Diabetes in elderly adults

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

The effects of diabetes, hypertension and subsequent health control behavior on the survival of a Taiwan cohort aged over 50 years

Purpose

This study used the Taiwan Longitudinal Study in Aging from 1996 to 2011 to investigate the effects of diabetes, hypertension, and healthy living behaviors of those aged over 50 years on the survival status in Taiwan.

Methods

Among the 5,131 participants aged 50 years and above in the 1996 survey were included in this study. Cox's proportional hazards model was used to examine the incidence of diabetes, hypertension, and related mortality risk in those aged over 50 years.

Results

After adjusting for age, gender, education level, diabetes, hypertension, health behavior, and leisure activity, results from the Cox model show that the elderly without diabetes have a lower mortality risk than those with diabetes. Regular exercise was associated with a lower risk of mortality. The hazard ratios of elderly with regular exercise were 0.78 (95 % CI: 0.64-0.96) for two times a week or less, 0.81 (95 % CI: 0.69-0.96) for 3-5 times a week, and 0.84 (95 % CI: 0.77-0.93) for 6 + times a week, respectively. On the other hand, leisure activity positively reduces mortality risk. For example, the hazard ratios of the elderly with watching TV and reading were 0.63 (95 % CI: 0.55-0.72) and 0.80 (95 % CI: 0.72-0.89), respectively. Moreover, smoking can increase mortality risk 23 % whether the elderly are with diabetes or hypertension or not.

Conclusions

Regarding preventing and controlling chronic diseases in the future, continuously encouraging improvement in health behavior and engaging in leisure activities for the middle-aged and over should be considered essential markers.

Interaction between depressive symptoms and obesity-related anthropometric measures on multimorbidity among community-dwelling older adults: evidence from India

BACKGROUND

This study aimed to examine the associations between depressive symptoms, body mass index (BMI), waist circumference, waist-hip ratio and multimorbidity among community-dwelling older adults. We also examine the interaction effects between depressive symptoms, BMI, waist circumference and waist-hip ratio on multimorbidity among older adults in India.

METHODS

A cross-sectional study was conducted, and the data were obtained from the Longitudinal Ageing Study in India (LASI) wave-1, with a sample of 31,464 older adults aged 60 years and above (men-15,098 and women-16,366). We used multinomial logistic regression to explore the independent associations between depressive symptoms, obesity-measures, and single and multimorbidity. We also estimated the interaction effects of depressive symptoms and obesity-measures on multimorbidity.

RESULTS

The prevalence of multimorbidity was higher among individuals with depressive symptoms (39.22%) than individuals with no depressive symptoms (29.94%). Adjusted models indicated that older adults with depressive symptoms had higher odds of single and multimorbidity [(AOR = 1.40, 95% CI: 1.17-1.68) and (AOR = 1.85, 95% CI: 1.58-2.16), respectively]. Similarly, in comparison to the normal BMI category, overweight and obese older adults were more likely to report single morbidity [(AOR = 1.62, 95% CI: 1.37-1.92 and (AOR = 2.14, 95% CI: 1.67-2.75), respectively] and multimorbidity [(AOR = 2.00, 95% CI: 1.72-2.33) and (AOR = 3.77, 95% CI: 2.94-4.82), respectively].

CONCLUSION

The findings revealed that the presence of depressive symptoms, overweight or obesity, and high-risk anthropometric measures such as high-risk waist circumference and high-risk waist to hip ratio significantly increased the risk of morbidity among older adults in India. Thus, it is suggested to adopt an integrated public health policy approach to control depressive symptoms and high-risk body composition to strategically prepare against the elevated risk of multimorbidity among ageing populations.

Daily low-dose aspirin and incident type 2 diabetes in community-dwelling healthy older adults: a post-hoc analysis of efficacy and safety in the ASPREE randomised placebo-controlled trial

BACKGROUND

Inflammation has been implicated in the pathogenesis of diabetes. This study investigated the randomised treatment effect of low-dose aspirin on incident type 2 diabetes and fasting plasma glucose (FPG) concentrations among older adults.

METHODS

ASPREE was a double-blind, placebo-controlled trial of daily oral low-dose aspirin. The study population included community-dwelling individuals aged 70 years or older (≥65 years for US minority ethnic groups) in the USA and Australia who were free of cardiovascular disease, independence-limiting physical disability, or dementia. For the post-hoc analysis, we excluded participants with diabetes at baseline or with incomplete or missing incident diabetes data during follow-up. Participants were randomly assigned 1:1 to oral 100 mg daily enteric-coated aspirin or placebo. Incident diabetes was defined as self-reported diabetes, commencement of glucose-lowering medication, or a FPG concentration of 7·0 mmol/L or more assessed at annual follow-up visits among participants with no diabetes at baseline. We used Cox proportional hazards models and mixed-model repeated measures to assess the effect of aspirin on incident diabetes and FPG concentrations in the intention-to-treat population. We assessed major bleeding in participants who had taken at least one dose of study medication.

FINDINGS

Between March 10, 2010, and Dec 24, 2014, a total of 16 209 participants were included (8086 [49·9%] randomly assigned to aspirin and 8123 [50·1%] randomly assigned to placebo). During a median follow-up of 4·7 years (IQR 3·6-5·7), 995 (in 6·1% individuals) incident cases of type 2 diabetes were recorded (459 in the aspirin group and 536 in the placebo group). Compared with placebo, the aspirin group had a 15% reduction in risk of incident diabetes (hazard ratio 0·85 [95% CI 0·75 to 0·97]; p=0·013) and a slower rate of increase in FPG concentration at year 5 (between-group difference estimate -0·048 mmol/L [95% CI -0·079 to -0·018]; p=0·0017). Major bleeding (major gastrointestinal bleeding, intracranial bleeding, and clinically significant bleeding at other sites) occurred in 510 (3·2%) of 16 104 participants (300 [3·7%] in the aspirin group and 210 [2·6%] in the placebo group). Compared with placebo, the aspirin group had a 44% increase in risk of major bleeding (hazard ratio 1·44 [95% CI 1·21 to 1·72]; p<0·0001).

INTERPRETATION

Aspirin treatment reduced the incidence of type 2 diabetes and slowed the increase in FPG concentration but increased major bleeding among community-dwelling older adults. Given the increasing prevalence of type 2 diabetes among older adults, the potential for anti-inflammatory agents such as aspirin to prevent type 2 diabetes or improve glucose levels warrants further study with a comprehensive assessment of all potential safety events of interest.

FUNDING

US National Institute on Aging, US National Cancer Institute, National Health and Medical Research Council of Australia, Monash University, and the Victorian Cancer Agency.

