitioners, psychiatrists, management, and therapists working in primary and secondary addiction and mental health. Responses were audio-recorded, transcribed, and analyzed thematically. Perceived barriers to the implementation of an ideal shared care model identified by participants include fragmented communication between primary and secondary healthcare providers, patient and family physician discomfort with discussing addiction and mental health, a lack of staff capacity, confidentiality issues, and practitioner buy-in. Participants also identified enablers to include implementing shared electronic medical record systems, improving communication and collaboration, physical co-location, and increasing practitioner awareness of appropriate referrals and services. This original research provides stakeholders’ perspectives on the features of an ideal shared care model and barriers to practicing shared care within addiction and mental health programs.

Anti-Hyperglycemic Medication Adherence and Health Services Utilization in People with Diabetes: A Longitudinal Study of Alberta's Tomorrow Project

BACKGROUND

Little is known about the long-term (>2 years) relationship between the time-varying drug adherence and healthcare utilization for patients with diabetes.

OBJECTIVE

To characterize the relationship between time-varying anti-hyperglycemic medication adherence and healthcare utilization in patients with diabetes, using data from Alberta's Tomorrow Project, a population-based cohort study in Alberta, Canada.

METHODS

Incident cases of diabetes with at least 24 months of follow-up were included in the study. Anti-hyperglycemic drug adherence was measured by proportion of days covered (PDC) in the past 12 months for each year after diagnosis. The rate of healthcare utilization was assessed for the subsequent 12 months, 36 months and 60 months. A time-varying, negative binomial generalized estimating equation model was used to examine the association between medication adherence and healthcare utilization.

RESULTS

Among 2155 incident cases of diabetes, average age at diagnosis was 59.6±9.3, 51.0% were female and average duration of follow-up was 7.3±3.7 (range, 2.0-16.2) years. The proportion of patients taking anti-hyperglycemic medications was 47.6% during the first year of diagnosis, which increased to 77.3% by the end of follow-up. Compared to adherent patients (PDC≥0.8), non-adherent patients (PDC<0.8) had substantially higher rate of all-cause hospitalization [incident rate ratio, IRR=1.48 (1.22-1.79), ED visits [1.30 (1.15-1.47)] and GP visits [1.17 (1.08-1.27)] in the subsequent 12 months. However, these associations became weaker with longer follow-up [eg, IRR=1.18 (0.98-1.39) and 1.05 (0.94-1.18) for all-cause hospitalization in the subsequent 36 and 60 months, respectively].

CONCLUSION

Poor adherence among diabetic patients was associated with substantially higher rate of healthcare utilization in the short term (eg, 12 months); however, this association weakened over a longer period (eg, 36-60 months).

[Risk factors associated with emergency service re-visits in frailty diabetic patients who consult for hypoglycaemia]

INTRODUCTION AND OBJECTIVES

Emergency department (ED) visits due to hypoglycaemia are frequent in elderly patients. The main objective of the study is to evaluate the risk factors associated to ED re-visits at 90days in elderly patients who visited ED with an episode of hypoglycaemia.

MATERIAL AND METHODS

A retrospective observational study was designed, including elderly diabetic patients (>65years) attended in a fragility area of an ED for an episode of hypoglycaemia. To evaluate the risk factors associated to ED re-visits at 90days a multivariate analysis with logistic regression was performed, including those variables related to comorbidity and antidiabetic treatment with a P<0.2 in a previous univariate analysis.

RESULTS

106 patients were included. %HbA1c value was available in 87 (82.1%) patients. Ten (11.5%) patients presented a value of HbA1c ≤5.5%. Antidiabetic treatment was changed to 63 (59.4%) patients at discharge. Thirty-eight (36.1%) patients re-visited the ED at 90days, 9 for glycaemic alterations. The risk factors associated to 90days ED re-visit were: being man (OR: 3.62 [95%CI: 1.24-10.51)), treatment modified at discharge (OR: 0.31 [0.11-0.91]) and to present an HbA1c value ≤5.5% (OR: 5.33 [1.16-14.51]).

CONCLUSIONS

Fragile patients with diabetes who visit ED for hypoglycaemia present, in high frequency, HbA1c values lower than those recommended, being associated to an increase of ED re-visit risk at 90days.

Metformin Improves Stemness of Human Adipose-Derived Stem Cells by Downmodulation of Mechanistic Target of Rapamycin (mTOR) and Extracellular Signal-Regulated Kinase (ERK) Signaling

Adipose tissue plays an important role in regulating metabolic homeostasis by storing excess fat and protecting other organs from lipotoxicity. Aging is associated with central fat redistribution, culminating in a decrease in insulin-sensitive subcutaneous and an increase in insulin-resistant visceral adipose depots. Adipose-derived stem cells (ASCs) play an important role in the regeneration of adipose tissue. Aged ASCs show decreased stemness and regenerative potential due to the accumulation of oxidative stress and mitochondrial dysfunction-related cell damage. Metformin is a well-established anti-diabetic drug that has shown anti-aging effects in different organisms and animal models. In this study, we analyzed the effect of metformin treatment on the stemness of human ASCs in cell culture and whole adipose tissue culture models. Our results demonstrate that metformin improves the stemness of ASCs, reducing their rate of proliferation and adipocyte differentiation. Investigating the possible underlying mechanism, we observed a decrease in the mTOR and ERK activity in metformin-treated ASCs. In addition, we observed an increase in autophagy activity upon metformin treatment. We conclude that metformin treatment improves ASCs stemness by reducing mTOR and ERK signaling and enhancing autophagy. Future in vivo evaluations in animal models and humans will pave the way for the clinical adaptation of this well-established drug for reviving the stemness of aged stem cells.

Patient Preferences for Discussing Life Expectancy: a Systematic Review

BACKGROUND

Discussing life expectancy helps inform decisions related to preventive medication, screening, and personal care planning. Our aim was to systematically review the literature on patient preferences for discussing life expectancy and to identify predictors for these preferences.

METHODS

We searched PubMed, Cochrane Library, Embase, MEDLINE, PsycInfo, and gray literature from inception until 17 February 2021. Two authors screened titles/abstracts and full texts, and extracted data and one author assessed quality. The outcome of interest was the proportion of patients willing to discuss life expectancy. We reported descriptive statistics, performed a narrative synthesis, and explored sub-groups of patients according to patient characteristics.

RESULTS

A total of 41 studies with an accumulated population of 27,570 participants were included, comprising quantitative survey/questionnaire studies (n=27) and qualitative interview studies (n=14). Willingness to discuss life expectancy ranged from 19 to 100% (median 61%, interquartile range (IQR) 50-73) across studies, with the majority (77%) reporting more than half of subjects willing to discuss. There was considerable heterogeneity in willingness to discuss life expectancy, even between studies from patients with similar ages, diseases, and cultural profiles. The highest variability in willingness to discuss was found among patients with cancer (range 19-100%, median 61%, IQR 51-81) and patients aged 50-64 years (range 19-97%, median 61%, IQR 45-87). This made it impossible to determine predictors for willingness to discuss life expectancy.

DISCUSSION

Most patients are willing to discuss life expectancy; however, a substantial proportion is not. Heterogeneity and variability in preferences make it challenging to identify clear predictors of willingness to discuss. Variability in preferences may to some extent be influenced by age, disease, and cultural differences. These findings highlight the individual and complex nature in which patients approach this topic and stress the importance of clinicians considering eliciting patient's individual preferences when initiating discussions about life expectancy.

