Effects of age on complications in adult onset diabetes

Hybrid Explainable Artificial Intelligence Models for Targeted Metabolomics Analysis of Diabetic Retinopathy

BACKGROUND

Diabetic retinopathy (DR) is a prevalent microvascular complication of diabetes mellitus, and early detection is crucial for effective management. Metabolomics profiling has emerged as a promising approach for identifying potential biomarkers associated with DR progression. This study aimed to develop a hybrid explainable artificial intelligence (XAI) model for targeted metabolomics analysis of patients with DR, utilizing a focused approach to identify specific metabolites exhibiting varying concentrations among individuals without DR (NDR), those with non-proliferative DR (NPDR), and individuals with proliferative DR (PDR) who have type 2 diabetes mellitus (T2DM).

METHODS

A total of 317 T2DM patients, including 143 NDR, 123 NPDR, and 51 PDR cases, were included in the study. Serum samples underwent targeted metabolomics analysis using liquid chromatography and mass spectrometry. Several machine learning models, including Support Vector Machines (SVC), Random Forest (RF), Decision Tree (DT), Logistic Regression (LR), and Multilayer Perceptrons (MLP), were implemented as solo models and in a two-stage ensemble hybrid approach. The models were trained and validated using 10-fold cross-validation. SHapley Additive exPlanations (SHAP) were employed to interpret the contributions of each feature to the model predictions. Statistical analyses were conducted using the Shapiro-Wilk test for normality, the Kruskal-Wallis H test for group differences, and the Mann-Whitney U test with Bonferroni correction for post-hoc comparisons.

RESULTS

The hybrid SVC + MLP model achieved the highest performance, with an accuracy of 89.58%, a precision of 87.18%, an F1-score of 88.20%, and an F-beta score of 87.55%. SHAP analysis revealed that glucose, glycine, and age were consistently important features across all DR classes, while creatinine and various phosphatidylcholines exhibited higher importance in the PDR class, suggesting their potential as biomarkers for severe DR.

CONCLUSION

The hybrid XAI models, particularly the SVC + MLP ensemble, demonstrated superior performance in predicting DR progression compared to solo models. The application of SHAP facilitates the interpretation of feature importance, providing valuable insights into the metabolic and physiological markers associated with different stages of DR. These findings highlight the potential of hybrid XAI models combined with explainable techniques for early detection, targeted interventions, and personalized treatment strategies in DR management.

Health-related quality of life in older Chinese patients with diabetes

BACKGROUND

Although older diabetes patients with unique characteristics should be cared carefully to improve their health-related quality of life (HRQOL), the association between diabetes and HRQOL remain unclear, especially in Asians. We aimed to compare the HRQOL between older Chinese patients with type 2 diabetes (T2D) and their age-gender-matched controls.

METHODS

Older patients with T2D were recruited from a community hospital in Suzhou located in the east part of China while controls were selected from a community-based health survey of older adults aged 60 years or older. HRQOL of cases and controls was assessed by the EQ-5D-3L. The impact of T2D on HRQOL was investigated using a liner regression model and the relationship between T2D and EQ-5D health problems was evaluated using logistic regression models.

RESULTS

A total of 220 cases and 440 controls were included. The mean age of the participants was 68.8 years and women accounted for 69.1% of the study sample. The EQ-5D-3L index score was lower for older people with T2D (0.886) than their controls (0.955). After multivariable adjustment, the difference in ED-5D-3L index score between older people with and without T2D was 0.072. In logistic regression analyses, T2D was positively associated with reporting of problems in mobility (odds ratio [OR] = 5.00); pain/discomfort (OR = 1.66), and anxiety/depression (OR = 3.2).

CONCLUSIONS

T2D has a detrimental effect on HRQOL of older Chinese people.