Effect of zinc supplementation on blood glucose level in different age groups of diabetes type 2

Background: Studies on humans have revealed the beneficial effects of zinc (Zn) supplementation in patients with type-2 diabetes. Aim: The present study was designed to investigate the effects of zinc supplementation on blood glucose level in type-2 diabetic patients and determine the interaction between age and zinc supplementation on type-2 diabetic patients. Methods: A randomized placebo-control trial conducted in Bashir Hospital of Sialkot, Allama Iqbal Memorial Hospital Sialkot and Civil Hospital of Daska, Sialkot. 144 diabetic patients were selected including an expected drop-out rate of 20%. All the participants were randomly divided into Group 1 (Treatment group with intervention given Zn tablets 20 mg/day) and Group 2 (control group with placebo effect). Each group was further divided into 2 age categories Category 1 (30-50 years of age) and Category 2 (51-70 Years of age). Demographic data, Anthropometric measurements, 24-h dietary recall, serum blood glucose analysis, HbA1C, and serum zinc levels were recorded at the beginning (0 day) and end of the study (60 days). Results: Final fasting serum glucose levels were significantly lowered in group 1 with (p < 0.05) as compared to group 2, but interestingly, results were significant (p < 0.05) in the older age group (51-70 years) as compared to their younger age counterparts (30-50 years) of group2. A similar trend was also found in the HbA1c, serum Zn levels and BMI of the participants. Conclusion: Results implied the possible phenomenon of better response to Zn supplementation among aged patients as compared to younger counterparts, which may suggest higher Zn demands with advanced age.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Adherence to the Taiwan Daily Food Guide and the Risk of Type 2 Diabetes: A Populational Study in Taiwan

This study aims to examine whether adherence to the Taiwan Daily Food Guide relates to the risk of type 2 diabetes. A population-based study was conducted using data from the Nutrition and Health Survey in Taiwan (NAHSIT) 2013-2016. Dietary intakes were assessed using a validated food-frequency questionnaire. Type 2 diabetes was defined as a fasting serum HbA1c level of 6.5% or higher or participants who have received treatment for type 2 diabetes or have reported a physician diagnosis of type 2 diabetes. A total of 2534 Taiwanese adults aged 19 and above were included. We found that the Daily Food Guide adherence was negatively associated with the prevalence of type 2 diabetes. The odds ratios (ORs) for those in the fourth quartile of the recommended total servings was 0.67 (95% confidence interval (CI) = 0.45-0.99) compared with those in the first quartile. In addition, those who were men (OR = 1.46, 95% CI = 1.07-1.98), aged more than 50 to 65 (OR = 6.48, 95% CI = 2.57-16.35), or more than 65 (OR = 6.81, 95% CI = 2.56-18.08), with body mass index (BMI) of 24 to less than 27 (OR = 2.08, 95% CI = 1.55-2.79), had BMI of more than 27 (OR = 3.63, 95% CI = 2.73-4.83), had an education level of junior high and high school (OR = 1.68, 95% CI = 1.03-2.74), were divorced, separated, widowed, or refused to answer (OR = 1.39, 95% CI = 1.03-1.88) were associated with an increased prevalence of type 2 diabetes. In conclusion, people who adhere better to the Taiwan Daily Food Guide were found to have a reduced risk of type 2 diabetes.

Interactive effects of intrinsic capacity and obesity on the KDIGO chronic kidney disease risk classification in older patients with type 2 diabetes mellitus

BACKGROUND

Intrinsic capacity (IC) is a novel concept focusing on normal and healthy aging. The effect of IC on the risk of chronic kidney disease (CKD) according to KDIGO category in older type 2 diabetes mellitus (T2DM) patients has rarely been studied. We investigated whether a decline in IC is associated with the risk of CKD according to KDIGO 2012 categories.

METHODS

This is a cross-sectional study. The exposure variables (IC score and body mass index) and outcome variable (KDIGO categories of the risk of CKD) were collected at the same timepoint. A total of 2482 older subjects with T2DM managed through a disease care program were enrolled. The five domains of IC, namely locomotion, cognition, vitality, sensory, and psychological capacity were assessed. Based on these domains, the IC composite score was calculated. CKD risk was classified according to the KDIGO 2012 CKD definition. Univariate and multivariate analyses were used to assess the association between IC score and KDIGO categories of risk of CKD.

RESULTS

The KDIGO CKD risk category increased in parallel with IC score (p for trend < 0.0001). In multivariate analysis, compared to those with an IC score 0, the odds ratio of having a KDIGO moderately increased to very high risk category of CKD was 1.76 (1.31-2.37) times higher for those with an IC score of 2-5. Furthermore, an increased IC score was associated with a higher prevalence of moderate and severe obesity. Moreover, there was a synergistic interaction between IC score and obesity on the KDIGO moderately increased to very high risk category of CKD (synergy index = 1.683; 95% CI 0.630-3.628), and the proportion of the KDIGO moderately increased to very high risk category of CKD caused by this interaction was 25.6% (attributable proportion of interaction = 0.256).

CONCLUSIONS

Our findings indicate that IC score may be closely related to the KDIGO moderately increased to very high risk category of CKD. In addition, there may be a synergistic interaction between IC score and obesity, and this synergistic interaction may increase the KDIGO CKD risk stage.

LncRNA KCNQ1OT1: Molecular mechanisms and pathogenic roles in human diseases

Long non-coding RNAs (lncRNAs) exhibit a length more than 200 nucleotides and they are characterized by non-coding RNAs (ncRNA) not encoded into proteins. Over the past few years, the role and development of lncRNAs have aroused the rising attention of researchers. To be specific, KCNQ1OT1, the KCNQ1 opposite strand/antisense transcript 1, is clearly classified as a regulatory ncRNA. KCNQ1OT1 is capable of interacting with miRNAs, RNAs and proteins, thereby affecting gene expression and various cell functions (e.g., cell proliferation, migration, epithelial-mesenchymal transition (EMT), apoptosis, viability, autophagy and inflammation). KCNQ1OT1 is dysregulated in a wide range of human diseases (e.g., cardiovascular disease, cancer, diabetes, osteoarthritis, osteoporosis and cataract), and it is speculated to act as a therapeutic target for treating various human diseases. On the whole, this review aims to explore the biological functions, underlying mechanisms and pathogenic roles of KCNQ1OT1 in human diseases.

Associating pathways with diseases using single-cell expression profiles and making inferences about potential drugs

Finding direct dependencies between genetic pathways and diseases has been the target of multiple studies as it has many applications. However, due to cellular heterogeneity and limitations of the number of samples for bulk expression profiles, such studies have faced hurdles in the past. Here, we propose a method to perform single-cell expression-based inference of association between pathway, disease and cell-type (sci-PDC), which can help to understand their cause and effect and guide precision therapy. Our approach highlighted reliable relationships between a few diseases and pathways. Using the example of diabetes, we have demonstrated how sci-PDC helps in tracking variation of association between pathways and diseases with changes in age and species. The variation in pathways-disease associations in mice and humans revealed critical facts about the suitability of the mouse model for a few pathways in the context of diabetes. The coherence between results from our method and previous reports, including information about the drug target pathways, highlights its reliability for multidimensional utility.

Associations of Daily Steps and Step Intensity With Incident Diabetes in a Prospective Cohort Study of Older Women: The OPACH Study

OBJECTIVE

The primary aim was to assess associations between total steps per day and incident diabetes, whereas the secondary aim was to assess whether the intensity and/or cadence of steps is associated with incident diabetes.

RESEARCH DESIGN AND METHODS

Women without physician-diagnosed diabetes (n = 4,838; mean [SD] age 78.9 [6.7] years) were followed up to 6.9 years; 395 developed diabetes. Hip-worn ActiGraph GT3X+ accelerometers worn for 1 week enabled measures of total, light-intensity, and moderate- to vigorous-intensity (MV-intensity) steps per day. Using Cox proportional hazards analysis we modeled adjusted change in the hazard rate for incident diabetes associated with total, light-intensity, and MV-intensity steps per day. We further estimated the proportion of the steps-diabetes association mediated by BMI.

RESULTS

On average, participants took 3,729 (SD 2,114) steps/day, of which 1,875 (791) were light-intensity steps and 1,854 ± 1,762 were MV-intensity. More steps per day were associated with a lower hazard rate for incident diabetes. Confounder-adjusted models for a 2,000 steps/day increment yielded hazard ratio (HR) 0.88 (95% CI 0.78-1.00; P = 0.046). After further adjustment for BMI, HR was 0.90 (95% CI 0.80-1.02; P = 0.11). BMI did not significantly mediate the steps-diabetes association (proportion mediated = 17.7% [95% CI -55.0 to 142.0]; P = 0.09]). The relationship between MV-intensity steps per day (HR 0.86 [95% CI 0.74-1.00]; P = 0.04) and incident diabetes was stronger than for light-intensity steps per day (HR 0.97 [95% CI 0.73-1.29]; P = 0.84).