A Comprehensive Review of Neuronal Changes in Diabetics

There has been an exponential rise in diabetes mellitus (DM) cases on a global scale. Diabetes affects almost every system of the body, and the nervous system is no exception. Although the brain is dependent on glucose, providing it with the energy required for optimal functionality, glucose also plays a key role in the regulation of oxidative stress, cell death, among others, which furthermore contribute to the pathophysiology of neurological disorders. The variety of biochemical processes engaged in this process is only matched by the multitude of clinical consequences resulting from it. The wide-ranging effects on the central and peripheral nervous system include, but are not limited to axonopathies, neurodegenerative diseases, neurovascular diseases, and general cognitive impairment. All language search was conducted on MEDLINE, COCHRANE, EMBASE, and GOOGLE SCHOLAR till September 2021. The following search strings and Medical Subject Headings (MeSH terms) were used: "Diabetes Mellitus," "CNS," "Diabetic Neuropathy," and "Insulin." We explored the literature on diabetic neuropathy, covering its epidemiology, pathophysiology with the respective molecular pathways, clinical consequences with a special focus on the central nervous system and finally, measures to prevent and treat neuronal changes. Diabetes is slowly becoming an epidemic, rapidly increasing the clinical burden on account of its wide-ranging complications. This review focuses on the neuronal changes occurring in diabetes such as the impact of hyperglycemia on brain function and structure, its association with various neurological disorders, and a few diabetes-induced peripheral neuropathic changes. It is an attempt to summarize the relevant literature about neuronal consequences of DM as treatment options available today are mostly focused on achieving better glycemic control; further research on novel treatment options to prevent or delay the progression of neuronal changes is still needed.

Risk of clinically relevant hyperglycemia with metoprolol compared to carvedilol in older adults with heart failure and diabetes

BACKGROUND

Although prior literature suggests that metoprolol may worsen glucose control compared to carvedilol, whether this has clinical relevance among older adults with diabetes and heart failure (HF) remains an open question.

METHODS

This was a US retrospective cohort study utilizing data sourced from a 50% national sample of Medicare fee-for-service claims of patients with part D prescription drug coverage (2007-2017). Among patients with diabetes and HF, we identified initiators of metoprolol or carvedilol, which were 1:1 propensity score matched on >90 variables. The primary outcome was initiation of a new oral or injectable antidiabetic medication (proxy for uncontrolled diabetes); secondary outcomes included initiation of insulin and severe hyperglycemic event (composite of emergency room visits or hospitalizations related to hyperglycemia).

RESULTS

Among 24 239 propensity score-matched pairs (mean [SD] age 77.7 [8.0] years; male [39.1%]), there were 8150 (incidence rate per 100 person-years [IR] = 33.5) episodes of antidiabetic medication initiation among metoprolol users (exposure arm) compared to 8576 (IR = 33.4) among carvedilol users (comparator arm) compared to corresponding to an adjusted hazard ratio (aHR) of 0.97 (95% confidence interval [CI]: 0.94, 1.01). Similarly, metoprolol was not associated with a significant increase in the risk of secondary outcomes including insulin initiation: aHR of 0.98 (95% CI: 0.93, 1.04) and severe hyperglycemic events: aHR of 0.98 (95% CI: 0.93, 1.02).

CONCLUSIONS

In this large study of older adults with HF and diabetes, initiation of metoprolol compared to carvedilol was not associated with an increase in the risk of clinically relevant hyperglycemia.

Is there an HbA1c Threshold for Symptoms of Chronic Hyperglycemia?

AIMS OF THE STUDY

The minimum therapeutic goal regarding metabolic control for people with diabetes mellitus is the "absence of symptoms of hyperglycemia." However, it is uncertain whether a level of HbA1c can be defined that guarantees the absence of these symptoms. The aim was to define an HbA1c threshold above which most patients show hyperglycemic symptoms.

METHODS

In a multicenter cross-sectional study, 137 patients with type 1 and 285 with type 2 diabetes were asked about their symptoms during periods of hyperglycemia with a standardized questionnaire. Seventeen symptoms of hyperglycemia were summarized to the total hyperglycemia symptom score (THSS; min. 0; max. 68). The answers could be given according to the frequency and intensity in the last 4 - 6 weeks.

RESULTS

The HbA1c threshold above which most patients showed hyperglycemic symptoms was 10.05% for patients with diabetes type 1 and 8.9%. for patients with type 2. Most confidence was reached on the symptoms of frequent urination" and "tiredness." The mean THSS was 19.4 (±9.0) and showed a positive correlation with age (r=0.167; p<0.001) and HbA1c (r=0.254; p<0.001).

CONCLUSIONS

We identified an HbA1c threshold above which most patients show symptoms of hyperglycemia. In the treatment of people with diabetes mellitus, a safety margin to this threshold should be maintained to preserve well-being and avoid distress. However, since hyperglycemia symptoms are subject to many influencing factors, an adjustment of the therapy-both intensification and de-intensification-should always be carried out in combination with the requested hyperglycemia symptoms and HbA1c value.

The impact of a nutrition counseling program on the use of hospital services for Meals on Wheels clients

Home-delivered meals have shown considerable promise in overcoming nutritional challenges among homebound older adults facing food insecurity and the risk of diabetes, while nutrition counseling provides knowledge and skills for diabetes management. The purpose of this study was to identify the impact of a program combining nutrition counseling with home-delivered meals by examining the use of hospital services 6 months before and after participating in the program. This study included 1009 clients who are at risk for diabetes and who received home-delivered meals and nutrition counseling via Meals on Wheels in Fort Worth, Texas. Hospital service data were extracted from a regional claims database. Generalized linear models were performed to examine changes in use of hospital services 6 months before and after program participation. The mean number of emergency department visits and hospitalizations decreased from 0.69 to 0.50 (p < .001) and from 0.35 to 0.22 (p < .001), respectively. The findings of this study indicate that combining structured nutritional counseling with home-delivered meals may contribute to reducing healthcare use among older adults facing the challenges of diabetes and food insecurity.

Efficacy, renal safety and tolerability of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in elderly patients with type 2 diabetes: A real-world experience

AIMS

To evaluate efficacy, renal safety and tolerability of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in a cohort of patients with type 2 diabetes (T2DM) aged ≥65 years.

METHODS

We retrospectively evaluated 364 elderly individuals with T2DM starting SGLT2i from June 2015 to June 2018. Patients were divided into 2 subgroups based on median age (70 years). Linear mixed effect models were used to estimate changes in glycated hemoglobin (HbA1c), body mass index (BMI), and glomerular filtration rate (eGFR). SGLT2i discontinuation rate and causes of treatment interruption were also recorded.

RESULTS

A significantly higher percentage of patients achieved HbA1c <7.5% (46.7% vs. 31.6%, p < 0.01) and <8.0% (68.9% vs. 47.2%, p < 0.01) compared to baseline. Each year of therapy was associated with an average HbA1c decrease of 0.34% (p < 0.01) and BMI loss of 0.71 kg/m² (p < 0.01), without significant interaction across age classes. In the younger group eGFR increased by 1.02 ml/min/year, while in the older group it declined by 0.42 ml/min/year (p = 0.08). Overall discontinuation rate during the follow-up period was similar across age groups (34.2% vs. 36.1%, long-rank p = 0.26). Genitourinary infections were the most frequent cause of treatment interruption (15.8% vs. 17.2%, p = 0.69) in both study groups, while persistent eGFR decline (4.4%) and orthostatic hypotension (1.7%) were only present in older age class.