Association of comorbid depression, anxiety, and stress disorders with Type 2 diabetes in Bahrain, a country with a very high prevalence of Type 2 diabetes

This study examined the association of depression, anxiety, and stress with Type 2 diabetes (T2DM) in Bahrain, an island-country with a very high prevalence of T2DM. This was a cross-sectional study involving administering Depression Anxiety Stress Scales (DASS)-21 structured depression, anxiety, and stress scale to 143 T2DM patients and 132 healthy controls. Higher proportion of T2DM patients were found in the mild-moderate and severe- extremely severe depression (p=0.002), anxiety (p<0.001), and stress (p<0.001) groups. Chronic disease and disease duration were significantly associated with the 3 disturbances, while employment status was associated with anxiety and depression. Logistic regression analysis showed that anxiety, depression, and stress were associated with T2DM after adjusting for all variables, while age was the only significant variable associated with stress. These results suggest a positive contribution of T2DM to increased depressive and/or anxiety and/or stress disorders among the patients examined, thereby recommending counseling for T2DM patients.

Parents matter: intergenerational influences of diabetes mellitus on glycemic control and morbidity in older type 2 diabetic males

In a cross-sectional study, the effects of disease duration of type 2 diabetes mellitus (DM) were examined along with parent history of DM on disease-related outcome variables. Specifically, the moderating role of parent history of DM on outcome variables was examined. Participants were 53 male veterans with DM. Chart reviews and self-reports were examined. Results showed that in those with a positive parent history of DM, hopelessness increased with diabetes duration. In the negative parent history group, glycemic control worsened with disease duration. These findings suggest parent history of DM should be considered in designing interventions to facilitate coping with type 2 diabetes.

Examining a bidirectional association between depressive symptoms and diabetes

CONTEXT

Depressive symptoms are associated with development of type 2 diabetes, but it is unclear whether type 2 diabetes is a risk factor for elevated depressive symptoms.

OBJECTIVE

To examine the bidirectional association between depressive symptoms and type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS

Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000-2002 and followed up until 2004-2005.

MAIN OUTCOME MEASURES

Elevated depressive symptoms defined by Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher, use of antidepressant medications, or both. The CES-D score was also modeled continuously. Participants were categorized as normal fasting glucose (< 100 mg/dL), impaired fasting glucose (100-125 mg/dL), or type 2 diabetes (> or = 126 mg/dL or receiving treatment). Analysis 1 included 5201 participants without type 2 diabetes at baseline and estimated the relative hazard of incident type 2 diabetes over 3.2 years for those with and without depressive symptoms. Analysis 2 included 4847 participants without depressive symptoms at baseline and calculated the relative odds of developing depressive symptoms over 3.1 years for those with and without type 2 diabetes.

RESULTS

In analysis 1, the incidence rate of type 2 diabetes was 22.0 and 16.6 per 1000 person-years for those with and without elevated depressive symptoms, respectively. The risk of incident type 2 diabetes was 1.10 times higher for each 5-unit increment in CES-D score (95% confidence interval [CI], 1.02-1.19) after adjustment for demographic factors and body mass index. This association persisted following adjustment for metabolic, inflammatory, socioeconomic, or lifestyle factors, although it was no longer statistically significant following adjustment for the latter (relative hazard, 1.08; 95% CI, 0.99-1.19). In analysis 2, the incidence rates of elevated depressive symptoms per 1000-person years were 36.8 for participants with normal fasting glucose; 27.9 for impaired fasting glucose; 31.2 for untreated type 2 diabetes, and 61.9 for treated type 2 diabetes. Compared with normal fasting glucose, the demographic-adjusted odds ratios of developing elevated depressive symptoms were 0.79 (95% CI, 0.63-0.99) for impaired fasting glucose, 0.75 (95% CI, 0.44-1.27) for untreated type 2 diabetes, and 1.54 (95% CI, 1.13-2.09) for treated type 2 diabetes. None of these associations with incident depressive symptoms were materially altered with adjustment for body mass index, socioeconomic and lifestyle factors, and comorbidities. Findings in both analyses were comparable across ethnic groups.