CONCLUSIONS

These findings suggest that for older adults, more steps per day are associated with lower incident diabetes and MV-intensity steps are most strongly associated with a lower hazard of diabetes. This evidence supports that regular stepping is an important risk factor for type 2 diabetes prevention in older adults.

Plasma Ceramides containing Saturated Fatty Acids are Associated with Risk of Type 2 Diabetes

Recent studies suggest that the type of saturated fatty acid bound to sphingolipids influences the biological activity of those sphingolipids. However, it is unknown whether associations of sphingolipids with diabetes may differ by the identity of bound lipid species. Here, we investigated associations of 15 ceramide (Cer) and SM species (i.e., all sphingolipids, measured with coefficient of variation less than 20%) with incident type 2 diabetes in the Cardiovascular Health Study (n = 3,645), a large cohort study of cardiovascular disease among elderly adults who were followed from 1989 to 2015. Diabetes incidence was defined as fasting glucose ≥126 mg/dl or nonfasting glucose ≥200 mg/dl; reported use of insulin or oral hypoglycemic medication; or documentation of diabetes diagnosis through the Centers for Medicare and Medicaid Services records. Associations of each sphingolipid with incident diabetes were assessed using a Cox proportional hazards regression model. We found that higher circulating levels of Cer with acylated palmitic acid (Cer-16), stearic acid containing Cer (Cer-18), arachidic acid containing Cer (Cer-20), and behenic acid containing Cer (Cer-22) were each associated with a higher risk of diabetes. The hazard ratios for incident diabetes per 1 SD higher log levels of each Cer species were as follows: 1.21 (95% CI: 1.09–1.34) for Cer-16, 1.23 (95% CI: 1.10–1.37) for Cer-18, 1.14 (95% CI: 1.02–1.26) for Cer-20, and 1.18 (95% CI: 1.06–1.32) for Cer-22. In conclusion, higher levels of Cer-16, Cer-18, Cer-20, and Cer-22 were associated with a higher risk of diabetes.

Self-efficacy in physical activity and glycemic control among older adults with diabetes in Jagir Subdistrict, Surabaya, Indonesia

Diabetes in older adults has shown an increase in prevalence, especially in urban areas of Indonesia. This study aimed to assess the relationship between self-efficacy in physical activity and glycemic control in older adults' population with diabetes mellitus in Indonesia. This research used cross sectional design that involved 52 adults with diabetes, aged between 55-90 years old who regularly attended the older adult's health post (Posyandu Lansia) at Jagir Sub-district, Surabaya. Those who had physical disabilities were excluded from the study. Questionnaires were used to measure the physical activity and two types of self-efficacy whilst the glycemic control was measured using HbA1c in basal condition. The relationship between the variables was tested using Pearson and partial correlation test. Results show that the level of physical activity was insufficient (216.4 ± 343.5 MET) with only 32.7% (N = 17) of the participants was categorized as being physically active. The mean of the HbA1c indicated poor glycaemic control (8.63 ± 2.34%) with majority of them (76.9%, N = 40) was in the poor glycaemic control group (HbA1c ≥ 6.5%). Their self-efficacy was at the average level (Against the barriers:52.65 ± 13.23; Engage in physical activity: 59.06 ± 26.2). The self-efficacy in performing the physical activity was found significantly related to the duration of physical activity (r = 0.278, p = 0.046). Other relationships, however, were not significant (p > 0.05). In conclusion, self-efficacy to engage in physical activity is paramount to increase the physical activity among the older adults. Nevertheless, further longitudinal research on self-efficacy in physical activity management is needed.

Neurotrophic signaling deficiency exacerbates environmental risks for Alzheimer's disease pathogenesis

The molecular mechanism of Alzheimer's disease (AD) pathogenesis remains obscure. Life and/or environmental events, such as traumatic brain injury (TBI), high-fat diet (HFD), and chronic cerebral hypoperfusion (CCH), are proposed exogenous risk factors for AD. BDNF/TrkB, an essential neurotrophic signaling for synaptic plasticity and neuronal survival, are reduced in the aged brain and in AD patients. Here, we show that environmental factors activate C/EBPβ, an inflammatory transcription factor, which subsequently up-regulates δ-secretase that simultaneously cleaves both APP and Tau, triggering AD neuropathological changes. These adverse effects are additively exacerbated in BDNF+/- or TrkB+/- mice. Strikingly, TBI provokes both senile plaque deposit and neurofibrillary tangles (NFT) formation in TrkB+/- mice, associated with augmented neuroinflammation and extensive neuronal loss, leading to cognitive deficits. Depletion of C/EBPβ inhibits TBI-induced AD-like pathologies in these mice. Remarkably, amyloid aggregates and NFT are tempospatially distributed in TrkB+/- mice brains after TBI, providing insight into their spreading in the progression of AD-like pathologies. Hence, our study revealed the roles of exogenous (TBI, HFD, and CCH) and endogenous (TrkB/BDNF) risk factors in the onset of AD-associated pathologies.

The relationship between frailty and diabetes: An investigation of self-rated health, depression symptoms and quality of life in the Study of Health Aging and Retirement in Europe

AIMS

To assess the impact of diabetes and frailty on self-rated health, depressive symptoms and quality of life (QoL).

METHODS

Data were pooled for participants aged ≥50 years from five waves of the Survey of Health, Ageing and Retirement in Europe. Measures included diabetes (self-reported), physical frailty (≥3/5 criteria), low self-rated health (SRH; "poor" or "fair"), depression (screened using the EURO-D ≥4) and low QoL (CASP-12 <35). Logistic regression was used to adjust for confounding.

RESULTS

Participants with diabetes (n=11,661/97,691) were more likely to be older (68 vs. 64 years, p<0.001), male (50% vs. 45%, p<0.001) and frail (21% vs. 8%, p<0.001). Age, sex, diabetes and frailty were all independently associated with low SRH, depression and low QoL. Frailty had the highest adjusted odds ratios for low SRH (9.43; 95% CI:8.89-10.02), depression (6.39; 95% CI:6.07-6.71) and low QoL (9.65; 95% CI:9.17-10.16). For diabetes, the adjusted odds ratios were 2.82 (2.70-2.95), 1.49 (1.42-1.56) and 1.67 (1.60-1.74), respectively. Participants with both diabetes and frailty reported the worst self-rated health, the most depression symptoms and the lowest QoL.

CONCLUSIONS

Frailty was prevalent in older people with diabetes and independently associated with low self-rated health, depressive symptoms and low QoL. Prompt identification and management of frailty should be a key consideration in diabetes care.

Improved Balance and Gait Ability and Basic Activities of Daily Living after Comprehensive Geriatric Care in Frail Older Patients with Fractures

(1) Purpose: Comprehensive geriatric care (CGC) is a multidisciplinary treatment approach for elderly patients. We aimed to investigate outcomes in fracture patients who had been treated using this approach in a large geriatric unit. (2) Methods: This observational cohort study assessed the gait function (using the Tinetti Balance and Gait Test (TBGT)) and basic activities of daily living (ADL) (using the Barthel index (BI)) before and after CGC and compared the results. Baseline data, walking ability assessments (Timed Up and Go, TUG), and cognitive status (mini mental status examination, MMSE) were also analyzed in the subgroup of patients with versus without fractures. (3) Results: Out of 1263 hospitalized patients, 1099 received CGC (median age: 83.1 years (IQR: 79.0–87.8 years); 64.1% were female). TBGT improvement was observed in 90.7% and BI increased in 82.7% of fracture patients. A TBGT improvement of >5 was noted in 47.3% and was associated with female sex, a lower BI at admission (median: 40 versus 45; p = 0.010), and poorer mobility on admission (TUG: median 5 versus 4; p = 0.001). An improvement in BI of ≥15 was observed in 63.0% of the cases, and was associated with a better cognitive status (MMSE: median 25 versus 18; p = 0.001) and inversely associated with diabetes mellitus and a previous stroke. (4) Conclusion: CGC in specialized geriatric units improves the balance and gait and the basic ADL in geriatric patients. After fracture, female patients are more likely to experience improvements in gait and balance, while patients with better cognitive condition are more likely to experience improvements in ADL.