CONCLUSIONS

Efficacy, renal safety and tolerability of SGLT2i were similar in people >70 compared to 65-70 years of age, suggesting that a wider use should not be worried even in the elderly. However, some caution must be paid to the occurrence of persistent eGFR decline and orthostatic hypotension, especially in patients >70 years old.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

Background

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

Methods

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

Results

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients’ race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

Conclusions

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01209-w.

Evaluation of the effectiveness of Persian diabetes self-management education in older adults with type 2 diabetes at a diabetes outpatient clinic in Tehran: a pilot randomized control trial

Purpose

The effectiveness of diabetes self-management interventions has been more generally demonstrated in adults, but there is little evidence of diabetes self-management specific to older adults situated in Iran. The purpose of this study was to evaluate the effectiveness of Persian Diabetes Self-Management Education on self-efficacy, quality of life, self-care activity, depression and loneliness in older adults with type 2 diabetes.

Methods

In pilot randomized controlled trial, a total of 34 participants ≥60 years with type 2 diabetes were randomly assigned into intervention (n = 17) and control (n = 17) group in an outpatient diabetes clinic in Tehran. To assess the primary outcome of participant experiences, the Diabetes Management Self-efficacy Scale (DMSES) was the method of measurement. The Diabetes Quality of Life-Basic Clinical Inventory (DQoL-BCI), Patient Health Questionnaire-9 (PHQ-9), Diabetes Self-Management Education Scale (DSMES), and adult Social-Emotional Loneliness Scale Short form (SELSA-S) were used as secondary outcomes. Participants' evaluations were completed at baseline, while measurements were conducted two and four weeks after allocation, using repeated measurements of Univariate and multivariate ANOVA (adjusted for baseline values) to analyze the data.

Results

In the multivariate model, there was a significant difference between the control and intervention groups regarding reported quality of life (p = 0.04) and the medical-domain's reported self-efficacy (p = 0.02). However, there were no significant differences in the reported self-management, depression, loneliness, as well as the other domain of self-efficacy; as compared between the two groups before and after intervention.

Conclusion

The study depicts a promising impact on older adults, imparted by the pertinent program. The finding showed PDSME has a positive effect on quality of life and medical control domain of self-efficacy. This pilot study showed that the program is feasible and duly beneficial if delivered to older adults. This pilot proves appealing to begin further testing within a larger sample population.

Prevalence of Diabetes and Its Relationship With Body Mass Index Among Elderly People in a Rural Area of Northeastern State of India

Background

Diabetes and its complications are a major public health concern in elderly populations. However, there is little population-based data on diabetes and its risk factors among the elderly population living in rural areas of India. The objective of this population-based study was to assess the prevalence of diabetes in the elderly population and its relationship with body mass index (BMI).

Methodology

A population-based, cross-sectional study was conducted among elderly individuals (≥60 years) during the period 2013-2016 in rural areas of Dibrugarh district of Assam. Multi-stage sampling design was adopted to select the study participants. Data on socio-demographic profile and diagnosis/treatment history of diabetes were collected using pre-designed and pre-tested questionnaire. Fasting blood sugar was tested. Weight and height were measured to calculate BMI. Multivariate logistic regression analysis was performed to assess the relationship between diabetes and BMI.

Results

Data were collected from 430 (male: 210, female: 220) individuals. The overall prevalence of diabetes was 7.9% (male: 7.1%, female: 8.6%). Higher level of education was associated with increased prevalence of diabetes. Prevalence of diabetes increased as the BMI of participants increased. Prevalence of diabetes among obese individuals (BMI ≥25 kg/m²) was 30.4% compared to only 5% among normal weight individuals. Obesity was associated with eight-fold higher risk of diabetes compared with the individuals of normal weight in multivariate analysis.

Conclusions

The study reveals nearly 8% population-based prevalence of diabetes in rural elderly people in the study district. Our study provides epidemiological evidence that obesity is a major driver of diabetes among rural elderly people.

Impact of Cognitive Impairment on Adherence to Treatment and Self-Care in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Elderly patients with diabetes have a significantly increased prevalence of mild cognitive impairment compared with people of similar age without diabetes. Tasks related to diabetes self-management involve multiple cognitive skills and processes, such as memory, attention, planning, and calculating. Impaired cognitive function can threaten the patient's ability to perform self-monitoring. The objectives of the study were: to assess cognitive deficits and the level of self-care in elderly patients with diabetes, to identify correlations between cognitive deficits and self-care, and to determine which variables influence self-care behaviors and cognitive deficits.

METHODS

The study involved 169 patients with type 2 DM. Standardized tools were used: Mini-mental State Examination (MMSE) to assess cognitive function and the Self-Care of Diabetes Inventory (SCODI) to assess the level of self-care. Socioclinical data were taken from the hospital records.

RESULTS

56.8% of patients had cognitive impairment (MMSE≤26). In the comparative analysis, patients with cognitive impairment had significantly lower results in all domains of the SCODI: self-care maintenance (72.9 vs 75), self-care monitoring (53.1 vs 56.3), self-care management (71.9 vs 84.4), self-care confidence (79.5 vs 86.4). Correlation analysis showed that the MMSE score correlates significantly and positively (p˂0.05; r˃0) with all SCODI subscales, and the higher the MMSE score the higher the level of self-care (A: r=0.252, B: r=0.244, C: r=0.019, D: r=0.28).

CONCLUSION

In this elderly type 2 diabetes population, and using only one test to verify the cognitive function, self-care management was worse in terms of self-care management (blood glucose control). Cognitive function components are independent determinants of self-care in patients with type 2 diabetes. Recall is an independent predictor of self-care maintenance, and writing a predictor of self-care monitoring.

Self-Efficacy and Diabetes Self-Management in Middle-Aged and Older Adults in the United States: A Systematic Review

OBJECTIVE | This study aimed to systematically review the existing literature on the relationship between self-efficacy and diabetes self-management in middle-aged and older adults in the United States and to determine whether the relationship applies across race and ethnicity. METHODS | Study selection followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method. Studies published between 1990 to 2018 that investigated self-efficacy and diabetes self-management in middle-aged and older adults were searched using eight search engines: PsycINFO, CINAHL, SocIndex, AgeLine, MedLine, Social Science Citation Index, Cochrane Library, and Academic Search Complete. Only quantitative studies were included. RESULTS | Eleven studies met the inclusion criteria. Ten studies found significant association between self-efficacy and at least one self-management behavior, which included exercise, healthy diet, adherence to medication, blood glucose testing, and foot care. Findings were mixed regarding the role of self-efficacy in exercise and medication adherence. Higher self-efficacy in Mexican Americans predicted better self-management behaviors, whereas no relationship between self-efficacy and diabetes self-management was found in a sample of Black and White participants. The methodological quality of the studies was assessed. In general, the included studies demonstrated moderate methodological quality. Their limitations included inconsistency in the self-efficacy measures, a lack of longitudinal studies, and confounding bias. CONCLUSION | Self-efficacy has significant effects on self-management in middle-aged and older adults, but the effects may differ by race. Efforts to improve self-efficacy and deliver culturally appropriate services could potentially promote self-management behaviors in middle-aged and older adults with diabetes.