CONCLUSIONS

A modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed a positive association with depressive symptoms. These associations were not substantively affected by adjustment for potential confounding or mediating factors.

Depression and type 2 diabetes mellitus: the multiethnic study of atherosclerosis

OBJECTIVE

To assess the cross-sectional association between depression and glucose tolerance status.

METHODS

We conducted a study of 6754 White, Black, Hispanic, and Chinese men and women aged 45 to 84 years in the Multiethnic Study of Atherosclerosis (MESA). Depression was defined as Center for Epidemiologic Studies Depression scale score of > or =16 and/or antidepressant use. Glucose tolerance status was defined as normal, impaired fasting glucose (IFG) or Type 2 diabetes mellitus (untreated and treated).

RESULTS

In the minimally adjusted model, although depression was not associated with a greater odds of IFG (odds ratio (OR) = 1.01; 95% confidence interval (CI): 0.87-1.18) or untreated diabetes (OR = 1.03; 95% CI: 0.74-1.45), it was associated with a greater odds of treated diabetes (OR = 1.57; 95% CI: 1.27-1.96). This persisted following adjustment for body mass index (OR = 1.52; 95% CI: 1.22-1.90), metabolic (OR = 1.54; 95% CI: 1.23-1.93), and inflammatory (OR=1.53; 95% CI: 1.21-1.92) factors, daily caloric intake and smoking (OR = 1.48; 95% CI: 1.16-1.88), and socioeconomic markers (OR = 1.47; 95% CI: 1.17-1.85). Among individuals with treated diabetes, median depression scores were higher in those with microalbuminuria compared with those without microalbuminuria (median = 7; interquartile range: 3-13 versus median = 6; interquartile range: 2-11; p = .046). Depression scores were not associated with homeostatic model assessment of insulin resistance among individuals without diabetes.

CONCLUSIONS

In MESA, depression was significantly associated with treated diabetes. Further studies are needed to determine the temporality of this association.

Prospective analysis of mortality, morbidity, and risk factors in elderly diabetic subjects: Nagano study

OBJECTIVE

To clarify mortality and morbidity of intensively managed elderly diabetic individuals and to explore factors predicting mortality and diabetes-related end points.

RESEARCH DESIGN AND METHODS

A total of 390 elderly (>or=65 years of age) outpatients with type 2 diabetes ( 173 men and 217 women, mean age 73.0 years) were analyzed. The mean HbA(1c) upon entry was 6.8% (332 receiving oral hypoglycemics and/or insulin) and blood pressure upon entry was 136/74 mmHg (219 receiving antihypertensive drugs). The patients have been followed-up for 3 years with HbA(1c) <7.0% and blood pressure <145/80 mmHg as targets, with mortality and an aggregate of fatal and nonfatal diabetes-related events as end points. Mortality rate and causes of mortality, as well as risk factors for mortality and morbidity, were determined.

RESULTS

The mortality rate, 2.9% per year, was comparable to that of the age- and sex-matched general population. Stroke was a leading cause of mortality after malignancy. By the univariate Cox proportional hazards model, only high serum creatinine and prior stroke were highly significant and strong risks for both end points. In those without prior stroke and receiving antihypertensive agents, the incidence of the diabetes-related end point based on their systolic blood pressure (SBP) quartile was U-shaped, with the nadir at the 3rd (SBP, 137-147 mmHg) and the peak at the 1st (SBP <or= 125 mmHg) quartile.

CONCLUSIONS

In well-controlled elderly diabetic subjects, there was no excessive mortality compared to the age- and sex-matched general population. Renal dysfunction and prior stroke were independent risks for mortality and morbidity. In those without prior stroke, a risk of too much lowering of blood pressure was suggested.

Retinopathy in older patients with diabetes mellitus

PURPOSE

We studied the effects of the age and/or disease duration in diabetics on the progression of diabetic retinopathy (DR).