Non-Coding RNAs Based Molecular Links in Type 2 Diabetes, Ischemic Stroke, and Vascular Dementia

This article reviews recent advances in the study of microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and their functions in type 2 diabetes mellitus (T2DM), ischemic stroke (IS), and vascular dementia (VaD). miRNAs and lncRNAs are gene regulation markers that both regulate translational aspects of a wide range of proteins and biological processes in healthy and disease states. Recent studies from our laboratory and others have revealed that miRNAs and lncRNAs expressed differently are potential therapeutic targets for neurological diseases, especially T2DM, IS, VaD, and Alzheimer's disease (AD). Currently, the effect of aging in T2DM, IS, and VaD and the cellular and molecular pathways are largely unknown. In this article, we highlight results from the works on the molecular connections between T2DM and IS, and IS and VaD. In each disease, we also summarize the pathophysiology and the differential expressions of miRNAs and lncRNAs. Based on current research findings, we hypothesize that 1) T2DM bi-directionally and age-dependently induces IS and VaD, and 2) these changes are precursors to the onset of dementia in elderly people. Research into these hypotheses is required to examine further whether research efforts on reducing T2DM, IS, and VaD may affect dementia and/or delay the AD disease process in the aged population.

Sedentary Behavior and Diabetes Risk Among Women Over the Age of 65 Years: The OPACH Study

OBJECTIVE

To evaluate whether sedentary time (ST) and/or sedentary behavior patterns are related to incident diabetes in the U.S.'s oldest age-groups.

RESEARCH DESIGN AND METHODS

Women without physician-diagnosed diabetes (n = 4,839, mean ± SD age = 79 ± 7 years) wore accelerometers for ≥4 days and were followed up to 6 years for self-reported newly diagnosed diabetes requiring treatment with medications. Hazard ratios (HRs) for incident diabetes were estimated across quartiles of accelerometer-measured ST and mean bout duration with use of Cox proportional hazards models. We conducted isotemporal substitution analyses using Cox regression and tested associations with risk for diabetes after statistically replacing ST with light physical activity (PA) or moderate-to-vigorous PA (MVPA) and after replacing light PA with MVPA.

RESULTS

During 20,949 person-years, 342 diabetes cases were identified. Women in ST quartile (Q)2, Q3, and Q4 (vs. Q1) had incident diabetes HR 1.20 (95% CI 0.87-1.65), 1.33 (0.97-1.82), and 1.21 (0.86-1.70); P _trend = 0.04. Respective HRs following additional adjustment for BMI and MVPA were 1.04 (95% CI 0.74-1.47), 1.04 (0.72-1.50), and 0.85 (0.56-1.29); P _trend = 0.90. Fully adjusted isotemporal substitution results indicated that each 30 min of ST replaced with MVPA (but not light PA) was associated with 15% lower risk for diabetes (HR 0.85 [95% CI 0.75-0.96]; P = 0.01); the HR for replacing 30 min of light PA with MVPA was 0.85 (95% CI 0.73-0.98); P = 0.03. Mean bout duration was not associated with incident diabetes.

CONCLUSIONS

Statistically replacing ST or light PA with MVPA was associated with lower diabetes risk in older women. While reducing ST is important for several health outcomes, results indicate that to reduce diabetes risk among older adults, the primary public health focus should be on increasing MVPA.

Correlations of sialic acid with glycated hemoglobin A1c and glycemia in postmenopausal women with type-2 diabetes mellitus

For women in the postmenopausal period, age-related changes in the hormonal status are associated with a higher risk for type-2 diabetes and its complications. The tissue injury caused by diabetic vascular complications can induce a release of sialic acid (SA) into the general circulation leading to increased levels. The present study is a cross-sectional single center study of 77 women in the postmenopausal period. The subjects selected for the study were divided into two groups: i) The control group, which included postmenopausal women without type-2 diabetes mellitus (n=27); and ii) a group of postmenopausal women diagnosed with type-2 diabetes (n=50). By analyzing how the serum values of SA were correlated with glycemia and glycated hemoglobin in the subjects with diabetes, it was determined that both parameters exhibited a strong positive correlation (P<0.0001) in the group with type-2 diabetes. Therefore, SA may be considered as a potential marker for the screening, diagnosis or prognosis of type-2 diabetes for postmenopausal women.

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.

Modeling the cardiometabolic benefits of sleep in older women: exploring the 24-hour day

STUDY OBJECTIVES

Activities throughout the day, including sleep, sedentary behavior (SB), light-intensity physical activity (LIPA), and moderate to vigorous physical activity (MVPA) are independently associated with cardiometabolic health. Few studies have examined interrelationships between sleep and 24-hour activity and associations with cardiometabolic risk. The objective of this study is to understand how replacing time in SB, LIPA, or MVPA with sleep impacts cardiometabolic risk.

METHODS

Women's Health Initiative OPACH Study participants (N = 3329; mean age = 78.5 ± 6) wore ActiGraph GT3X+ accelerometers 24 hours/7 days. Adjusted linear regression estimated the relationship between sleep duration and cardiometabolic markers. Separately for shorter (<8 hours) and longer (≥8 hours) sleepers, isotemporal substitution models estimated the cross-sectional associations with cardiometabolic markers with reallocating time in daytime activities to or from sleep.

RESULTS

Longer sleep duration was associated with higher insulin, HOMA-IR, glucose, total cholesterol, and triglycerides (all p < 0.05). The associations between sleep duration and C-reactive protein, waist circumference, and body mass index (BMI) were U-shaped (both p < 0.05). For shorter sleepers, reallocating 33 minutes of MVPA to sleep was associated with higher values of insulin, HOMA-IR, glucose, triglycerides, waist circumference, and BMI (0.7%-11.5%). Replacing 91 minutes of SB time with sleep was associated with lower waist circumference and BMI (-1.3%, -1.8%). For long sleepers, shifting 91 minutes of sleep to SB was associated with higher waist circumference and BMI (1.3%, 1.4%).

CONCLUSIONS

This is one of the first isotemporal analyses to include objectively measured sleep duration. Results illuminate possible cardiometabolic risks and benefits of reallocating time to or from sleep.

The Effect of Educational Intervention Based on BASNEF Model on Self-Medication Behavior of Type 2 Diabetic Patients

BACKGROUND

Diabetes is one of the main reasons of the increase of morbidity and mortality around the world. Considering the burden of disease, self-medication can result in irrecoverable consequences. The aim of this study is to investigate the effect of educational intervention based on Beliefs, Attitudes, Subjective Norms and Enabling Factors (BASNEF) model on self-medication behaviors of type 2 diabetic patients in Fasa, Fars province, Iran, in 2017-2018.

MATERIALS AND METHODS

In this quasi-experimental study, 200 type 2 diabetic patients under cover of the diabetes center of Fasa were investigated (100 patients for experimental group and 100 patients for control group). A questionnaire investigating demographic information and BASNEF Model constructs (knowledge, attitude, enabling factors, subjective norms, and behavioral intention) was used for evaluating self-medication behaviors of patients before and 3 months after intervention.