Improving the American Diabetes Association Framework for individualizing treatment in older adults: evaluating life expectancy

INTRODUCTION

For older adults with type 2 diabetes, the American Diabetes Association (ADA) Framework uses comorbidities and functional status to categorize patients by estimated life expectancy to guide individualization of glycemic treatment. We evaluated whether modifying the ADA Framework by removing three comorbidities and incorporating age could improve life expectancy stratification and better identify patients likely to benefit from intensive treatment.

RESEARCH DESIGN AND METHODS

We examined 3166 Health and Retirement Study participants aged ≥65 with diabetes from 1998 to 2004, using a prospective cohort design with mortality follow-up through 2016. We classified participants into one of three ADA Framework categories: Healthy, Intermediate Health, and Poor Health. We created modified categories by excluding comorbidities weakly associated with mortality (hypertension, arthritis, and incontinence). Using Gompertz regression, we estimated life expectancy across age strata for both original and modified ADA Framework categories.

RESULTS

The original ADA Framework classified 34% as Healthy (likely to benefit from intensive treatment), 50% as Intermediate Health, and 16% as Poor Health (unlikely to benefit from intensive treatment). Our comorbidity modification reclassified 20% of participants from Intermediate Health to Healthy. Using the modified ADA Framework, median life expectancy of the Healthy varied greatly by age (aged 65-69: 16.3 years; aged ≥80: 7.6 years), indicating differing likelihood of benefit. Additionally, age ≥80 made extended life expectancy unlikely (median life expectancy for Healthy 7.6 years, Intermediate Health 5.9 years, Poor Health 2.5 years), suggesting adults ≥80 are unlikely to benefit from intensive treatment.

CONCLUSIONS

Modifying the ADA Framework by incorporating age and focusing on comorbidities associated with mortality improved life expectancy stratification, resulting in different treatment recommendations for many older adults.

Predictors of intra-hospital mortality in patients with diabetic foot ulcers in Nigeria: data from the MEDFUN study

BACKGROUND

Diabetic foot ulcers (DFU) are associated with high morbidity and mortality globally. Mortality in patients hospitalized for DFU in Nigeria is unacceptably high. This study was undertaken to determine factors that predict mortality in patients hospitalized for DFU in Nigeria.

METHODS

The current study was part of Multi-centre Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN), an observational study conducted in six tertiary healthcare institutions across the 6 geopolitical zones of Nigeria. Consecutive type 1 or 2 diabetic patients hospitalized for DFU who consented to participate were recruited and subjected to relevant clinical, biochemical, and radiological assessments and multidisciplinary care until discharge or death. Data for type 1 diabetes mellitus (DM) patients were expunged from current mortality analysis due to their small number.

RESULTS

Three hundred and twenty-three type 2 DM subjects with mean age and mean duration of DM of 57.2 ± 11.4 years and 8.7 ± 5.8 years respectively participated in this study. The median duration of ulcers was 39 days with a range of 28 to 54 days and the majority (79.9%) presented with advanced ulcers of at least Wagner grade 3. Mortality of 21.4% was recorded in the study, with the highest mortality observed among subjects with Wagner grade 5. Variables significantly associated with mortality with their respective p values were DM duration more than 120 months (p 0.005), ulcer duration > 1 month (p 0.020), ulcer severity of Wagner grade 3 and above (p 0.001), peripheral arterial disease (p 0.005), proteinuria (p < 0.001), positive blood cultures (p < 0.001), low HDL (p < 0.001), shock at presentation (p < 0.001), cardiac failure (p 0.027), and renal impairment (p < 0.001). On Multivariate regression analysis, presence of bacteraemia (OR 5.053; 95% CI 2.572-9.428) and renal impairment (OR 2.838; 95% CI 1.349-5.971) were significantly predictive of mortality independent of other variables.

CONCLUSIONS

This study showed high intra-hospital mortality among patients with DFU, with the majority of deaths occurring among those with advanced ulcers, bacteraemia, cardiac failure, and renal impairment. Prompt attention to these factors might help improve survival from DFU in Nigeria.

The achievement of comprehensive control targets among type 2 diabetes mellitus patients of different ages

Objective: To evaluate achievement of comprehensive controls among patients with type 2 diabetes mellitus (T2DM) in different age groups.

Results: The elderly patients had higher control rates for BMI (44.36%), TC (50.83%) and LDL-C (48.27%) than those aged 60-80 years and younger patients (all P <0.05). Multiple logistic regression revealed that elderly patients were more likely to achieve control targets for HbA1c (odd ratio (OR) = 2.19), TC (OR = 1.32), HDL-C (OR = 1.35), and TG (OR = 1.74) than younger patients. This effect was stronger in males (OR_HbA1c = 2.27; OR_TC = 1.41; OR_HDL-C = 1.51; OR_TG = 1.80). By contrast, elderly females were only more likely to achieve HbA1c < 7.0% (OR=1.88).

Conclusions: Our findings suggest that comprehensive control strategies still should be strengthened.

Methods: A total of 3126 T2DM patients were included, and detected blood pressure (BP), body mass index (BMI), glycosylated hemoglobin (HbA1c), fasting plasma glucose (FPG), postprandial plasma glucose (PPG), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), triglycerides (TG), and high-density lipoprotein cholesterol (HDL-C). We divided patients into three age groups (<60, 60-80 and ≥ 80 years), to assess the differences in achieving the control targets.

Using the Multidimensional Prognostic Index to Predict Clinical Outcomes of Hospitalized Older Persons: A Prospective, Multicenter, International Study

BACKGROUND

Multidimensional Prognostic Index (MPI) is useful as a prognostic tool in hospitalized older patients, but our knowledge is derived from retrospective studies. We therefore aimed to evaluate in a multicenter, longitudinal, cohort study whether the MPI at hospital admission is useful to identify groups with different mortality risk and whether MPI at discharge may predict institutionalization, rehospitalization, and use of home care services during 12 months.

METHODS

This longitudinal study, carried out between February 2015 and August 2017, included nine public hospitals in Europe and Australia. A standardized comprehensive geriatric assessment including information on functional, nutritional, cognitive status, risk of pressure sores, comorbidities, medications, and cohabitation status was used to calculate the MPI and to categorize participants in low, moderate, and severe risk of mortality. Data regarding mortality, institutionalization, rehospitalization, and use of home care services were recorded through administrative information.

RESULTS

Altogether, 1,140 hospitalized patients (mean age 84.1 years, women = 60.8%) were included. In the multivariable analysis, compared to patients with low risk group at admission, patients in moderate (odds ratio [OR] = 3.32; 95% CI: 1.79-6.17; p < .001) and severe risk (OR = 10.72, 95% CI: 5.70-20.18, p < .0001) groups were at higher risk of overall mortality. Among the 984 older patients with follow-up data available, those in the severe-risk group experienced a higher risk of overall mortality, institutionalization, rehospitalization, and access to home care services.

CONCLUSIONS

In this cohort of hospitalized older adults, higher MPI values are associated with higher mortality and other negative outcomes. Multidimensional assessment of older people admitted to hospital may facilitate appropriate clinical and postdischarge management.

