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Du J, Zhang D, Chen Y, Zhang W. Development of a prediction model for frailty among older Chinese individuals with type 2 diabetes residing in the community. Public Health Nurs 2024. [PMID: 39101656 DOI: 10.1111/phn.13377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 06/17/2024] [Accepted: 07/11/2024] [Indexed: 08/06/2024]
Abstract
METHODS The study employed a retrospective survey of 458 older individuals with T2D residing in a Chinese community, conducted between June 2020 and May 2021, to develop a predictive model for frailty. Among the participants, 83 individuals (18.1%) were diagnosed with frailty using modified frailty phenotypic criteria. The predictors of frailty in this community-dwelling older population with T2D were determined using least absolute shrinkage and selection operator (LASSO) regression and multivariable logistic regression. These predictors were utilized to construct a nomogram. The discrimination, calibration, and medical usefulness of the prediction model were assessed through the C-index, calibration plot, and decision curve analysis (DCA), respectively. Additionally, internal validation of the prediction model was conducted using bootstrapping validation. RESULTS The developed nomogram for frailty prediction predominantly incorporated age, smoking status, regular exercise, depression, albumin (ALB) levels, sleep condition, HbA1c, and polypharmacy as significant predictors. Our prediction model demonstrated excellent discrimination and calibration, as evidenced by a C-index of 0.768 (95% CI, 0.714-0.822) and strong calibration. Internal validation yielded a C-index of 0.732, further confirming the reliability of the model. DCA indicated the utility of the nomogram in identifying frailty among the studied population. CONCLUSION The development of a predictive model enables a valuable estimation of frailty among community-dwelling older individuals with type 2 diabetes. This evidence-based tool provides crucial guidance to community healthcare professionals in implementing timely preventive measures to mitigate the occurrence of frailty in high-risk patients. By identifying established predictors of frailty, interventions and resources can be appropriately targeted, promoting better overall health outcomes and improved quality of life in this vulnerable population.
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Affiliation(s)
- Jin Du
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Di Zhang
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yurong Chen
- Community Health Service Center of Zhengzhou City, Zhengzhou, China
| | - Weihong Zhang
- School of Nursing and Health, Zhengzhou University, Zhengzhou, China
- Hami Vocational and Technical College, Hami, China
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Abdel-Rahman N, Manor O, Cohen A, Elran E, Cohen AG, Krieger M, Paltiel O, Valinsky L, Ben-Yehuda A, Calderon-Margalit R. Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study. PLoS One 2024; 19:e0302422. [PMID: 38723050 PMCID: PMC11081362 DOI: 10.1371/journal.pone.0302422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 04/03/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND In the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting. METHODS A nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators. RESULTS During 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years). CONCLUSIONS Longitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators.
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Affiliation(s)
- Nura Abdel-Rahman
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | - Orly Manor
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | | | - Einat Elran
- Maccabi Healthcare Services, Tel Aviv, Israel
| | | | - Michal Krieger
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | - Ora Paltiel
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
| | | | | | - Ronit Calderon-Margalit
- Braun School of Public Health, Hebrew University of Jerusalem Hadassah Medical School, Jerusalem, Israel
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Seidu S, Hambling CE, Kunutsor SK, Topsever P. Associations of blood pressure with cardiovascular and mortality outcomes in over 2 million older persons with or without diabetes mellitus: A systematic review and meta-analysis of 45 cohort studies. Prim Care Diabetes 2023; 17:554-567. [PMID: 37806800 DOI: 10.1016/j.pcd.2023.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/28/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND The impact of blood pressure on cardiovascular disease (CVD) and mortality outcomes in older people with diabetes mellitus (DM) is not well quantified. Using a systematic review and meta-analysis of observational cohort studies, we aimed to compare the associations of blood pressure levels with cardiovascular and mortality outcomes in older people aged ≥ 65 years with or without DM. METHODS Studies were identified from MEDLINE, Embase, Web of Science, and search of bibliographies to July 2022. Study-specific risk ratios (RRs) with 95% confidence intervals (CIs) were pooled. RESULTS Forty-five unique observational cohort studies (n = 2305,189 participants) assessing the associations of systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) levels with adverse cardiovascular outcomes were included. In the general population, the pooled RRs (95% CIs) of SBP ≥ 140 vs < 140 mmHg and per 10 mmHg increase for composite CVD/MACE were 1.26 (0.96-1.64) and 1.15 (1.08-1.23), respectively. The respective estimates were 1.56 (1.04-2.34) and 1.10 (1.04-1.18) for patients with DM. SBP ≥ 130 vs < 130 mmHg was not associated with an increased risk of adverse cardiovascular outcomes in both populations. SBP < 120 vs ≥ 120 mmHg was associated with an increased risk of all cause-mortality in the general population (n = 10 studies). DBP ≥ 90 mmHg was associated with an increased risk of some adverse cardiovascular outcomes in both populations. Interaction analyses suggested similar risk of outcomes in both populations. CONCLUSIONS Observational evidence suggests SBP and DBP confer similar cardiovascular and mortality risk in older adults in the general population and those with DM. A blood pressure target range of > 130/80 to < 140/90 mmHg may be optimal for patients ≥ 65 years with DM, but specific targets may need to be individualised based on patients' unique circumstances. Furthermore, findings do not support stringent blood pressure control in this population group. Definitive RCTs are needed to support these observational findings.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, UK; NIHR Applied Research Collaboration, East Midlands, Leicester, UK.