RESULTS

The average age of experimental group was 53.25 ± 8.42 and the average age of control group was 54.18 ± 8.13. Three months after intervention, experimental group showed significant enhancement in knowledge, attitude, enabling factors, subjective norms, and behavioral intention and their self-medication behaviors reduced, while control group showed no significant changes in mentioned factors.

CONCLUSION

The present study indicated the efficiency of BASNEF model on reduction of self-medication behaviors of diabetic patients. Hence, this model can act as a framework for designing and implementing educational interventions in this field.

Trends and Disparities in Quality of Diabetes Care in the US: The National Health and Nutrition Examination Survey, 1999-2016

Objectives: To examine trends and disparities in the quality of diabetes care among US adults with diabetes. Methods: Individuals aged 20 years or older with diabetes from NHANES (1999-2016) were included in the study. Quality indicators for diabetes care included Hemoglobin A1c (HbA1c) < 8%, Blood Pressure (BP) < 130/80 mm Hg, Low-Density Lipoprotein (LDL-C) < 100 mg/dL, triglycerides < 150 mg/dL, receiving eye and foot examinations in the past year, and meeting with a diabetes educator in the past year. Results: A total of 7,521 adults with diabetes were identified. During the 18-year study period, significant improvements in diabetes care were observed in the overall study sample. Adjusted regression analyses showed that compared with their White counterparts, Blacks were more likely to have received eye (OR=1.37; P=0.01) and foot (OR=1.42;P=0.01) examinations and met a diabetes educator (OR=1.40;P<0.01) over the past year. However, Blacks were significantly less likely to achieve treatment goals for HbA1c (OR=0.77, P=0.02), BP (OR=0.75, P<0.01), LDL-C (OR=0.68, P<0.01). Hispanics in general had suboptimal healthcare utilization for diabetes but the Hispanic-white disparities in diabetes care outcomes were attenuated after controlling for patient sociodemographic, clinical and utilization characteristics. Overall, suboptimal quality of diabetes care were particularly prominent among adults without health insurance and those with lower educational attainment. Conclusions: In the United States, despite persistent efforts, racial disparities in quality of diabetes care still persist. Lack of health insurance and lower socioeconomic status are among the strongest predictors of poor quality of diabetes care. These findings provide valuable information in developing policies and practices to promote racial equity in diabetes care.

Self-efficacy to Engage in Physical Activity and Overcome Barriers, Sedentary Behavior, and Their Relation to Body Mass Index Among Elderly Indonesians With Diabetes

OBJECTIVES

Elderly individuals with diabetes should maintain a normal body mass index (BMI) to help control their blood glucose levels. This study investigated barriers to physical activity (PA), self-efficacy to overcome those barriers, and PA self-efficacy among elderly individuals with diabetes in relation to BMI.

METHODS

This cross-sectional study included 56 participants. Data were collected by a questionnaire interview and direct measurements for anthropometric data. PA self-efficacy was measured using 8 questions describing different levels of PA, where participants rated the strength of their belief that they could engage in that activity. Self-efficacy to overcome barriers was measured using 10 questions capturing participants' confidence in their ability to engage in PA despite different possible barriers. Mean scores for these parameters were analyzed using the chi-square test and the independent t-test.

RESULTS

In total, 89.3% of participants had a low PA level and 58.9% had more than 3 hours of sedentary activity per day. Furthermore, 55.4% were obese and 14.3% were overweight. The mean scores for PA self-efficacy and self-efficacy to overcome barriers were 59.1± 26.4 and 52.5±13.8, respectively. PA level was related to BMI (p<0.001; r=0.116) and sedentary activity (p<0.05; r=0.274). PA self-efficacy and age were not related to BMI. Barriers to PA were associated with PA levels (p<0.05).

CONCLUSIONS

Physical inactivity was a major problem in elderly individuals with diabetes, and was correlated with higher BMI. Lower levels of PA might be mediated by sedentary activity.

Carbohydrate oxidation and glucose utilisation under hyperglycaemia in aged and young males during exercise at the same relative exercise intensity

PURPOSE

The purpose of the present study was to investigate the age-related carbohydrate oxidation and glucose utilisation rate response during exercise at the same relative intensity under hyperglycaemia in aged and young males.

METHODS

16 endurance-trained aged (n = 8; 69.1 ± 5.2 year) and young (n = 8; 22.4 ± 2.9 year) males were studied during 40 min of cycling exercise (60% [Formula: see text]) under both hyperglycaemic and euglycaemic (control) conditions. Venous blood samples were collected at baseline, post-infusion, mid- and post-exercise. Carbohydrate and fat oxidation rates were determined at both 15 and 35 min during exercise, and glucose utilisation rates were calculated.

RESULTS

The aged group displayed significantly lower rates of carbohydrate oxidation during exercise during maintained hyperglycemia (15 min = 2.3 ± 0.4 vs. 1.6 ± 0.5 g min^-1; 35 min = 2.3 ± 0.5 vs. 1.5 ± 0.5 g min^-1) and control (15 min = 2.2 ± 0.4 vs. 1.6 ± 0.7 g min^-1; 35 min = 1.9 ± 0.7 vs. 1.3 ± 0.7 g min^-1) conditions (P = 0.01). The rate of glucose utilisation during exercise was also significantly reduced (85.76 ± 23.95 vs. 56.67 ± 15.09 μM kg^-1 min^-1). There were no differences between age groups for anthropometric measures, fat oxidation, insulin, glucose, NEFA, glycerol and lactate (P > 0.05) although hyperglycemia resulted in elevated glucose and insulin, and attenuated fat metabolite levels.

CONCLUSION

Our findings highlight that ageing results in a reduction in carbohydrate oxidation and utilisation rates during exercise at the same relative exercise intensity.

Effectiveness of a Community Health Worker-Led Diabetes Intervention among Older and Younger Latino Participants: Results from a Randomized Controlled Trial

Diabetes management for older Latino adults is complex, given a higher incidence of multiple coexisting medical conditions and psychosocial barriers to self-management. Community health workers (CHWs) may be effective in reducing these barriers. The REACH Detroit CHW randomized controlled intervention studies with Latino/as with diabetes found improvements in self-management behaviors and glucose control after participating in a CHW-led intervention. Using data from the REACH Detroit Partnership's cohort 3, this study used descriptive statistics and multiple linear regression analyses to evaluate whether the six-month CHW intervention had a greater effect on older Latino/as (ages 55 and older) than younger participants between baseline and post-intervention follow-up at six months. There were significant intervention effects by age group that varied by outcome. Compared to a control group that received enhanced usual care, there were statistically significant intervention effects demonstrating greater self-efficacy scores 1.27 (0.23, 2.32); p < 0.05, and reductions in HbA1c 1.02 (-1.96,-0.07); p < 0.05, among older participants in the CHW intervention, and increases in diabetes support 0.74 (0.34, 1.13); p < 0.001; and understanding of diabetes management 0.39 (0.08, 0.70); p < 0.01 among younger participants.