Does social support effect knowledge and diabetes self-management practices in older persons with Type 2 diabetes attending primary care clinics in Cape Town, South Africa?

BACKGROUND

In South Africa with one of the most rapidly ageing populations in Africa despite the demographic impact of the HIV/AIDS epidemic, diabetes is a major cause of morbidity and mortality. Self-management is challenging for all those with the condition but is likely to create a higher demand for those who may have existing co-morbidities associated with age, and long-standing chronic diseases.

OBJECTIVE

To determine the relationship of social support, especially that of family and friends with their self-management.

METHODS

This cross-sectional study was undertaken in the Cape Town metropole primary care clinics. The sample comprised 406 people drawn from four community health centres (CHC) that are served by Groote Schuur Hospital at the tertiary level.

RESULTS

Of the 406 participants, 68.5% were females, 60.5% were living with a family member, and almost half were married. The mean duration of diabetes from diagnosis was eight years. More than half (57.4%) had no or only primary education. Half the participants (50.2%) had poor knowledge level in relation to symptoms and complications of diabetes. Multivariable linear regression showed older age was associated with poor knowledge (®: -1.893, 95% CI-3.754; -0.031) and higher income was associated with self-management practice (®: 3.434, 95% CI 0.797; 6.070). Most participants received family support to follow aspects of diabetes self-management. The ordinal logistic regression indicated that family support was positively associated with the self-management practice score for following a diabetic meal plan, taking care of feet, physical activity, testing blood sugar and handling participants' feelings about being diabetic, but not for taking medication.

CONCLUSIONS

Consideration needs to be given to developing and testing education programmes that focus on needs of older people with diabetes and emphases the role of family and friends.

Evaluation of ameliorative effect of sodium nitrate in experimental model of streptozotocin-induced diabetic neuropathy in male rats

OBJECTIVE

Diabetes induces sensory symptoms of neuropathy as positive (hyperalgesia), negative (hypoalgesia), or both.

METHODS

In the present study, fifty male Wistar rats were allocated to five groups: control, control+nitrate, diabetes, diabetes+insulin, and diabetes+nitrate. Thirty days after diabetes confirmation, insulin (2-4 U/day) was injected subcutaneously in diabetes+insulin group and nitrate (100 mg/l) was added into drinking water of the control+nitrate and diabetes+nitrate groups for a period of 2 months. In order to assess the mechanical and thermal algesia, tail immersion, hot plate, and von Frey tests were performed. The serum insulin levels were determined with insulin ELISA Kit. Serum level of NOx was determined by the Griess method.

RESULTS

Both thermal and mechanical nociceptive thresholds showed a significant decrease (p<0.05) which was followed by a significant increase (p<0.01) in the thermal nociceptive threshold in the diabetes group. Chronic nitrate or insulin treatment led to a significant decrease (p<0.01) in blood glucose levels, as well as a significant (p<0.05) increase in the body weight and serum NOx. Moreover, nitrate treatment significantly increased serum insulin levels (p<0.001) compared to the other groups.

CONCLUSION

Chronic nitrate treatment modified the thermal and mechanical sensitivities in diabetic animals.

Diabetes Detection and Communication among Patients Admitted through the Emergency Department of a Public Hospital

Early identification/diagnosis of diabetes and frequent monitoring of hyperglycemia reduces hospitalizations and diabetes-related complications. The present study investigated the proportion of older adults coded with diabetes or newly diagnosed during their admissions and assessed discharge summary content for diabetes-related information. The study used electronic data on 4796 individuals aged ≥60 years admitted through the emergency department (ED) of a public hospital from 2017 to 2018 extracted using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM code). The proportion of admitted patients who were diagnosed with diabetes over a one-year period, proportion with glycated hemoglobin A1c (HbA1c) and random blood glucose (RBG) test performed during their stay, length of stay, discharge summary information and the factors associated with elevated HbA1c (>7%/53 mmol/mol) were investigated. In total, 8.6% of ED presentations to the hospital were coded with diabetes, excluding gestational consisting of 879 patients (449 males, 430 females) aged ≥ 60 years (74.6 ± 8.9 years). In total, 98% had type 2 diabetes (n = 863), 53% were Australian-born (n = 467), and the mean body mass index (BMI, 31 ± 7 kg/m²; n = 499, 56.8%), RBG (9.8 ± 5.2 mmol/L; n = 824, 93.7%) and HbA1c (8.0 ± 2.0%; n = 137, 15.6%) and length of stay (6.7 ± 25.4 days) were similar between gender, age, and nationality (p > 0.05). Three coded patients (0.3%) were newly diagnosed during the admission. In total, 86% had elevated HbA1c, but this was recorded in 20% of discharge summaries. Patients who are on a combination therapy (adjusted odds ratio 23%, 95% confidence intervals: 7%/38%), those on SGLT2 Inhibitors (aOR, 14%: 2%/26%) or had a change in medication (aOR, 40%: 22%/59%) had lower odds of having elevated HbA1c during admission. The low diagnosis rate of diabetes and the lack of clinical assessment of HbA1c in older adults admitted through the ED of a South Western Sydney public hospital suggest that many patients with diabetes either remain undiagnosed even during admission and/or are going to the ED with unknown diabetes that is unidentified with current practices. The clinically important HbA1c results were only infrequently communicated with general practitioners (GPs).

Cognitive dysfunction in diabetes: how to implement emerging guidelines

Cognitive dysfunction, including mild cognitive impairment and dementia, is increasingly recognised as an important comorbidity and complication of diabetes that affects an individual's well-being and diabetes management, and is associated with diabetes treatment-related complications. Recent guidelines therefore recommend screening for cognitive impairment in older individuals with diabetes. In addition, these guidelines suggest that glucose-lowering treatment should be tailored in those diagnosed with cognitive impairment, to reduce the risk of hypoglycaemia and improve treatment adherence. This review gives an overview of cognitive dysfunction in people with diabetes, briefly describing the clinical features of different stages of cognitive dysfunction and their epidemiology. In particular, it addresses essential additional steps that need to be taken to fully implement the emerging guidelines on screening and management of cognitive dysfunction in diabetes into daily practice.

Teaching physicians the GPGP method promotes deprescribing in both inpatient and outpatient settings

Background

In complex older patients, inappropriate medication use and polypharmacy (IMUP) are commonplace and increasing exponentially. Reducing IMUP is a challenge in multiple clinical contexts, including acute admission and family practice, due to several key barriers. In the global effort against this epidemic, educational programs geared toward changing physicians’ prescribing patterns represent an important means of promoting deprescribing.

Methods

This is a nonrandomized, controlled interventional study investigating polypharmacy outcomes and prescribing patterns in patients whose physicians were trained in the Good Palliative-Geriatric Practice (GPGP) method, an algorithm for the reduction of polypharmacy, with patients whose physicians were not. Training involved a one-time, full-day workshop led by a senior geriatrician. Two separate settings were examined. In the inpatient setting, one internal medicine ward was trained and compared with another ward which was not trained. In the family practice setting, 28 physicians were trained and compared with practices of 15 physicians not trained. Patients were above the age of 70, representative of the general geriatric population, and not terminally ill.