METHODS

The population consisted of 3614 type 2 diabetes mellitus (DM) patients. The subjects were divided into three age groups (elderly, > or = 65 years old; middle-aged, 64-40 years old, and younger < 40 years old) for disease duration-adjusted comparison with and without DR and proliferative diabetic retinopathy (PDR). Then, in 503 patients with 8-year follow-up data available, the frequency of development/progression of DR and the rate of progression to PDR were compared among the three groups. Thirdly, in the elderly patients, DR prevalence and the frequency of the development/progression of DR were compared between two groups with different diabetes duration (> or = 6 years and < or = 5 years).

RESULTS

The prevalence of DR increased significantly with age (P < 0.001). The prevalence of PDR decreased significantly with age (P < 0.001). The overall frequency of the development and/or progression of DR increased significantly with age (P = 0.002); however, age was not related to the frequency of progression to PDR. In the patients with diabetes duration of 6-15 years, the frequency of the development/progression of DR and of progression to PDR after an 8-year follow up tended to decrease with age. Elderly patients with a diabetes duration of > or = 6 years showed significantly higher rate of prevalence of DR and frequency of development/progression of DR in an 8-year period than those with diabetes of a shorter duration (P < 0.001 and P < 0.001, respectively).

CONCLUSION

In elderly DM patients, the prevalence of DR was increased even in the short duration and development/progression rates of DR were increased, while the relative frequency of PDR was decreased. Older-onset DM patients appear to be at a lower risk for progression to PDR.

Association of depression and diabetes complications: a meta-analysis

OBJECTIVE

The objective of this study was to examine the strength and consistency of the relationship between depression and diabetes complications in studies of type 1 and type 2 adult patients with diabetes.

METHOD

MEDLINE and PsycINFO databases were searched for articles examining depression and diabetes complications in type 1 and type 2 diabetes samples published between 1975 and 1999. Meta-analytic procedures were used. Studies were reviewed for diabetes type, sample size, statistical tests, and measures of diabetes complications and depression. Significance values, weighted effect sizes r, 95% confidence intervals (CI), and tests of homogeneity of variance were calculated for the overall sample (k = 27) and for subsets of interest.

RESULTS

A total of 27 studies (total combined N = 5374) met the inclusion criteria. A significant association was found between depression and complications of diabetes (p < .00001, z = 5.94). A moderate and significant weighted effect size (r = 0.25; 95% CI: 0.22-0.28) was calculated for all studies reporting sufficient data (k = 22). Depression was significantly associated with a variety of diabetes complications (diabetic retinopathy, nephropathy, neuropathy, macrovascular complications, and sexual dysfunction). Effect sizes were in the small to moderate range (r = 0.17 to 0.32).

CONCLUSIONS

These findings demonstrate a significant and consistent association of diabetes complications and depressive symptoms. Prospective, longitudinal studies are needed to identify the pathways that mediate this association.

The prevalence of comorbid depression in adults with diabetes: a meta-analysis

OBJECTIVE

To estimate the odds and prevalence of clinically relevant depression in adults with type 1 or type 2 diabetes. Depression is associated with hyperglycemia and an increased risk for diabetic complications; relief of depression is associated with improved glycemic control. A more accurate estimate of depression prevalence than what is currently available is needed to gauge the potential impact of depression management in diabetes.

RESEARCH DESIGN AND METHODS

MEDLINE and PsycINFO databases and published references were used to identify studies that reported the prevalence of depression in diabetes. Prevalence was calculated as an aggregate mean weighted by the combined number of subjects in the included studies. We used chi(2) statistics and odds ratios (ORs) to assess the rate and likelihood of depression as a function of type of diabetes, sex, subject source, depression assessment method, and study design.