| | - Clare E Hambling
- Bridge Street Surgery, Bridge Street, Downham Market, Norfolk PE38 9DH, UK
| | - Setor K Kunutsor
- Diabetes Research Centre, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, UK; NIHR Applied Research Collaboration, East Midlands, Leicester, UK
| | - Pinar Topsever
- Department of Family Medicine, Acibadem Mehmet Ali Aydinlar University School of Medicine, Kerem Aydinlar Campus, Atasehir, Turkey
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Ribero VA, Alwan H, Efthimiou O, Abolhassani N, Bauer DC, Henrard S, Christiaens A, Waeber G, Rodondi N, Gencer B, Del Giovane C. Cardiovascular disease and type 2 diabetes in older adults: a combined protocol for an individual participant data analysis for risk prediction and a network meta-analysis of novel anti-diabetic drugs. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.03.13.23287105. [PMID: 36993427 PMCID: PMC10055459 DOI: 10.1101/2023.03.13.23287105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Introduction Older and multimorbid adults with type 2 diabetes (T2D) are at high risk of cardiovascular disease (CVD) and chronic kidney disease (CKD). Estimating risk and preventing CVD is a challenge in this population notably because it is underrepresented in clinical trials. Our study aims to (1) assess if T2D and haemoglobin A1c (HbA1c) are associated with the risk of CVD events and mortality in older adults, (2) develop a risk score for CVD events and mortality for older adults with T2D, (3) evaluate the comparative efficacy and safety of novel antidiabetics. Methods and analysis For Aim 1, we will analyse individual participant data on individuals aged ≥65 years from five cohort studies: the Optimising Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older People study; the Cohorte Lausannoise study; the Health, Aging and Body Composition study; the Health and Retirement Study; and the Survey of Health, Ageing and Retirement in Europe. We will fit flexible parametric survival models (FPSM) to assess the association of T2D and HbA1c with CVD events and mortality. For Aim 2, we will use data on individuals aged ≥65 years with T2D from the same cohorts to develop risk prediction models for CVD events and mortality using FPSM. We will assess model performance, perform internal-external cross validation, and derive a point-based risk score. For Aim 3, we will systematically search randomized controlled trials of novel antidiabetics. Network meta-analysis will be used to determine comparative efficacy in terms of CVD, CKD, and retinopathy outcomes, and safety of these drugs. Confidence in results will be judged using the CINeMA tool. Ethics and dissemination Aims 1 and 2 were approved by the local ethics committee (Kantonale Ethikkommission Bern); no approval is required for Aim 3. Results will be published in peer-reviewed journals and presented in scientific conferences.
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Affiliation(s)
- Valerie Aponte Ribero
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Heba Alwan
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland
| | - Orestis Efthimiou
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Institute of Social and Preventive Medicine, University of Bern, 3012, Bern, Switzerland
| | - Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisante), University of Lausanne, Switzerland
| | - Douglas C Bauer
- Departments of Medicine and Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Séverine Henrard
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, 1200, Brussels, Belgium
- Institute of Health and Society (IRSS), Université catholique de Louvain, 1200 Brussels, Belgium
| | - Antoine Christiaens
- Clinical Pharmacy research group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain, 1200, Brussels, Belgium
- Fonds de la Recherche Scientifique – FNRS, 1000 Brussels, Belgium
| | - Gérard Waeber
- Department of Medicine, Lausanne University Hospital (CHUV), University of Lausanne, 1011, Lausanne, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland
| | - Baris Gencer
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
- Cardiology Division, Geneva University Hospitals, 1205, Geneva, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, 3012, Bern, Switzerland
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Hand grip strength: A reliable assessment tool of frailty status on the person with type 2 diabetes Mellitus. NUTR CLIN METAB 2023. [DOI: 10.1016/j.nupar.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Abstract
Cardiovascular risk factors (CVRF) are very prevalent in the elderly population and in addition to predisposing to cardiovascular disease they are related to functional decline, which limits the quality of life in this population. The objective of this work is to offer a review of the current evidence in the management of CVRF in the elderly population. The search strategy was executed in PubMed, Clinicalstrials.org and Embase, to search for clinical trials, observational cohort or cross-sectional studies, reviews, and clinical practice guidelines focused or including elderly population. The results provided were refined after reading the title and abstract, as well as elimination of duplicates, and were finally identified and assessed following the GRADE methodology. A total of 136 studies were obtained for all predefined risk factors, such as sedentary lifestyle, smoking, obesity and metabolic syndrome, hypertension, diabetes mellitus, dyslipidemia and alcohol. We described the results of the studies identified and assessed according to their methodological quality in different recommendation sections: diagnostic and prevention, intervention, or treatment in the elderly population. As the main limitation to the results of this review, there is the lack of quality studies whose target population is elderly patients. This issue limits the recommendations that can be made in this population. Due to this reason, comprehensive geriatric assessment seems the best tool currently available to implement the most appropriate treatment plans based on the baseline situation and comorbidity of each elderly patient.