Results

In the inpatient arm, the intervention group (n = 100) experienced a decrease in medications prescribed from admission to discharge of 18.5%, compared with a decrease of 1.9% in the control group (n = 100, difference between groups p < 0.0001). In the outpatient arm, the intervention group (n = 100) experienced a decrease in medication number of 6.1% compared with 0.07% in the control group (n = 100, difference between groups p = 0.001) over a 6-month period. Preferential decreases in specific drug classes were observed in both groups, including benzodiazepines, psychotropics, and antihypertensives.

Conclusions

A one-time educational intervention based on GPGP can change prescribing patterns in both outpatient and inpatient settings leading to a moderate reduction in polypharmacy. Future work should focus on longitudinal interventions, and longer-term clinical outcomes such as morbidity, mortality, and quality of life.

Predictors of poor glycemic control in adult with type 2 diabetes in South-Eastern Nigeria

BACKGROUND

The study investigated predictors of poor glycemic control in type 2 diabetes (T2DM).

METHODS

Data on demographics, anthropometric and clinical parameters were collected in a cross-section survey from 140 adults with T2DM, using standard tools/instruments. Glycated hemoglobin (A1C) was assessed as a measure of glycemic control.

RESULTS

Majority (83.3%) had poor glycemic control status of which about 95% constitute the elderly. The elderly (OR= 5.90, 95% Cl: 1.66-20.96) were more likely associated with poor glycemic control than the non-elderly (p = 0.006). Adjustment for significant predictor variables: Age, waist-hip ratio (WHR), Fasting plasma glucose (FPG) and Systolic blood pressure (SBP), although attenuated the odds (OR= 5.00, 95% CI: 1.19-20.96) of poor glycemic control, it still remained significantly (p = 0.028) higher in the elderly. Patients outside tight FPG control significantly (p = 0.001) showed poor glycemic cotrol than those within tight FPG (OR= 17.39, 95%Cl: 5.83-51.90), even with attenuated OR (OR= 10.85, 95%Cl: 3.10-37.96) and (OR=12.08, 95%Cl: 3.64-40.09) when non-significant and significant predictor variables were accounted for, respectively.

CONCLUSION

Age, WHR, FPG, and SBP were significantly associated with differences in glycemic control. The elderly and FPG outside tight control showed significantly increased odds of poor glycemic control status.

Adherence to Medication, Physical Activity and Diet in Older Adults With Diabetes: Its Association With Cognition, Anxiety and Depression

Background

Adherence to medication, physical activity (PA) and diet in diabetes mellitus (DM) patients is crucial for its good management, avoiding acute and chronic complications. There are several risk factors associated with non-adherence, including cognitive impairment, depression and anxiety. Nevertheless, studies on therapeutic adherence in older patients with DM are scarce. In this context, the present study aimed to analyze whether adherence to medication, PA and diet are associated with cognitive impairment, anxiety and depression. It also aimed to identity predictors of medication non-adherence.

Methods

A cross-sectional study of older patients (≥ 65 years old) with DM was carried out in the Outpatient Department of Internal Medicine Service of CHUSJ-Porto, Portugal. Those unable to communicate were excluded. Cognition (mini-mental state examination), anxiety and depression (hospital anxiety and depression scale) were assessed. Adherence to medication, PA and diet was measured, based on self-reporting patient/family, questionnaires, physician clinical opinion, hemoglobin test and pharmacy records. Patient groups were compared, using the Mann-Whitney or the Kruskal-Wallis test for continuous variables and the Chi-square test for paired categorical variables (significance level of 0.05). The odds ratio (OR) was calculated to identify independent predictors of non-adherence to medication.

Results

The final sample (n = 94) had a mean age of 75.2 years (standard deviation: 6.7) and mostly were female (53.2%), married (63.8%) and with a low education level (61.7%). Also, 22.3% with cognitive impairment, 16% with depression and 23.4% with anxiety were found. Patients non-adherent to medication had higher depression (P = 0.048) and anxiety (P = 0.010), compared to adherents/partial adherents. Patients non-adherent to PA showed higher anxiety (P = 0.035) and depression (P = 0.004), compared to adherents. Non-adherents to PA had more cognitive impairment than adherents (26.3% vs. 0%; P = 0.034). Patients who had insulin prescribed presented a higher risk of non-adherence to medication (OR: 4.041, 95% confidence interval (CI): 1.404 - 11.628; P = 0.010). Also, the risk of non-adherence to medication is higher by an increase of one unit in anxiety (OR: 1.252, 95% CI: 1.046 - 1.499; P = 0.014).

Conclusions

Higher anxiety and depression were associated with non-adherence to medication and to PA. Insulin prescribed and high anxiety scores were predictors of medication non-adherence. This study appears to contribute to the knowledge about the influence of cognitive and psychological factors in therapeutic adherence in these older diabetic patients.

OVERTREATMENT AND HYPOGLYCEMIA PREVALENCE IN GERIATRIC PATIENTS WITH TYPE-2 DIABETES IN THE TURKISH POPULATION

OBJECTIVE

To determine the prevalence of over-treatment and hypoglycemia in Turkish type-2 diabetes patients and to identify the risk factors.

METHODS

Patients ≥ 65 years, having a minimum 5 years of type-2 diabetes, were included in the study. Patients' body mass index, mean HbA1c level, disease onset and medications related with their co-morbidities were recorded. Over-treatment is defined as the use of non-metformin therapies despite having HbA1c levels < 7%. A history of hypoglycemia episodes in the last three months and patients' home blood glucose measurements were recorded. Factors relating to hypoglycemia and over-treatment were analyzed.

RESULTS

After applying criteria, 755 patients were included in the study: 728 patients (96.4%) had at least one comorbidity. 257 patients (34%) were found to have HbA1c levels < 7%. 217 of them (84.4%) were using non-metformin therapies. 497 patients (65.8%) were using insulin. The over-treatment prevalence in the ≥ 65 years group was 28.7%. The over-treatment ratio in ≥ 80 years group was 28.2%. Hypoglycemia prevalence in the last three months was 23.3%. It was 22.7% for patients ≥ 80 years. Mean age, disease duration, body mass index, insulin usage and doses were found to be significantly different in over-treated patients compared to the others.

CONCLUSIONS

This study showed that despite recent guidelines, there is still a considerable amount of over-treated geriatric patients who are at risk of hypoglycemia and related morbidity and mortality. Insulinization rate was high. Physicians should not avoid de-intensifying the treatment of geriatric patients who have multiple co-morbidities.

Drug Therapy of Dyslipidemia in the Elderly

Abnormal lipoprotein metabolism is an important and modifiable risk factor for atherosclerotic cardiovascular disease (ASCVD), which has been shown in numerous studies to lead to adverse cardiovascular outcomes. As cardiovascular disease (CVD) remains the major cause of morbidity and mortality globally, management of dyslipidemia is a key component of primary and secondary risk-reduction strategies. Because ASCVD risk increases with age, as the population ages, many more people-particularly the elderly-will meet guideline criteria for drug treatment. Statins (HMG-CoA reductase inhibitors) have an unequivocal benefit in reducing ASCVD risk across age groups for secondary prevention. However, the benefit of these drugs for primary prevention in those > 75 years of age remains controversial. We strongly believe that statins should be offered for primary prevention to all older individuals after a shared decision-making process that takes polypharmacy, frailty, and potential adverse effects into consideration. When considering statin therapy in the very old, competing risks of death, and therefore the likelihood that patients will live long enough to benefit from drug therapy, should inform this process. Combination therapies with ezetimibe or proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors should be considered to facilitate the use of tolerable doses of statins. Future investigations of dyslipidemia therapies must appropriately include this at-risk population to identify optimal drugs and drug combinations that have a high benefit:risk ratio for the prevention of ASCVD in the elderly.