RESULTS

A total of 42 eligible studies were identified; 20 (48%) included a nondiabetic comparison group. In the controlled studies, the odds of depression in the diabetic group were twice that of the nondiabetic comparison group (OR = 2.0, 95% CI 1.8-2.2) and did not differ by sex, type of diabetes, subject source, or assessment method. The prevalence of comorbid depression was significantly higher in diabetic women (28%) than in diabetic men (18%), in uncontrolled (30%) than in controlled studies (21%), in clinical (32%) than in community (20%) samples, and when assessed by self-report questionnaires (31%) than by standardized diagnostic interviews (11%).

CONCLUSIONS

The presence of diabetes doubles the odds of comorbid depression. Prevalence estimates are affected by several clinical and methodological variables that do not affect the stability of the ORs.

Age 85+ years accelerates large-fiber peripheral nerve dysfunction and diabetes contributes even in the oldest-old: the Women's Health and Aging Study

BACKGROUND

Both diabetes mellitus and advancing age are associated with peripheral nerve dysfunction (PND). However, the independent and potentially synergistic effects of these factors in old age are poorly described, especially among the oldest-old and among people with an existing disability.

METHODS

A total of 894 women aged 65+ years participating in the Women's Health and Aging Study received a baseline home interview and clinical examination during which PND was evaluated by the Vibratron II. Age and diabetes were examined in relation to the level of PND (normal, mild, moderate, or severe). Height, alcohol consumption, smoking, report of neurologic symptoms, and diabetes duration were examined as potential confounders.

RESULTS

Eighteen percent of the sample reported diabetes, 42% had normal nerve function, and 23.9%, 14.5%, and 19.5% had mild, moderate, and severe PND, respectively. Women aged 85+ years had 6.5, 7.5, and 13.3 times the odds of mild, moderate, and severe PND relative to women aged 65-74 years, adjusted for diabetes and height. Women who reported diabetes had 1.8, 2.4, and 1.6 times the risk of mild, moderate, and severe PND relative to those who did not, adjusted for age and height. No interaction between age and diabetes was observed.

CONCLUSIONS

Age is strongly associated with decrements in large-fiber peripheral nerve function in disabled women aged 65+ years, with greatly accelerated risk among those aged 85+ years. Despite the overwhelmingly strong effects of advancing age on PND in this cohort, diabetes remains a significant correlate of PND. Future studies may determine whether prevention or control of diabetes is effective in reducing the occurrence of PND in old age and whether a reduction in PND will translate into reduced disability in this age group.

Glycemic control in older subjects with type 2 diabetes mellitus in the Fremantle Diabetes Study

OBJECTIVES

We investigated whether there were differences in glycemic control in older compared with younger subjects with type 2 diabetes mellitus enrolled in the Fremantle Diabetes Study, a prospective study of diabetes care, control, and complications in an urban setting.

DESIGN

Cross-sectional observational study.

SETTING

University teaching hospital clinical research center.

PARTICIPANTS

A total of 1,205 patients with type 2 diabetes mellitus, 404 (33.3%) of whom were aged over 70 years and 83 (6.9%) aged over 80 years.

MEASUREMENTS

Fasting plasma glucose, HbA1c, body mass index, and waist/hip ratio.

RESULTS

In multiple linear regression analysis, age was inversely associated with glycemic control whereas duration of diabetes and treatment with either oral hypoglycemic agents or insulin were positively associated with glycemic control. For most age groups there was a significant worsening of glycemic control with duration of diabetes. Octogenarians differed significantly from younger age groups in that those with longer diabetes duration did not demonstrate the increase in hyperglycemia seen in other age groups. As a result, significantly greater proportions of these oldest diabetic subjects had satisfactory glycosylated hemoglobin levels compared with younger subjects.

CONCLUSIONS

Octogenarians do not demonstrate the usual progressive deterioration of glycemic control with diabetes duration seen in type 2 diabetes mellitus. The reasons for this difference are unknown but are likely to have clinical significance with regard to therapy and the development of diabetic complications.