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Crabtree T, Ogendo JJ, Vinogradova Y, Gordon J, Idris I. Intensive glycemic control and macrovascular, microvascular, hypoglycemia complications and mortality in older (age ≥60years) or frail adults with type 2 diabetes: a systematic review and meta-analysis from randomized controlled trial and observation studies. Expert Rev Endocrinol Metab 2022; 17:255-267. [PMID: 35614863 DOI: 10.1080/17446651.2022.2079495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/16/2022] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Guidelines for type 2 diabetes (T2D) recommend individualized HbA1c targets to take into account patient age or frailty. We synthesized evidence from randomized controlled trials and observational studies for intensive glycemic control (HbA1c target ≤58 mmol/mol) versus standard care, in elderly (age ≥60 years) or frail adults with T2D. METHODS Searches were performed utilizing recognized terms for T2D, frailty, older age, and HbA1c control and outcomes of interest. Meta-analysis was performed where possible. Primary outcomes included all-cause mortality, severe hypoglycemia, and hospital admission rates. Vascular complications, cognitive decline, and falls/fractures were secondary outcomes. RESULTS 7,528 studies were identified of which 15 different clinical studies were selected. No difference was noted in all-cause mortality with intensive control (pooled hazard ratio 0.96, 95% confidence interval 0.90-1.03), but risk of severe hypoglycemia increased (2.45, 2.22-2.72). Intensive control was associated reductions in microvascular (0.73, 0.68-0.79) and macrovascular complications (0.84, 0.79-0.89). Outcome data for risk of hospitalization, cognition, and falls/fractures were limited. CONCLUSION Intensive glycemic control was associated with reduced rates of complications but increased severe hypoglycemia. Significant heterogeneity exists and the impact of different drug regimens is unclear. Caution is needed when setting glycemic targets in elderly or frail individuals.
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Affiliation(s)
- Thomas Crabtree
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jael-Joy Ogendo
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Jason Gordon
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Health Economic Outcomes Research, Birmingham, UK
| | - Iskandar Idris
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Nottingham, UK
- Arthritis Centre for Musculoskeletal Ageing Research, University of Nottingham, NIHR, Nottingham BRC, University of Nottingham, UK
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Heald A, Stedman M, Robinson A, Davies M, Livingston M, Alshames R, Moreno G, Gadsby R, Rayman G, Gibson M, de Lusignan S, Whyte M. Mortality Rate Associated with Diabetes: Outcomes From a General Practice Level Analysis in England Using the Royal College of General Practitioners (RCGP) Database Indicate Stability Over a 15 Year Period. Diabetes Ther 2022; 13:505-516. [PMID: 35187627 PMCID: PMC8934837 DOI: 10.1007/s13300-022-01215-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 01/28/2022] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Total population mortality rates have been falling and life expectancy increasing for more than 30 years. Diabetes remains a significant risk factor for premature death. Here we used the Oxford Royal College of General Practitioners Research and Surveillance Centre (RCGP RSC) practices to determine diabetes-related vs non-diabetes-related mortality rates. METHODS RCGP RSC data were provided on annual patient numbers and deaths, at practice level, for those with and without diabetes across four age groups (< 50, 50-64, 65-79, ≥ 80 years) over 15 years. Investment in diabetes control, as measured by the cost of primary care medication, was also taken from GP prescribing data. RESULTS We included 527 general practices. Over the period 2004-2019, there was no significant change in life years lost, which varied between 4.6 and 5.1 years over this period. The proportion of all diabetes deaths by age band was significantly higher in the 65-79 years age group for men and women with diabetes than for their non-diabetic counterparts. For the year 2019, 26.6% of deaths were of people with diabetes. Of this 26.6%, 18.5% would be expected from age group and non-diabetes status, while the other 8.1% would not have been expected-pro rata to nation, this approximates to approximately 40,000 excess deaths in people with diabetes vs the general population. CONCLUSION There remains a wide variation in mortality rate of people with diabetes between general practices in UK. The mortality rate and life years lost for people with diabetes vs non-diabetes individuals have remained stable in recent years, while mortality rates for the general population have fallen. Investment in diabetes management at a local and national level is enabling us to hold the ground regarding the life-shortening consequences of having diabetes as increasing numbers of people develop T2DM at a younger age.
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Affiliation(s)
- Adrian Heald
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK.
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK.
| | | | - Adam Robinson
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK
| | | | - Mark Livingston
- Black Country Pathology Services, Walsall Manor Hospital, Walsall, UK
| | - Ramadan Alshames
- Biochemistry Department, Faculty of Dentistry, Tripoli University, Tripoli, Libya, UK
| | - Gabriela Moreno
- , Marina Nacional 162, Anáhuac Secc, Miguel Hidalgo, 11320, Mexico City, Mexico
| | - Roger Gadsby
- Warwick Medical School, University of Warwick, Warwick, UK
| | - Gerry Rayman
- The Ipswich Diabetes Centre and Research Unit, Ipswich Hospital NHS Trust, Colchester, Essex, UK
| | - Martin Gibson
- The School of Medicine and Manchester Academic Health Sciences Centre, Manchester University, Manchester, UK
- Department of Endocrinology and Diabetes, Salford Royal Hospital, Salford, M6 8HD, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Martin Whyte
- Clinical and Experimental Medicine, University of Surrey, Guildford, UK
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Abdel-Qadir H, Gunn M, Lega IC, Pang A, Austin PC, Singh SM, Jackevicius CA, Tu K, Dorian P, Lee DS, Ko DT. Association of Diabetes Duration and Glycemic Control With Stroke Rate in Patients With Atrial Fibrillation and Diabetes: A Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e023643. [PMID: 35132863 PMCID: PMC9245806 DOI: 10.1161/jaha.121.023643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background There are limited data on the association of diabetes duration and glycemic control with stroke risk in atrial fibrillation (AF). Our objective was to study the association of diabetes duration and glycated hemoglobin (HbA1c) with the rate of stroke in people with diabetes and newly diagnosed AF. Methods and Results This was a population‐based cohort study using linked administrative data sets. We studied 37 209 individuals aged ≥66 years diagnosed with AF in Ontario between April 2009 and March 2019, who had diabetes diagnosed 1 to 16 years beforehand. The primary outcome was hospitalization for stroke at 1 year. Cause‐specific hazard regression was used to model the association of diabetes duration and glycated hemoglobin (HbA1c) with the rate of stroke. Restricted cubic spline analyses showed increasing hazard ratios (HR) for stroke with longer diabetes duration that plateaued after 10 years and increasing HRs for stroke with HbA1c levels >7%. Relative to patients with <5 years diabetes duration, stroke rates were significantly higher for patients with ≥10 years duration (HR, 1.45; 95% CI, 1.16–1.82; P=0.001), while diabetes duration 5 to <10 years was not significantly different. Relative to glycated hemoglobin 6% to <7%, values ≥8% were associated with higher stroke rates (HR, 1.44; 95% CI, 1.12–1.84; P=0.004), while other HbA1c categories were not significantly different. Conclusions Longer diabetes duration and higher glycated hemoglobin were associated with significantly higher stroke rates in patients with AF and diabetes. Models for stroke risk prediction and preventive care in AF may be improved by considering patients’ diabetes characteristics.