Geriatric syndromes and quality of life in older adults with diabetes

AIM

To describe geriatric syndromes and their relationships with quality of life in older adults with diabetes.

METHODS

Community-dwelling older adults (aged >60 years) with diabetes (n = 316) participated in the present study. Eight geriatric syndromes, including polypharmacy (number of medications), pain (Brief Pain Inventory), urinary incontinence (International Consultation on Incontinence Questionnaire), sleep disturbance (hours of sleep), lower cognitive level (Mini-Mental State Examination), falls, depressive symptoms (Geriatric Depression Scale short form) and functional limitation (Barthel Index and Instrumental Activity of Daily Living), were assessed. The WHOQOL-BREF Taiwan version was used to measure physical, psychological, social and environmental domains of quality of life.

RESULTS

Polypharmacy was the most common geriatric syndrome (46.6%), followed by pain (41.5%). Participants with any of the geriatric syndromes, except for polypharmacy and sleep disturbance, had significantly poorer quality of life than those without. The Geriatric Depression Scale score was the only common and significant contributor to all four domains of quality of life, explaining 16~29% of the variance. Number of medications, pain level and cognitive level were also significant contributors, although they explained a small amount (<5%) of the variance. The number of geriatric syndromes (mode = 2) was significantly correlated with all four domains of quality of life (partial correlation r = -0.278~0.460, all P < 0.001).

CONCLUSIONS

Geriatric syndromes, especially polypharmacy and pain, were common among older adults with diabetes. A greater number of geriatric syndromes or a higher Geriatric Depression Scale score were associated with poorer quality of life. Further studies focusing on combinations of different geriatric syndromes or comorbidities are required. Geriatr Gerontol Int 2019; 19: 518-524.

Exploring the Relationship Between Lifestyle Behaviors and Health-Related Quality of Life Among Older Adults With Diabetes

Purpose

The purpose of the study was to examine the association between 3 lifestyle behaviors (smoking, physical activity, and fruit and vegetable consumption) and health-related quality of life (HRQOL) among older adults diagnosed with diabetes.

Methods

A sample of the US population 65 years and older who were diagnosed with diabetes from the 2015 Behavioral Risk factor Surveillance System (N = 11 503) was analyzed. The 4 HRQOL measures were self-rated health, physically unhealthy days, mentally unhealthy days, and impaired activity days in the past month. Multiple logistic regression analysis was conducted to predict HRQOL.

Results

The multiple logistic regression results showed that smoking and lack of physical activity were significant predictors for higher odds of fair or poor self-rated health, more physically unhealthy days, more mentally unhealthy days, and more impaired activity days during past 30 days. No significant relationship was found between fruit and vegetable consumption and any HRQOL measure.

Conclusions

Findings imply that diabetes education could continue and enhance efforts in smoking cessation and increase physical activity to promote the HRQOL among older adults diagnosed with diabetes. In addition, the measure of fruit and vegetable consumption should be further studied to reflect the needs of older adults with diabetes.

Impact of New Technologies for Middle-Aged and Older Patients: In-Depth Interviews With Type 2 Diabetes Patients Using Continuous Glucose Monitoring

Background

Continuous glucose monitoring (CGM) uses subcutaneous sensors and records the average interstitial sensor current every 5 min in the recorder; data are subsequently exported to a computer 4 to 7 days later when calibration with self-measured blood glucose is made retrospectively. How middle-aged and older patients perceive the added technology intervention is not clear.

Objective

The study aimed to understand the factors associated with the adoption of new technology in diabetes care, to understand the feelings and behaviors while using it, and to determine the changes in attitudes and behavior after completing the use of the new technology at the 3-month follow-up.

Methods

Middle-aged and older type 2 diabetes patients who had received professional continuous glucose monitoring (iPro 2 [Medtronic]) were invited for semistructured in-depth interviews on the day of the CGM sensor removal and at 3 months after CGM-based counseling. A phenomenography approach was used to analyze the interview data.

Results

A total of 20 type 2 diabetes patients (aged 53 to 72 years, 13 males and 7 females, 4 to 40 years duration of diabetes, mean glycated hemoglobin 8.54% [SD 0.71%]) completed 2 sections of semistructured in-depth interviews. Physician guidance and participant motivation toward problem solving were found to be factors associated with adoption of the device. Participants indicated that technology can be a reminder, a supervisor, and a visualizer of blood glucose, all of which are helpful for disease management. However, CGM is somewhat inconvenient, and some participants also reported that the provision of this new technology might be a hint of disease progression. There was a higher percentage of women compared with men who reported that CGM can be a reminder or a supervisor to help them with diet control.

Conclusions

Physician guidance and participants’ degree of motivation are keys to adopting new technology in the case of middle-aged and older adults. Although the CGM sensor may cause inconvenience to patients on their limited body movement when wearing the device, it is helpful for diet control and is an effective behavioral modification tool that offers support, especially in the case of women.

Efficacy and Safety of IDegAsp Versus BIAsp 30, Both Twice Daily, in Elderly Patients with Type 2 Diabetes: Post Hoc Analysis of Two Phase 3 Randomized Controlled BOOST Trials

INTRODUCTION

The majority of elderly patients (≥ 65 years of age) with type 2 diabetes mellitus (T2DM) will eventually require insulin therapy, but they are particularly vulnerable to hypoglycemia and challenging to treat. Insulin degludec/insulin aspart (IDegAsp) is a novel co-formulation of 70% insulin degludec and 30% insulin aspart administered in a single injection, either once or twice daily with main meals.

METHODS

A combined analysis of the phase 3 BOOST INTENSIFY PREMIX I (NCT01009580) and BOOST INTENSIFY ALL (NCT01059812) trials has previously reported lower rates of hypoglycemia during the maintenance period in patients with T2DM treated with IDegAsp twice daily (BID) versus biphasic insulin aspart 30 (BIAsp 30) BID. This post hoc analysis examined the safety and efficacy of IDegAsp versus BIAsp 30 in elderly patients from the global population of these two trials, and also from the Japanese cohort of BOOST INTENSIFY ALL.

RESULTS

Change in HbA1c was similar for IDegAsp versus BIAsp 30 (p > 0.5). Compared with BIAsp 30, IDegAsp resulted in significant reductions in fasting plasma glucose (p  < 0.0001), numerically lower rates of overall and nocturnal hypoglycemia (global estimated rate ratios: 0.92 [0.67; 1.26]95% confidence interval [CI], p  = 0.5980 and 0.67 [0.39; 1.18]95% CI, p  = 0.1676, respectively), and a significantly lower total daily insulin dose at end of trial (global estimated treatment difference 0.79 [0.73; 0.87]95% CI, p  < 0.0001) in elderly patients.

CONCLUSION

The results described here are consistent with those of the overall trial populations, demonstrating that IDegAsp BID is efficacious in elderly patients and suggesting that there is no need for special safety precautions.

FUNDING

Novo Nordisk.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT01009580 and NCT01059812. Plain language summary available for this article.