Ageing potentiates diet-induced glucose intolerance, β-cell failure and tissue inflammation through TLR4

Ageing and obesity are two major risk factors for the development of type 2 diabetes (T2D). A chronic, low-grade, sterile inflammation contributes to insulin resistance and β-cell failure. Toll-like receptor-4 (TLR4) is a major pro-inflammatory pathway; its ligands as well as downstream signals are increased systemically in patients with T2D and at-risk individuals. In the present study we investigated the combined effects of high fat/high sucrose diet (HFD) feeding, ageing and TLR4-deficiency on tissue inflammation, insulin resistance and β-cell failure. In young mice, a short-term HFD resulted in a mildly impaired glucose tolerance and reduced insulin secretion, together with a β-cell mass compensation. In older mice, HFD further deteriorated insulin secretion and induced a significantly impaired glucose tolerance and augmented tissue inflammation in adipose, liver and pancreatic islets, all of which was attenuated by TLR4 deficiency. Our results show that ageing exacerbates HFD-induced impairment of glucose homeostasis and pancreatic β-cell function and survival, and deteriorates HFD-induced induction of mRNA expression of inflammatory cytokines and pro-inflammatory macrophage markers. TLR4-deficiency protects against these combined deleterious effects of a high fat diet and ageing through a reduced expression of inflammatory products in both insulin sensitive tissues and pancreatic islets.

Glucagon-Like Peptide-1 Receptor Agonist (GLP-1RA) Therapy Adherence for Patients with Type 2 Diabetes in a Medicare Population

INTRODUCTION

Anti-diabetes medication regimen adherence is a clinical challenge in elderly patients with type 2 diabetes (T2D) and other comorbidities associated with aging. Glucagon-like peptide-1 receptor agonists (GLP-1RA) therapies such as exenatide once weekly (QW), exenatide twice daily (BID), and liraglutide once daily (QD) are an increasingly used class of drugs with proven efficacy and tolerability. Real-world evidence on adherence to GLP-1RAs in elderly or disabled patients is limited. To further the understanding of this drug class, the current study examined medication adherence in Medicare patients aged ≥65 years with T2D initiating a GLP-1RA.

METHODS

This retrospective cohort study used medical and pharmacy claims between 2010 and 2013 for Medicare members in a United States health plan diagnosed with T2D who were new initiators of either exenatide QW (n = 537), exenatide BID (n = 923), or liraglutide QD (n = 3,673). Included patients were between the ages of 65 and 89 and were continuously enrolled for 6 months pre- and post-index. Medication adherence was examined during the post-index period using proportion of days covered (PDC) ≥80% and ≥90%.

RESULTS

A significantly higher percentage of patients receiving exenatide QW had a PDC ≥80% (43.2%) versus exenatide BID (39.0%, P < 0.01) and liraglutide QD (35.0%, P < 0.001). The patients receiving exenatide QW were significantly more likely to reach a PDC of ≥90% (37.2%, P < 0.001) than those initiating exenatide BID (20.6%) or liraglutide QD (23.3%).

CONCLUSIONS

While results from this retrospective study suggest room for improvement in adherence to GLP-1RAs, medication adherence rates for patients initiating therapy with exenatide QW were higher than patients initiating therapy with exenatide BID or liraglutide QD. Further research is needed to validate these findings in other T2D patient populations.

FUNDING

AstraZeneca Pharmaceuticals.

Effects of transgenic methionine sulfoxide reductase A (MsrA) expression on lifespan and age-dependent changes in metabolic function in mice

Mechanisms that preserve and maintain the cellular proteome are associated with long life and healthy aging. Oxidative damage is a significant contributor to perturbation of proteostasis and is dealt with by the cell through regulation of antioxidants, protein degradation, and repair of oxidized amino acids. Methionine sulfoxide reductase A (MsrA) repairs oxidation of free- and protein-bound methionine residues through enzymatic reduction and is found in both the cytosol and the mitochondria. Previous studies in Drosophila have shown that increasing expression of MsrA can extend longevity. Here we test the effects of increasing MsrA on longevity and healthy aging in two transgenic mouse models. We show that elevated expression of MsrA targeted specifically to the cytosol reduces the rate of age-related death in female mice when assessed by Gompertz analysis. However, neither cytosolic nor mitochondrial MsrA overexpression extends lifespan when measured by log-rank analysis. In mice with MsrA overexpression targeted to the mitochondria, we see evidence for improved insulin sensitivity in aged female mice. With these and our previous data, we conclude that the increasing MsrA expression in mice has differential effects on aging and healthy aging that are dependent on the target of its subcellular localization.

Diabetes management in older people: a focus on cardiovascular risk reduction

Cardiovascular disease remains the most common cause of death in persons with diabetes regardless of age. Increasing age combined with diabetes exert a synergistic effect on the vascular system increasing the atherosclerosis burden in older people with diabetes. Due to their high baseline risk, they stand to benefit most from interventions to reduce cardiovascular risk. Older people with diabetes are functionally heterogeneous and their management is challenging. Fit and independent individuals are likely to benefit from tight targets while a relaxed approach putting quality of life at the heart of management plans is more appropriate in the frail and dependent individuals with limited life expectancy.

Comparison of Age of Onset and Frequency of Diabetic Complications in the Very Elderly Patients with Type 2 Diabetes

BACKGROUND

The prevalence of type 2 diabetes in elderly people has increased dramatically in the last few decades. This study was designed to clarify the clinical characteristics of type 2 diabetes in patients aged ≥80 years according to age of onset.

METHODS

We reviewed the medical records of 289 patients aged ≥80 years with type 2 diabetes at the outpatient diabetes clinics of Kangwon National University Hospital from September 2010 to June 2014. We divided the patients into middle-age-onset diabetes (onset before 65 years of age) and elderly-onset diabetes (onset at 65+ years of age).

RESULTS

There were 141 male and 148 female patients. The patients had a mean age of 83.2±2.9 years and the mean duration of diabetes was 14.3±10.4 years. One hundred and ninety-nine patients had elderly-onset diabetes. The patients with elderly-onset diabetes had a significantly lower frequency of diabetic retinopathy and nephropathy, lower serum creatinine levels, lower glycated hemoglobin (HbA1c) levels, and similar coronary revascularization and cerebral infarction rates compared to those with middle-age-onset diabetes. There was no frequency difference in coronary revascularization and cerebral infarction and HbA1c levels between three subgroups (<5, 5 to 15, and ≥15 years) of diabetes duration in elderly onset diabetes. However, both in the elderly onset diabetes and middle-age-onset diabetes, the cumulative incidence of retinopathy was increasing rapidly according to the duration of diabetes.

CONCLUSION

We report that individuals with elderly-onset diabetes have a lower frequency of diabetic retinopathy and nephropathy and similar cardiovascular complications compared to those with middle-age-onset diabetes.

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.

Descriptive study of the prevalence of anemia, hypertension, diabetes and quality of life in a randomly selected population of elderly subjects from São Paulo

BACKGROUND

The rapid increase in the aged population has resulted in a growing number of cases of chronic diseases. This increase is an important demographic change that low- and middle-income countries have to face and poses a new challenge to health services. One of the first steps to formulate public policies is to understand the reality of each country's aging population. This study describes the prevalence of anemia, hypertension and diabetes and the overall health status in pre-elderly and elderly subjects enrolled in two primary health care clinics, Eldorado and Piraporinha, in the city of Diadema, São Paulo.

METHOD

A cross-sectional study was conducted with 373 participants. Clinical data were collected from patient charts and the degree of disability and common mental disorders, as well as demographic data were obtained by interviews.

RESULTS

The prevalence of anemia was approximately 11% and hypertension was 70% and 81% in Eldorado and Piraporinha, respectively. The frequency of diabetes was 52% in Eldorado and 30% in Piraporinha. The subjects of both health care clinics reported having difficulties in some of their daily physical and instrumental activities, with physical symptoms and emotional disorders.

CONCLUSION

Anemia, hypertension and diabetes are prevalent in the studied population, and patients showed degrees of dependency and impaired health status.