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Affiliation(s)
- Husam Abdel-Qadir
- Women's College Hospital Toronto Canada.,University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Madison Gunn
- Schulich School of Medicine Western University London ON Canada
| | - Iliana C Lega
- Women's College Hospital Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Andrea Pang
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada
| | - Peter C Austin
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada
| | - Sheldon M Singh
- Department of Medicine University of Toronto Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Canada
| | - Cynthia A Jackevicius
- University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,College of Pharmacy Western University of Health Sciences Pomona CA
| | - Karen Tu
- University Health Network Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,North York General Hospital Toronto Canada.,Department of Family and Community Medicine University of Toronto Canada
| | - Paul Dorian
- Department of Medicine University of Toronto Canada.,Division of Cardiology Unity Health Toronto Canada
| | - Douglas S Lee
- University Health Network Toronto Canada.,ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada
| | - Dennis T Ko
- ICES (Formerly Known as the Institute for Clinical Evaluative Sciences) Toronto Canada.,Institute of Health Policy Management, and Evaluation University of Toronto Canada.,Department of Medicine University of Toronto Canada.,Schulich Heart Centre Sunnybrook Health Sciences Centre Toronto Canada
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10
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Yang T, Fu P, Chen J, Fu X, Xu C, Liu X, Niu T. Increased risk of adverse cardiovascular events by strict glycemic control after percutaneous coronary intervention (HbA1c < 6.5% at 2 years) in type 2 diabetes mellitus combined with acute coronary syndrome: a 5-years follow-up study. Curr Med Res Opin 2021; 37:1517-1528. [PMID: 34166166 DOI: 10.1080/03007995.2021.1947219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study assessed the association between HbA1c level measured 2 years after percutaneous coronary intervention (PCI) and long-term clinical outcomes in type 2 diabetes mellitus combined with acute coronary syndrome (ACS) who underwent PCI. METHODS This prospective observational study analyzed 2877 ACS patients with type 2 diabetes mellitus whose baseline HbA1c ≥ 7.0% and underwent PCI. All patients were divided into 6 groups according to the HbA1c level at 2 years after PCI. The clinical outcome was major adverse cardiovascular events (MACEs), defined as all-cause death, all myocardial infarction, any revascularization, congestive heart failure, ischemic stroke. The median follow-up duration was 4.1 years. RESULTS All 2877 patients were divided into 6 groups: 2-year after PCI HbA1c < 6.0% (n = 219), 6.0-6.5% (n = 348), 6.5-7.0% (n = 882), 7.0-7.5% (n = 567), 7.5-8.0% (n = 441), ≥8.0% (n = 420). The 5-year incidence rate of MACEs in HbA1c <6.0% and 6.0-6.5% groups were similar to 7.5-8.0% and ≥8.0% groups, which were significantly higher than in 6.5-7.0% and 7.0-7.5% groups (p = .044). The cumulative incidence rate of MACEs significantly differed among the groups (p = .046). Multivariate Cox regression analysis revealed a U-shaped relationship between 2-year HbA1c level after PCI and risk of MACEs. 2-year HbA1c <6.5% after PCI was an independent risk factor for MACEs in type 2 diabetes mellitus combined with ACS who underwent PCI (p < .001). CONCLUSIONS The findings indicated an increased risk of MACEs by strict glycemic control after PCI (2-year HbA1c < 6.5% after PCI) in type 2 diabetes mellitus combined with ACS who underwent PCI.