Management of elderly diabetic patients in the subacute care setting

Type 2 diabetes is a commonly encountered condition in the subacute care setting. The results of the landmark UK prospective studies have confirmed that aggressive glycemic and blood pressure control delayed diabetes-related microvascular and macrovascular complications and significantly improved diabetic outcomes. Within the past few years, new drugs have been developed to address both aspects of the type 2 diabetes syndrome: insulin resistance and insulin secretory defect. C-peptide analysis may be useful to predict a successful response to therapy with insulin sensitizers or the need to initiate therapy with insulin or insulin stimulators. The issues regarding the general approach to elderly diabetics and the strategies of dealing with diabetic complications encountered in the subacute care program are discussed and updated. It is hoped that diabetic management can be improved and that suggested alternate therapies can be used in the subacute care facilities.

Diabetes mellitus in older persons

The relative importance and mechanisms of deficient insulin secretion versus deficient action during aging are still debated. Whatever mechanisms eventually explain the emergence of impaired glucose tolerance during aging, the clinically important extrinsic modifiers of glycemic levels include diet, medications, activity, and chronic illness and stress. Although prospective studies are not available in the elderly, retrospective studies suggest that good blood glucose control reduces the likelihood and severity of stroke, cardiovascular disease, visual impairment, nephropathy, infections, and even cognitive dysfunction. Good control also seems to reduce nocturia, polyuria, and hypovolemia. Therapy of older persons begins with diet, exercise, and oral agents, failing which, insulin is employed. Since many of the newer oral agents carry less risk of hypoglycemia, achieving tighter control in the elderly has become more feasible.

Advantages of alpha-glucosidase inhibition as monotherapy in elderly type 2 diabetic patients

The objective of this study was to determine the safety, efficacy, and tolerability of the alpha-glucosidase inhibitor miglitol vs. the sulfonylurea glyburide in the treatment of elderly patients with type 2 diabetes mellitus, inadequately controlled by diet alone. This was a double-blind, randomized, placebo-controlled, 1-yr trial of miglitol 25 mg TID and 50 mg TID compared with placebo and a titrated dose of glyburide in a parallel group comparison study conducted in 30 out-patient sites across the United States. Four hundred eleven (411) diet-treated patients age 60 yr or greater were randomized to receive either placebo TID (n = 101), miglitol 25 mg TID (n = 104), miglitol 50 mg TID (n = 102), or a once-daily dose of glyburide titrated based on fasting plasma glucose (FPG) (n = 104), for a period of 56 weeks. Efficacy was assessed by glycated hemoglobin (HbA1c), fasting and post-meal glucose, insulin, and lipid levels, and by 24-h urinary excretion of glucose and albumin. Safety and tolerability were assessed by tabulation of adverse events, periodic laboratory determinations, and home blood glucose monitoring. HbA1c treatment effects (placebo-subtracted change in HbA1c from baseline) at the 1-yr endpoint were -0.49%, -0.40%, and -0.92% in the miglitol 25 mg TID, miglitol 50 mg TID, and glyburide groups, respectively (P < 0.05- 0.01 vs. placebo). Postprandial insulin levels were significantly greater than placebo and miglitol in the glyburide group (P < 0.01). Hypoglycemia, weight gain, and both routine and serious cardiovascular events were more frequent in the glyburide group (P < 0.05-0.01 vs. placebo or miglitol groups). Diarrhea (or soft stools) and flatulence were more common in both miglitol groups than in the other two groups in a dose-dependent manner, but resulted in relatively few study dropouts. Treatment with miglitol offers the elderly type 2 diabetic patient significant reductions in daylong glycemia as measured by HbA1c. The greater HbA1c reductions seen with once-a-day glyburide occurred at a cost of significant increases in weight, insulin levels, and the incidences of clinical and subclinical hypoglycemia, which did not occur in the miglitol groups. alpha-glucosidase inhibitors are a useful and relatively safe therapeutic option in the elderly patient with type 2 diabetes.