Periodontal considerations in older individuals

In the next few years there will be a great increase in the percentage of the population aged over 65. Not only will they have more teeth than previous generations, but also a large number of implants. The increase in age is accompanied by an increase in the prevalence and incidence of periodontal diseases. In addition, there is a decrease in manual dexterity and an increase in co-morbidity and medications affecting the oral cavity. Dental care in aged care facilities can be poor and access to dental professionals difficult. This article discusses these issues.

Psychotherapy for depression in older veterans via telemedicine: a randomised, open-label, non-inferiority trial

BACKGROUND

Many older adults with major depression, particularly veterans, do not have access to evidence-based psychotherapy. Telemedicine could increase access to best-practice care for older adults facing barriers of mobility, stigma, and geographical isolation. We aimed to establish non-inferiority of behavioural activation therapy for major depression delivered via telemedicine to same-room care in largely male, older adult veterans.

METHODS

In this randomised, controlled, open-label, non-inferiority trial, we recruited veterans (aged ≥58 years) meeting DSM-IV criteria for major depressive disorder from the Ralph H Johnson Veterans Affairs Medical Center and four associated community outpatient-based clinics in the USA. We excluded actively psychotic or demented people, those with both suicidal ideation and clear intent, and those with substance dependence. The study coordinator randomly assigned participants (1:1; block size 2-6; stratified by race; computer-generated randomisation sequence by RGK) to eight sessions of behavioural activation for depression either via telemedicine or in the same room. The primary outcome was treatment response according to the Geriatric Depression Scale (GDS) and Beck Depression Inventory (BDI; defined as a 50% reduction in symptoms from baseline at 12 months), and Structured Clinical Interview for DSM-IV, clinician version (defined as no longer being diagnosed with major depressive disorder at 12 months follow-up), in the per-protocol population (those who completed at least four treatment sessions and for whom all outcome measurements were done). Those assessing outcomes were masked. The non-inferiority margin was 15%. This trial is registered with ClinicalTrials.gov, number NCT00324701.

FINDINGS

Between April 1, 2007, and July 31, 2011, we screened 780 patients, and the study coordinator randomly assigned participants to either telemedicine (120 [50%]) or same-room treatment (121 [50%]). We included 100 (83%) patients in the per-protocol analysis in the telemedicine group and 104 (86%) in the same-room group. Treatment response according to GDS did not differ significantly between the telemedicine (22 [22·45%, 90% CI 15·52-29·38] patients) and same-room (21 [20·39%, 90% CI 13·86-26·92]) groups, with an absolute difference of 2·06% (90% CI -7·46 to 11·58). Response according to BDI also did not differ significantly (telemedicine 19 [24·05%, 90% CI 16·14-31·96] patients; same room 19 [23·17%, 90% CI 15·51-30·83]), with an absolute difference of 0·88% (90% CI -10·13 to 11·89). Response on the Structured Clinical Interview for DSM-IV, clinician version, also did not differ significantly (39 [43·33%, 90% CI 34·74-51·93] patients in the telemedicine group and 46 [48·42%, 90% CI 39·99-56·85] in the same-room group), with a difference of -5·09% (-17·13 to 6·95; p=0·487). Results from the intention-to-treat population were similar. MEM analyses showed that no significant differences existed between treatment trajectories over time for BDI and GDS. The criteria for non-inferiority were met. We did not note any adverse events.

INTERPRETATION

Telemedicine-delivered psychotherapy for older adults with major depression is not inferior to same-room treatment. This finding shows that evidence-based psychotherapy can be delivered, without modification, via home-based telemedicine, and that this method can be used to overcome barriers to care associated with distance from and difficulty with attendance at in-person sessions in older adults.

FUNDING

US Department of Veterans Affairs.

Diabetes mellitus onset in geriatric patients: does long-term atypical antipsychotic exposure increase risk?

BACKGROUND

Diabetes mellitus (DM) in common in adults using psychotropic medications. However, it remains largely unknown whether there is an additional risk of diabetes mellitus (DM) in elderly psychiatric outpatients, particularly those with long-term exposure to atypical antipsychotics (AP).

METHODS

In this retrospective longitudinal study, 61 atypical AP-exposed and 64 atypical AP-unexposed geriatric psychiatric patients were compared to a group of 200 psychotropic-naïve controls. Our main composite outcome was diabetes incidence over a 4-year period, defined by fasting blood glucose ≥ 7.0 mmol/L or a new-onset oral hypoglycaemic or insulin prescription during the 4-year period.

RESULTS

The 4-year incidence of DM did not differ significantly between groups: 12.3%, 6.7%, and 11.9% in the atypical AP-exposed, atypical AP-unexposed, and control groups, respectively (χ(2) = 1.40, P = 0.50). Depression and antidepressant, cholinesterase inhibitor, and valproate use were independently associated with increases in fasting glucose. However, hyperglycaemia and hypoglycaemic prescriptions were not more common in geriatric psychiatric patients.

CONCLUSIONS

DM does not appear to be more common in geriatric psychiatric patients than similarly aged controls and is not more common in atypical AP users. However, depression and antidepressant, cholinesterase inhibitor, and valproate use may increase fasting glucose levels, and the clinical significance of this warrants further investigation. Nonetheless, given the rates of untreated and undertreated fasting hyperglycaemia in both our geriatric psychiatric and control samples (>10% of all patients), we recommend regular screening for DM in these populations.

Efficacy and safety of lixisenatide in elderly (≥65 years old) and very elderly (≥75 years old) patients with type 2 diabetes: an analysis from the GetGoal phase III programme

BACKGROUND

The objective of this article is to evaluate the pharmacokinetics, efficacy and safety of lixisenatide (subcutaneous injection) in elderly (≥65 years old) and very elderly (≥75 years old) patients with type 2 diabetes mellitus.

METHODS

We conducted a phase I, single-centre, open-label study to evaluate the safety and pharmacokinetics of a single lixisenatide 20 µg dose and a pooled analysis of six randomized, placebo-controlled, phase III studies (12-month or 24-month duration) that evaluated glycaemic parameters and safety in patients receiving lixisenatide 20 µg once daily or placebo.

RESULTS

The pharmacokinetics study included 36 healthy subjects, including 18 elderly healthy subjects (≥65 years old) and 18 matched young healthy subjects (18-45 years old). The pooled analysis included 3188 patients, including 2565 patients <65 years old and 623 patients ≥65 years old (including 79 patients ≥75 years old). Mean exposure with lixisenatide 20 µg was ~30% higher in elderly than in young subjects, and the terminal half-life was prolonged by ~1.6 times. Maximum concentration (C(max)) and time to C(max) (t(max)) were comparable in both groups. Equal numbers of elderly and young subjects reported treatment-emergent adverse events, the majority of which were gastrointestinal disorders. In the pooled analysis, lixisenatide 20 µg once daily provided significant reductions in HbA1c versus placebo for all age groups. There was a similar incidence of treatment-emergent adverse events across all age groups (range: 69-73%). The incidence of symptomatic hypoglycaemia was generally comparable between lixisenatide-treated and placebo-treated patients.

CONCLUSION

These data suggest that lixisenatide is effective and well tolerated in elderly and very elderly patients with type 2 diabetes mellitus.

Trends in prevalence, incidence and pharmacologic management of diabetes mellitus among seniors newly admitted to long-term care facilities in Saskatchewan between 2003 and 2011

OBJECTIVE

We aimed to describe trends in the prevalence and incidence of diabetes mellitus and also report the overall use of diabetes medications among patients newly admitted to a long-term care facility (LTCF).