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Affiliation(s)
- Tiangui Yang
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Peng Fu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Jie Chen
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xi Fu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Changlu Xu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Xiaoxia Liu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Tiesheng Niu
- Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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Rooney MR, Tang O, Pankow JS, Selvin E. Glycaemic markers and all-cause mortality in older adults with and without diabetes: the Atherosclerosis Risk in Communities (ARIC) study. Diabetologia 2021; 64:339-348. [PMID: 32990802 PMCID: PMC7855037 DOI: 10.1007/s00125-020-05285-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/11/2020] [Indexed: 12/19/2022]
Abstract
AIMS/HYPOTHESIS There is controversy regarding the performance of HbA1c in old age. We evaluated the prognostic value of HbA1c and other glycaemic markers (fructosamine, glycated albumin, fasting glucose) with mortality risk in older adults (66-90 years). METHODS This was a prospective analysis of 5636 participants (31% with diagnosed diabetes, mean age 76, 58% female, 21% black) in the Atherosclerosis Risk in Communities (ARIC) study, baseline 2011-2013. We used Cox regression to examine associations of glycaemic markers (modelled in categories) with mortality risk, stratified by diagnosed diabetes status. RESULTS During a median of 6 years of follow-up, 983 deaths occurred. Among older adults with diabetes, 30% had low HbA1c (<42 mmol/mol [<6.0%]) and 10% had high HbA1c (≥64 mmol/mol [≥8.0%]); low (HR 1.32 [95% CI 1.04, 1.68]) and high (HR 1.86 [95% CI 1.32, 2.62]) HbA1c were associated with mortality risk vs HbA1c 42-52 mmol/mol (6.0-6.9%) after demographic adjustment. Low fructosamine and glycated albumin were not associated with mortality risk. Both low and high fasting glucose were associated with mortality risk. After further adjustment for lifestyle and clinical risk factors, high HbA1c (HR 1.81 [95% CI 1.28, 2.56]), fructosamine (HR 1.96 [95% CI 1.43-2.69]), glycated albumin (HR 1.81 [95% CI 1.33-2.47]) and fasting glucose (HR 1.81 [95% CI 1.24, 2.66]) were associated with mortality risk. Low HbA1c and fasting glucose were no longer significantly associated with mortality risk. Among participants without diabetes, associations of glycaemic markers with mortality risk were less robust. CONCLUSIONS/INTERPRETATION Elevated HbA1c, fructosamine, glycated albumin and fasting glucose were associated with risk of mortality in older adults with diabetes. Low HbA1c and fasting glucose may be markers of poor prognosis but are possibly confounded by health status. Our findings support the clinical use of HbA1c in older adults with diabetes. Graphical abstract.
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Affiliation(s)
- Mary R Rooney
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
| | - Olive Tang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, MD, USA
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12
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White AMB, Mishcon HR, Redwanski JL, Hills RD. Statin Treatment in Specific Patient Groups: Role for Improved Cardiovascular Risk Markers. J Clin Med 2020; 9:E3748. [PMID: 33233352 PMCID: PMC7700563 DOI: 10.3390/jcm9113748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 01/17/2023] Open
Abstract
Ample evidence supports the use of statin therapy for secondary prevention in patients with a history of atherosclerotic cardiovascular disease (ASCVD), but evidence is wanting in the case of primary prevention, low-risk individuals, and elderly adults 65+. Statins are effective in lowering low-density lipoprotein (LDL), which has long been a target for treatment decisions. We discuss the weakening dependence between cholesterol levels and mortality as a function of age and highlight recent findings on lipoprotein subfractions and other superior markers of ASCVD risk. The efficacy of statins is compared for distinct subsets of patients based on age, diabetes, ASCVD, and coronary artery calcium (CAC) status. Most cardiovascular risk calculators heavily weight age and overestimate one's absolute risk of ASCVD, particularly in very old adults. Improvements in risk assessment enable the identification of specific patient populations that benefit most from statin treatment. Derisking is particularly important for adults over 75, in whom treatment benefits are reduced and adverse musculoskeletal effects are amplified. The CAC score stratifies the benefit effect size obtainable with statins, and forms of coenzyme Q are discussed for improving patient outcomes. Robust risk estimator tools and personalized, evidence-based approaches are needed to optimally reduce cardiovascular events and mortality rates through administration of cholesterol-lowering medications.
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Affiliation(s)
- Alyssa M. B. White
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - Hillary R. Mishcon
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
| | - John L. Redwanski
- Department of Pharmacy Practice, School of Pharmacy, University of New England, Portland, ME 04103, USA;
| | - Ronald D. Hills
- Department of Pharmaceutical Sciences and Administration, University of New England, Portland, ME 04103, USA; (A.M.B.W.); (H.R.M.)
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13
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Koufakis T, Grammatiki M, Kotsa K. Type 2 diabetes management in people aged over seventy-five years: targets and treatment strategies. Maturitas 2020; 143:118-126. [PMID: 33308617 DOI: 10.1016/j.maturitas.2020.10.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/06/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023]
Abstract
Older people (those aged 65 years or more) with diabetes comprise a heterogenous group of patients with special needs and features; this is particularly true for those aged 75 years or more. It is important that individualized glycemic targets be adopted in this population, after considering life expectancy, presence of diabetic complications and other comorbidities. In general, less rigorous targets and avoidance of overtreatment seems to be a reasonable strategy in daily clinical settings. There is a paucity of data regarding the efficacy and safety of various hypoglycemic agents, especially for those aged over 75. The evidence suggests that sulfonylureas and insulin regimens should be used with caution due to a high risk of hypoglycemia. Dipeptidyl peptidase-4 inhibitors are a good choice for the management of diabetes in older age groups, although a warning against the use of specific agents in people with heart failure is valid. There are insufficient data to decide whether the cardiorenal protective properties of sodium-glucose co-transporter 2 inhibitors outweigh the risks associated with these drugs. The use of glucagon-like peptide-1 receptor agonists by older patients is supported not only by their good safety and efficacy profiles, but also by their potential to improve glucose-independent outcomes, through their pleiotropic actions. The aim of this narrative review is to summarize the evidence on glycemic targets and optimal therapeutic approaches for older patients with type 2 diabetes and discuss the risk-benefit balance of various therapeutic approaches in this group.
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Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece
| | - Maria Grammatiki
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, 1 St. Kiriakidi Street, Thessaloniki, 54636, Greece.