Diabetic retinopathy in people aged 70 years or older. The Oulu Eye Study

AIMS

To evaluate the presence and severity of diabetic retinopathy and the value of retinopathy screening in people aged 70 years or older.

METHODS

In a population based study on 500 of 560 eligible (89%) people aged 70 years or older, signs of diabetic retinopathy were evaluated through dilated pupils by an ophthalmologist using photographic and/or ophthalmoscopic methods.

RESULTS

23% of the study population (113/500) had diabetes mellitus. Signs of diabetic retinopathy were found in 24 people (21% of the diabetic population). Retinopathy changes were graded as mild to moderate non-proliferative retinopathy (NPDR) in 40 eyes (18 people), severe NPDR (preproliferative) in five eyes (four people), and proliferative in three eyes (two people). Preproliferative or proliferative changes were present in four people (3.5% of the diabetic population) and diabetic maculopathy was diagnosed in nine (8% of the diabetic population). Laser treatment was considered to be indicated in seven people for maculopathy, and in two for proliferative changes. In four people the visual acuity was reduced to a low vision level as a result of diabetic retinopathy.

CONCLUSION

In spite of the high prevalence of diabetes mellitus in the elderly population, the prevalence of vision threatening diabetic retinopathy, particularly proliferative retinopathy, is low. Ophthalmoscopically, reliable information on fundus changes could be obtained in 94%, but photographs were gradable in only 76% of the diabetic population. Therefore, the value of photographic screening for diabetic retinopathy in this age group is poor in comparison with younger age groups.

Diabetes mellitus in older patients. Is tight blood glucose control warranted?

Diabetes mellitus is a major health problem in the older population, where it is mainly of the non-insulin-dependent type [i.e. non-insulin-dependent diabetes mellitus (NIDDM)]. Epidemiological evidence and extrapolation of trial data from patients with insulin-dependent diabetes mellitus (IDDM) suggests that improving glycaemic control reduces the risk of developing microvascular complications (i.e. retinopathy, nephropathy and neuropathy) and also slows the rate of progression of these complications in patients with early disease. Macrovascular morbidity and mortality is, however, more common than microvascular disease in the older population and the evidence that improved glycaemic control significantly reduces the impact of macrovascular disease is weak. Thus, the overall benefits of tight glycaemic control are less well defined in older patients, who tend to have NIDDM, than in younger patients with IDDM. There are small but significant risks associated with tight glycaemic control in the older patient, including potentially fatal hypoglycaemia with sulphonyl-ureas and/or insulin, and fatal metformin-induced lactic acidosis. Patients at especially high risk of these complications can, however, be identified and inappropriate pharmacological intervention can be avoided.

Diabetes in the elderly

Diabetes affects at least 20% of the population over the age of 65. Half of these patients are unaware that they have the disease. Diabetes in middle-aged subjects is characterized by an impairment in glucose induced insulin release, increased fasting hepatic glucose output and resistance to insulin mediated glucose disposal. In contrast, diabetes in the elderly is primarily associated with insulin deficiency. The presentation of diabetes in the aged is often non-specific. The elderly have an increased frequency of complications from diabetes. They are particularly susceptible to hypoglycaemia, because of reduced awareness of hypoglycaemic warning symptoms and altered release of counterregulatory hormones. Although no data are yet available from randomized controlled trials, there is abundant epidemiological evidence to suggest that adequate control of blood glucose can be expected to reduce the risk of long-term complications. A team approach is ideal for the management of the elderly patient with diabetes. Little data is available on which to base a diet and exercise prescription for elderly patients. Gliclazide appears to be the sulphonylurea of choice in the aged because it is associated with a lower frequency of hypoglycaemic reactions. Urine glucose testing is unreliable, and capillary glucose monitoring is preferred. Fructosamine may prove to be superior to haemoglobin A1C for monitoring long-term control.