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.

Medication appropriateness criteria for older adults: a narrative review of criteria and supporting studies

Polypharmacy is common among older adults and is associated with adverse outcomes. Polypharmacy increases the likelihood of receiving a potentially inappropriate medication (PIM). PIMs have traditionally been defined as medications that have either no benefit (e.g. therapeutic duplication) or increased risk (e.g. altered pharmacodynamics/kinetics with aging). A growing literature supports the notion that these represent only a subset of the potential risks of medications prescribed to older adults. Different authors have proposed new sets of criteria for evaluating medication appropriateness. This narrative review had two objectives: 1) to summarize the contents of these criteria in order to obtain preliminary information about where clinical consensus exists regarding appropriateness; 2) The second was to describe studies examining the risks and benefits of medications identified by the criteria to determine the strength of the evidence supporting the derivation of these criteria. We identified 13 articles sharing overlapping criteria for evaluating appropriateness including: (1) delayed time to benefit; (2) altered benefit-harm ratios in the face of competing risks; (3) effects that do not match patients' goals; and (4) nonadherence. The similarities across the articles suggested strong clinical consensus; however, the articles presented little data directly supporting these criteria. Additional studies provide evidence for the proof of concept that average estimates of benefit and harm derived from randomized controlled trials may differ from the benefits and harms experienced by older persons. However, more data are required to characterize the benefits and harms of medications in the context of the regimen as a whole and the individual's health status.

Primary Prevention of Cardiovascular Risk in Octogenarians by Risk Factors Control

Primary prevention of cardiovascular events in older adults is a relevant problem, due to lack of evidence for safe and efficacious therapy, its costs and elderly quality of life, Italy's aging population is constantly increasing, so cardiovascular disease (CVD) primary prevention in the elderly is a prime objective. Life expectancy has dramatically increased over the last 2 decades, the proportion of individuals aged 80 years and older has grown rapidly in Europe and the United States, but cost / effective ratio of CVD prevention through risk factors control is debated. It is therefore important to implement cardiovascular risk factors estimation in the elderly to maximize the quality of life of patients and to lengthen their healthy life expectancy, choosing the better treatment for each patient sharing the choice with himself when it is possible, always remembering that elderly patients often have multiple co-morbidities that require a high number of concurrent medications; this may increase the risk for drug-drug interactions, thereby reducing the potential benefits of CVD prevention therapy. Nevertheless, CVD is not an inevitable concomitant of aging. Sometimes, autopsy in the elderly reveals atheroma-free coronary arteries, a normal-sized heart and unscarred valves. All primary prevention strategy decisions should consider estimated life expectancy and overall function and not just the cardiovascular event risks, magnitude and time to benefit or harm, potentially altered adverse effect profiles, and informed patient preferences. CVD primary prevention needs to be more implemented in the elderly, this might contribute to improve health status and quality of life in this growing population if correctly performed.

Older patients' preferences and views related to non-face-to-face diabetes chronic care management: a qualitative study from southeast Louisiana

Background: Management of diabetes may be uniquely challenging for older individuals with multiple chronic conditions. Health systems and policymakers have attempted to reduce barriers to chronic care management (CCM) through incentives to provide non-face-to-face care. This qualitative study aimed to investigate and present views on non-face-to-face care management held by elderly patients with diabetes and other chronic conditions in order to contribute to improved programming for this population. Materials and methods: Semi-structured interviews were conducted with patients over the age of 64 who have been diagnosed with diabetes and at least one other chronic health condition. Interview recordings were transcribed and analyzed by experienced researchers using a thematic analytic approach, and an illustrative case study was developed. Results: Thirty individuals participated in this study. Participants were drawn from three health systems in south Louisiana, an area with high rates of morbidity and mortality related to chronic diseases. We identified themes related to lived experiences with diabetes and other medical conditions, perception of personal health status, perceived value of non-face-to-face programs, and support needs for future programming. Additionally, we present one case study describing in detail an individual patient's experience with non-face-to-face CCM. Conclusion: Health systems should consider intentionally recruiting participants who would benefit most from non-face-to-face care, including higher-need, less self-sufficient patients with resource constraints, while continuing to offer in-person services. Future research should examine whether tailoring non-face-to-face programming and support to address unique barriers can further enhance diabetes care at the population level.

Development and Validation of a Self-Administered Multidimensional Prognostic Index to Predict Negative Health Outcomes in Community-Dwelling Persons

The multidimensional prognostic index (MPI) is a comprehensive geriatric assessment (CGA)-based tool that accurately predicts negative health outcomes in older subjects with different diseases and settings. To calculate the MPI several validated tools are assessed by health care professionals according to the CGA, whereas self-reported information by the patients is not available, but it could be of importance for the early identification of frailty. We aimed to develop and validate a self-administered MPI (SELFY-MPI) in community-dwelling subjects. For this reason, we enrolled 167 subjects (mean age = 67.3, range = 20–88 years, 51% = men). All subjects underwent a CGA-based assessment to calculate the MPI and the SELFY-MPI. The SELFY-MPI included the assessment of (1) basic and instrumental activities of daily living, (2) mobility, (3) memory, (4) nutrition, (5) comorbidity, (6) number of medications, and (7) socioeconomic situation. The Bland–Altman methodology was used to measure the agreement between MPI and SELFY-MPI. The mean MPI and SELFY-MPI values were 0.147 and 0.145, respectively. The mean difference was +0.002 ± standard deviation of 0.07. Lower and upper 95% limits of agreement were −0.135 and +0.139, respectively, with only 5 of 167 (3%) of observations outside the limits. Stratified analysis by age provided similar results for younger (≤65 years old, n = 45) and older subjects (>65 years, n = 122). The analysis of variances in subjects subdivided according to different year decades showed no differences of agreement according to age. In conclusion, the SELFY-MPI can be used as a prognostic tool in subjects of different ages.

Multimorbidity patterns in high-need, high-cost elderly patients

Introduction

Patients with complex health care needs (PCHCN) are individuals who require numerous, costly care services and have been shown to place a heavy burden on health care resources. It has been argued that an important issue in providing value-based primary care concerns how to identify groups of patients with similar needs (who pose similar challenges) so that care teams and care delivery processes can be tailored to each patient subgroup. Our study aims to describe the most common chronic conditions and their combinations in a cohort of elderly PCHCN.

Methods

We focused on a cohort of PCHCN residing in an area served by a local public health unit (the “Azienda ULSS4-Veneto”) and belonging to Resource Utilization Bands 4 and 5 according to the ACG System. For each patient we extracted Expanded Diagnosis Clusters, and combined them with information available from Rx-MGs diagnoses. For the present work we focused on 15 diseases/disorders, analyzing their combinations as dyads and triads. Latent class analysis was used to elucidate the patterns of the morbidities considered in the PCHCN.

Results

Five disease clusters were identified: one concerned metabolic-ischemic heart diseases; one was labelled as neurological and mental disorders; one mainly comprised cardiac diseases such as congestive heart failure and atrial fibrillation; one was largely associated with respiratory conditions; and one involved neoplasms.

Conclusions

Our study showed specific common associations between certain chronic diseases, shedding light on the patterns of multimorbidity often seen in PCHCN. Studying these patterns in more depth may help to better organize the intervention needed to deal with these patients.