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14
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Pinsker JE, Leas S, Müller L, Habif S. Real-World Improvements in Hypoglycemia in an Insulin-Dependent Cohort With Diabetes Mellitus Pre/Post Tandem Basal-Iq Technology Remote Software Update. Endocr Pract 2020; 26:714-721. [PMID: 33471639 DOI: 10.4158/ep-2019-0554] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 02/01/2020] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Software updatable insulin pumps, such as the t:slim X2 pump from Tandem Diabetes Care, enable access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump; however, little quantitative data exist on the software update process or on pre/post therapeutic outcomes. We examined real-world usage and impact of a remote software updatable predictive low-glucose suspend (PLGS) technology designed to reduce hypoglycemic events in people with insulin-dependent diabetes. METHODS Approximately 15,000 U.S. Tandem pump users remotely updated their t:slim X2 software to Basal-IQ PLGS technology since its commercial release. We performed a retrospective analysis of users who uploaded at least 21 days of pre/post PLGS update usage data to the Tandem t:connect web application between August 28, 2018, and October 21, 2019 (N = 6,170). Insulin delivery and sensor-glucose values were analyzed per recent international consensus and American Diabetes Association guidelines. Software update performance was also assessed. RESULTS Median software update time was 5.36 minutes. Overall glycemic outcomes for pre and post software update showed a decrease in sensor time <70 mg/dL from 2.14 to 1.18% (-1.01; 95% confidence interval [CI], -0.97, -1.05; P<.001), with overall sensor time 70 to 180 mg/dL increasing from 57.8 to 58.5% (0.64; 95% CI, 0.04, 1.24; P<.001). These improvements were sustained at 3, 6, and 9 months after the update. CONCLUSION Introduction of a software updatable PLGS algorithm for the Tandem t:slim X2 insulin pump resulted in sustained reductions of hypoglycemia. ABBREVIATIONS ADA = American Diabetes Association; CGM = continuous glucose monitoring; CI = confidence interval; PLGS = predictive low-glucose suspend; SG = sensor glucose; T1D = type 1 diabetes; T2D = type 2 diabetes; TIR = time-in-range.
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Affiliation(s)
- Jordan E Pinsker
- From (1)Sansum Diabetes Research Institute, Santa Barbara, California.
| | - Scott Leas
- Tandem Diabetes Care, Information Technology, San Diego, California
| | - Lars Müller
- University of California San Diego, Design Lab, La Jolla, California
| | - Steph Habif
- Tandem Diabetes Care, Behavioral Sciences, San Diego, California
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15
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The age-related blood pressure trajectories from young-old adults to centenarians: A cohort study. Int J Cardiol 2019; 296:141-148. [DOI: 10.1016/j.ijcard.2019.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 07/03/2019] [Accepted: 08/05/2019] [Indexed: 02/04/2023]
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16
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Sertbas M, Guduk O, Guduk O, Yazici Z, Dagci S, Sertbas Y. Current situation analysis of diabetic home care patients. North Clin Istanb 2019; 7:140-145. [PMID: 32259035 PMCID: PMC7117632 DOI: 10.14744/nci.2019.59751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/22/2019] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Diabetes is one of the primary diagnoses for admission to home health care units. Although there are many studies about elderly diabetic patients, there are not many studies on home care patients with diabetes. The present study aims to analyze the current status of diabetic home care patients with their biochemical data and medications. METHODS This was a retrospective study, including 256 diabetic patients who were following up by the Home Health Unit of Istanbul Provincial Health Directorate Public Hospitals Services-2. In this study, we analyzed the current biochemical data of the patients with their medications. RESULTS In this study, 185 female (72.3%) and 71 male (27.7%) patients were recruited with the mean HbA1c of 8.25±1.77. Among these patients, 65% of them were using oral antidiabetic (OAD), and 58% were using insulin. There were 21 (8.2%) patients who were not receiving any treatment. While patients who were using only oral antidiabetic have better A1c levels (A1c: 7.73±1.45), patients who were insülin using had HbA1c levels as high as the patients who were not using any medication. This may be due to the progression of diabetes, fear of hypoglycemia or insufficient insülin use. While metformin was the most commonly used OAD, with a 38% usage rate. When compared to HbA1c levels, there was no difference between the types of insulin used (p=0.167). CONCLUSION As a result, it is important to plan regular visits and personalized treatment by keeping in mind the benefits to risk ratios in home-care diabetic patients.