Utilizing content analysis of counseling sessions to identify psychosocial stressors among patients with type II diabetes

This qualitative, descriptive study identified specific individual and family psychosocial stressors that impact on the ability of patients with type II, non-insulin-dependent diabetes mellitus to manage the self-care regimens recommended by healthcare professionals. A series of 2 to 12 counseling sessions was incorporated into a nationally recognized outpatient diabetes education program. Data collection consisted of in-depth interviews in which six patients with type II diabetes and their families discussed current problems associated with their diabetes. Content analysis identified the following themes and problem areas: patients' inner experience with diabetes, family stressors that affect patients with diabetes, coping strategies of type II diabetes patients, and psychopathology. Based on these findings, specific interventions that emphasize family involvement and support were developed for the healthcare team to use with patients with type II diabetes.

Measurable deficit of autonomic and sensory nerve function in asymptomatic diabetic patients

In a group of 46 consecutive outpatients attending the diabetic clinic of our Metabolic Department, 30 insulin-dependent and 16 non-insulin-dependent diabetic patients in stable metabolic control, and in 38 age-matched controls, we measured vibration perception threshold with biothesiometer and autonomic function, by means of the five classical cardiovascular tests: R-R interval variations during deep breathing, Valsalva ratio, lying-to-standing, postural hypotension, and sustained handgrip. None of the patients complained of symptoms related to diabetic autonomic neuropathy (DAN) or sensory polyneuropathy. Vibration perception threshold positively correlated with Valsalva ratio (p < 0.05) and deep breathing (p < 0.01), and all of them correlated with age (p < 0.001), but not with duration of diabetes and metabolic control. Patients scored significantly lower than controls in vibration perception threshold and all of the autonomic function tests. According to the outcomes of cardiovascular tests ["Autonomic Score" (AS)] patients were divided into two different groups: presence (DAN+ = AS > or = 3) or absence (DAN- = AS < 3) of autonomic neuropathy. The DAN- group (n = 28, 60.9%) showed no significant differences from the DAN+ group (n = 18, 39.1%) in age, duration of diabetes, glycated hemoglobin, or body mass index. DAN+ patients had vibration perception threshold measured at the first toe tip and at external malleolus significantly higher than DAN- patients (p < 0.01 and p < 0.001, respectively) and controls (p < 0.005), as well as all the other cardiovascular tests except sustained handgrip. No difference in any of these items was observed between DAN- patients and controls.(ABSTRACT TRUNCATED AT 250 WORDS)

The management of diabetes mellitus in older individuals

Nearly 50% of individuals with type II diabetes mellitus are over the age of 65 years. There are numerous reasons to maintain blood glucose levels below 11.1 nmol/L (200 mg/dl) in older persons, and there are a number of changes often seen with advancing age that persons, and there are a number of changes often seen with advancing age that may interfere with the management of diabetes mellitus, e.g. hypodipsia, anorexia, visual disturbance, altered renal and hepatic function, depression, impaired basoreceptor response and multiple medications. Hyperglycaemia appears to produce cognitive impairment which may lead to poor compliance. It is often difficult to manipulate diet in older people, and in fact dietary changes can lead to severe protein energy malnutrition. High maximum voluntary oxygen intake has been correlated with increased glucose disposal, but there is little evidence that physical exercise can improve diabetic control in the elderly. Oral sulphonylurea hypoglycaemic agents are extremely useful in the treatment of diabetes in these patients, but it should be remembered that they are more liable to develop hypoglycaemia than are younger diabetics. The role of metformin in the management of older diabetic patients is poorly studied. Many older persons can cope well with insulin therapy, but those with visual disturbances often make errors when drawing up insulin and require special attention. Combination therapy of insulin with oral hypoglycaemic agents is not recommended in this group of patients, and serum fructosamine is preferred to glycated haemoglobin to monitor control. Successful management of elderly diabetic patients thus requires an interdisciplinary team approach.