METHODS

A retrospective cohort study was done using health administrative databases in Saskatchewan. Eligible patients were newly admitted to LTCF in Saskatchewan between 2003 and 2011 and maintained LTCF residency for at least 6 months. Prevalence of diabetes was defined with physician or hospital claims in the 2 years preceding admission. Antihyperglycemic medication use was estimated from prescription claims data during the first 6 months after LTCF admission. All data were descriptively analyzed.

RESULTS

The validated case definition for diabetes (≥2 diagnostic claims) in the 2 years before or 6 months after admission was met by 16.9% of patients (2471 of 14,624). An additional 965 patients (6.6%) had a single diabetes diagnostic claim or antihyperglycemic prescriptions only. Among patients receiving antihyperglycemic therapies, 64.9% (1518 of 2338) were exclusively managed with oral medications, and metformin was the most commonly used medication. Glyburide was commonly withdrawn after LTCF admission. Insulin use was observed in 23.9% of diabetes patients, with a mean daily average consumption of 54.7 units per day.

CONCLUSIONS

Use of diabetes medications appear to generally align with Canadian practice recommendations as evidenced by declining use of glyburide and frequent use of metformin. Future studies should examine clinical benefits and safety of hypoglycemic agent use in LTCFs.

Differential subtypes of diabetic older adults diagnosed with Alzheimer's disease

AIM

The clinical management of diabetic elderly patients with Alzheimer's disease (AD) is hindered by several difficulties. The present study aimed to clarify the clinical characteristics and pathophysiological properties of AD in diabetic older adults.

METHODS

A total of 91 patients with type 2 diabetes mellitus and 161 non-diabetic individuals who were diagnosed with AD were recruited. Diabetic patients were classified into two groups with glycated hemoglobin (HbA1c) < 7.0% or ≥ 7.0%. The demographics, cognition, daily-life function, metabolic changes, treatment, and behavioral and psychological symptoms of dementia (BPSD), as well as brain pathophysiology, were compared among the three groups.

RESULTS

Patients with higher HbA1c had increased diabetic vascular complications and impaired activities of daily living with decreased levels of serum high-molecular-weight adiponectin and 25-hydroxyvitamin D. Although cognitive status was similar among the three groups, BPSD, including apathy, overeating and excessive daytime sleeping appeared to be increased in the patients with HbA1c ≥ 7.0%. The frequency of apolipoprotein E4 carriers and of posterior cerebral hypoperfusion (AD-pattern) on single-photon emission computed tomography in poorly controlled diabetic subjects was similar to that in non-diabetic AD patients, whereas diabetic patients with HbA1c <7.0% included fewer apolipoprotein E4 carriers and fewer patients with an AD pattern on single-photon emission computed tomography.

CONCLUSION

Subtypes of older diabetic patients with AD were identified based on clinical features and brain pathophysiology. Physical and psychological complications of dementia are prevalent in patients with higher HbA1c. It seems likely that difficulties in the management of diabetes with AD are due not only to non-adherence to diabetes treatment, but also several symptoms and pathophysiological characteristics of dementia.

Compositional dynamics of the human intestinal microbiota with aging: implications for health

The human gut contains trillions of microbes which form an essential part of the complex ecosystem of the host. This microbiota is relatively stable throughout adult life, but may fluctuate over time with aging and disease. The gut microbiota serves a number of functions including roles in energy provision, nutrition and also in the maintenance of host health such as protection against pathogens. This review summarizes the age-related changes in the microbiota of the gastrointestinal tract (GIT) and the link between the gut microbiota in health and disease. Understanding the composition and function of the gut microbiota along with the changes it undergoes overtime should aid the design of novel therapeutic strategies to counteract such alterations. These strategies include probiotic and prebiotic preparations as well as targeted nutrients, designed to enrich the gut microbiota of the aging population.

Compositional dynamics of the human intestinal microbiota with aging: implications for health

The human gut contains trillions of microbes which form an essential part of the complex ecosystem of the host. This microbiota is relatively stable throughout adult life, but may fluctuate over time with aging and disease. The gut microbiota serves a number of functions including roles in energy provision, nutrition and also in the maintenance of host health such as protection against pathogens. This review summarizes the age-related changes in the microbiota of the gastrointestinal tract (GIT) and the link between the gut microbiota in health and disease. Understanding the composition and function of the gut microbiota along with the changes it undergoes overtime should aid the design of novel therapeutic strategies to counteract such alterations. These strategies include probiotic and prebiotic preparations as well as targeted nutrients, designed to enrich the gut microbiota of the aging population.

High or low calcium intake increases cardiovascular disease risks in older patients with type 2 diabetes

Background

We investigated the effects of dietary calcium (Ca) and magnesium (Mg) intakes on cardiovascular disease risks in older patients with diabetes.

Methods

In this cross-sectional study, 197 patients with type 2 diabetes aged 65 years and above were recruited. The 24-h dietary recalls and 1-week self-reported typical dietary intake patterns were collected. The Ca and Mg intakes of <67% of the recommended dietary allowance (RDA), 67%–100% of RDA, and >100% of RDA were defined as low, moderate, and high Ca and Mg intakes, respectively. Anthropometric measurements were determined and biochemical analysis of blood and urine was performed.

Results

Our data indicated that 60.9% and 87.3% of our patients were Ca and Mg intakes below RDA, respectively. Patients whose Ca intake was high or low (81.2%) had significantly higher C-reactive protein (CRP) than those whose Ca intake was moderate (p = 0.043). Furthermore, patients whose Mg intake was low (87.3%) had significantly higher CRP than that of those who took adequate Mg (p = 0.025). The dietary Ca:Mg intake ratios were highly correlated with CRP, platelet counts, and red blood cell distribution (p < 0.05). A dietary Ca:Mg intake ratio of 2.0–2.5 was significantly correlated to lower CRP levels (p = 0.013).

Conclusions

High or low calcium intake increases cardiovascular disease risks. We suggest that “moderate” intake of 402–600 mg Ca/day (approximately 67%–100% of Taiwan RDA for Ca) and adequate Mg intake (or meeting RDA for Mg) with Ca:Mg intake ratio of 2.0–2.5 are important for reducing cardiovascular disease risks in older patients with diabetes.

Effects of educational intervention based on PRECEDE model on self care behaviors and control in patients with type 2 diabetes in 2012

BACKGROUND

Diabetes is a chronic disease and its control requires essential change in patients' life style. The aim of this study was survey of effects of educational intervention based on PRECEDE Model on self care behaviors and control in patients with type 2 diabetes.

METHODS

This was a quasi-experimental study carried out in 78 patients with type 2 diabetes who have referred to Minoodasht clinic of diabetes. The educational program has been designed according to the PRECEDE Model. Prior to perform the educational intervention, the patients filled a questionnaire which was designed according to the structure of PRECEDE Model for type 2 diabetes patients. The diabetes education program was performed on three target groups (patients, their families and Health care personnel). After four weeks, the effects of the educational program have been evaluated through the same questionnaire. The findings were analyzed by SPSS version 16 and p-value less than 0.05 was taken as statistically significant.

RESULTS

The mean age of participants was 49 years, 87.2% were married and 19.2% was illiterate. The rate of income of 44.9% was low. 66% had a family history of diabetes and 64% had been afflicted with diabetes more than 5 years. The Chi-square test showed a significant relationship between formation of a file in diabetes clinic and on-time presence to receive services and participation in the educational classes with the marital status variable. The results also showed that there is a significant relationship between observing food diet and job. The mean scores of knowledge, attitude, practice, reinforcing factors and enabling factors has increased after educational intervention. The Chi-square test shows a significant difference before and after of education intervention in stages of the model.

CONCLUSION

The obtained results based on PRECEDE Model would support the positive effect of the educational intervention and its major elements (predisposing, enabling and reinforcing factors) on diabetes self-care behaviors.