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Affiliation(s)
- Meltem Sertbas
- Department of Internal Medicine, Health Sciences University Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ozlem Guduk
- Department of Internal Medicine, Health Sciences University Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
| | - Ozden Guduk
- Health Institutes of Turkey, Istanbul, Turkey
| | - Zeynep Yazici
- Department of Cardiology, Siyami Ersek Training and Research Hospital, Istanbul, Turkey
| | - Selma Dagci
- Department of Internal Medicine, Health Sciences University, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Yasar Sertbas
- Department of Internal Medicine, Health Sciences University Fatih Sultan Mehmet Training and Research Hospital, Istanbul, Turkey
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17
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Montesanto A, Bonfigli AR, De Luca M, Crocco P, Garagnani P, Marasco E, Pirazzini C, Giuliani C, Romagnoli F, Franceschi C, Passarino G, Testa R, Olivieri F, Rose G. Erythropoietin (EPO) haplotype associated with all-cause mortality in a cohort of Italian patients with Type-2 Diabetes. Sci Rep 2019; 9:10395. [PMID: 31316151 PMCID: PMC6637129 DOI: 10.1038/s41598-019-46894-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/27/2019] [Indexed: 01/04/2023] Open
Abstract
Type-2 Diabetes (T2D), diabetic complications, and their clinical risk factors harbor a substantial genetic component but the genetic factors contributing to overall diabetes mortality remain unknown. Here, we examined the association between genetic variants at 21 T2D-susceptibility loci and all-cause mortality in an elderly cohort of 542 Italian diabetic patients who were followed for an average of 12.08 years. Univariate Cox regression analyses detected age, waist-to-hip ratio (WHR), glycosylated haemoglobin (HbA1c), diabetes duration, retinopathy, nephropathy, chronic kidney disease (CKD), and anaemia as predictors of all-cause mortality. When Cox proportional hazards multivariate models adjusted for these factors were run, three erythropoietin (EPO) genetic variants in linkage disequilibrium (LD) with each other (rs1617640-T/G, rs507392-T/C and rs551238-A/C) were significantly (False Discovery Rate < 0.1) associated with mortality. Haplotype multivariate analysis revealed that patients carrying the G-C-C haplotype have an increased probability of survival, while an opposite effect was observed among subjects carrying the T-T-A haplotype. Our findings provide evidence that the EPO gene is an independent predictor of mortality in patients with T2D. Thus, understanding the mechanisms by which the genetic variability of EPO affects the mortality of T2D patients may provide potential targets for therapeutic interventions to improve the survival of these patients.
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Affiliation(s)
- Alberto Montesanto
- Department of Biology, Ecology and Earth Sciences, University of Calabria, 87036, Rende, Italy
| | | | - Maria De Luca
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, 35294, USA
| | - Paolina Crocco
- Department of Biology, Ecology and Earth Sciences, University of Calabria, 87036, Rende, Italy
| | - Paolo Garagnani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Clinical Chemistry, Department of Laboratory Medicine, Karolinska Institutet at Huddinge University Hospital, Stockholm, Sweden
| | - Elena Marasco
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Chiara Pirazzini
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Cristina Giuliani
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Fabio Romagnoli
- Diabetology Unit, IRCCS INRCA, National Institute, Ancona, Italy
| | - Claudio Franceschi
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Alma Mater Studiorum, University of Bologna, Bologna, Italy.,IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Giuseppe Passarino
- Department of Biology, Ecology and Earth Sciences, University of Calabria, 87036, Rende, Italy
| | - Roberto Testa
- Clinical Laboratory and Molecular Diagnostics, IRCCS INRCA, Ancona, Italy
| | - Fabiola Olivieri
- Department of Clinical and Molecular Sciences, DISCLIMO, Università Politecnica delle Marche, Ancona, Italy.,Center of Clinical Pathology and Innovative Therapy, National Institute IRCCS INRCA, Ancona, Italy
| | - Giuseppina Rose
- Department of Biology, Ecology and Earth Sciences, University of Calabria, 87036, Rende, Italy.
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18
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Nakanishi S, Hirukawa H, Shimoda M, Tatsumi F, Kohara K, Obata A, Kimura T, Okauchi S, Kinoshita T, Sanada J, Fushimi Y, Nishioka M, Mizoguchi A, Mune T, Kaku K, Kaneto H. Verification of Kumamoto Declaration 2013 and Glycemic Targets for Elderly Patients with Diabetes in Japan for prevention of diabetic complications: A retrospective longitudinal study using outpatient clinical data. J Diabetes Investig 2019; 10:290-301. [PMID: 30099853 PMCID: PMC6400169 DOI: 10.1111/jdi.12909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 11/29/2022] Open
Abstract
AIMS/INTRODUCTION The present study examined the association between the onset of micro- and macroangiopathy in type 2 diabetes mellitus patients and levels of glycated hemoglobin (HbA1c) described in the Evidence-based Practice Guideline for the Treatment for Diabetes in Japan 2013 or those indicated in the Japan Diabetes Society and the Japan Geriatrics Society Joint Committee on Improving Care for Elderly Patients with Diabetes. MATERIALS AND METHODS Patients with type 2 diabetes mellitus who visited the outpatient clinic at Kawasaki Medical School Hospital between 2000 and 2016 and received follow up for >2 years were eligible for the present study. Two datasets, comprising 2,424 or 3,316 patients without micro- or macroangiopathy at the start of follow up, were used, respectively. The Cox model was used in two categories of patients, younger and elderly, with the dividing line set at the age of 65 years. RESULTS For the prevention of microangiopathy, in all patients, there was found to be no advantage in controlling HbA1c at a level of <6.0% based on the categories in the Evidence-based Practice Guideline for the Treatment for Diabetes in Japan 2013, and there was found to be a disadvantage in maintaining HbA1c ≥8.5% based on the categories in the Japan Diabetes Society and the Japan Geriatrics Society Joint Committee on Improving Care for Elderly Patients with Diabetes guideline. For the prevention of macroangiopathy in younger patients, there seemed to be an advantage in maintaining HbA1c within the range of 6.0-6.9% and <7.0% based on the Evidence-based Practice Guideline for the Treatment for Diabetes in Japan 2013 and the Japan Diabetes Society and the Japan Geriatrics Society Joint Committee on Improving Care for Elderly Patients with Diabetes, respectively. CONCLUSIONS In all type 2 diabetes mellitus patients, average HbA1c should be maintained <7.0% to prevent microangiopathy. However, in elderly patients, no optimal target for preventing macroangiopathy was found, in contrast to the younger patients in the present study.
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Affiliation(s)
- Shuhei Nakanishi
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Hidenori Hirukawa
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Masashi Shimoda
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Fuminori Tatsumi
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Kenji Kohara
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Atsushi Obata
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Tomohiko Kimura
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Seizo Okauchi
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Tomoe Kinoshita
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Junpei Sanada
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Yoshiro Fushimi
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Momoyo Nishioka
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Akiko Mizoguchi
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Tomoatsu Mune
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
| | - Kohei Kaku
- Department of General Internal Medicine 1Kawasaki HospitalKawasaki Medical SchoolOkayamaJapan
| | - Hideaki Kaneto
- Division of Diabetes, Metabolism and EndocrinologyKawasaki Medical SchoolOkayamaJapan
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Aspinall SL, Hanlon JT, Niznik JD, Springer SP, Thorpe CT. Deprescribing in Older Nursing Home Patients: Focus on Innovative Composite Measures for Dosage Deintensification. Innov Aging 2018; 1:igx031. [PMID: 30564752 DOI: 10.1093/geroni/igx031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Indexed: 01/15/2023] Open
Abstract
Deprescribing, which includes stopping or reducing the dosage of medications, is designed to improve safety and prevent adverse drug reactions in older patients. To date, there has been limited work on measuring decreases in dosage intensity, or deintensification, across therapeutic classes of medications. Given the ongoing focus on central nervous system (CNS) medications and the frequency with which providers encounter hypertension and diabetes in older nursing home patients, the objective of this expert review is to describe and critique innovative composite dosage intensity measures that have been, or could be, applied to quantify deintensification within three therapeutic medication targets commonly encountered in nursing home patients: CNS agents, antihypertensive therapy, and antidiabetic therapy and the extent to which they are associated with health outcomes. Composite measures for CNS medication intensity considered dividing a patient's daily dose by defined daily dosage (DDD), or the minimum effective adult or geriatric daily dosage. In contrast, composite measures for antihypertensives used either DDD or maximum recommended daily dosage in the denominator. We were not able to identify any composite measure of intensity for antidiabetic classes. There was a paucity of interventional studies that showed reducing the dosage intensity resulted in improved health outcomes. In conclusion, we identified several innovative composite measures of dosage intensity for CNS and antihypertensive medications, and discussed possible approaches for developing an antidiabetic regimen composite measure. It is critical for future research to compare and contrast various measures and to determine their impact on important clinical outcomes.
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Affiliation(s)
- Sherrie L Aspinall
- VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, Illinois.,VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pennsylvania.,Department of Epidemiology, School of Public Health, University of Pittsburgh, Pennsylvania
| | - Joshua D Niznik
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania.,Department of Medicine (Geriatrics), School of Medicine, University of Pittsburgh, Pennsylvania
| | - Sydney P Springer
- VA Center for Medication Safety/Pharmacy Benefits Management Services, Hines, Illinois.,VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pennsylvania.,Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pennsylvania
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20
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Meneilly GS, Knip A, Miller DB, Sherifali D, Tessier D, Zahedi A. Diabetes in Older People. Can J Diabetes 2018; 42 Suppl 1:S283-S295. [PMID: 29650107 DOI: 10.1016/j.jcjd.2017.10.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 12/15/2022]
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21
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Schernthaner G, Schernthaner-Reiter MH. Diabetes in the older patient: heterogeneity requires individualisation of therapeutic strategies. Diabetologia 2018; 61:1503-1516. [PMID: 29417185 PMCID: PMC6445482 DOI: 10.1007/s00125-018-4547-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 11/29/2017] [Indexed: 12/11/2022]
Abstract
Owing to the worldwide increase in life expectancy, the high incidence of diabetes in older individuals and the improved survival of people with diabetes, about one-third of all individuals with diabetes are now older than 65 years. Evidence is accumulating that type 2 diabetes is associated with cognitive impairment, dementia and frailty. Older people with diabetes have significantly more comorbidities, such as myocardial infarction, stroke, peripheral arterial disease and renal impairment, compared with those without diabetes. However, as a consequence of the increased use of multifactorial risk factor intervention, a considerable number of older individuals can now survive for many years without any vascular complications. Given the heterogeneity of older individuals with type 2 diabetes, an individualised approach is warranted, which must take into account the health status, presence or absence of complications, and life expectancy. In doing so, undertreatment of otherwise healthy older individuals and overtreatment of those who are frail may be avoided. Specifically, overtreatment of hyperglycaemia in older patients is potentially harmful; in particular, insulin and sulfonylureas should be avoided or, if necessary, used with caution. Instead, glucose-dependent drugs that do not induce hypoglycaemia are preferable since older patients with diabetes and impaired kidney function are especially vulnerable to this adverse event.
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Affiliation(s)
- Guntram Schernthaner
- Department of Medicine 1, Rudolfstiftung Hospital, Juchgasse 25, 1030, Vienna, Austria.
| | - Marie Helene Schernthaner-Reiter
- Clinical Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel, 18-20 1090, Vienna, Austria.
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22
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Yanagita I, Fujihara Y, Eda T, Tajima M, Yonemura K, Kawajiri T, Yamaguchi N, Asakawa H, Nei Y, Kayashima Y, Yoshimoto M, Kitajima Y, Harada M, Araki Y, Yoshimoto S, Aida E, Yanase T, Nawata H, Muta K. Low glycated hemoglobin level is associated with severity of frailty in Japanese elderly diabetes patients. J Diabetes Investig 2018; 9:419-425. [PMID: 28556518 PMCID: PMC5835456 DOI: 10.1111/jdi.12698] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 05/01/2017] [Accepted: 05/23/2017] [Indexed: 12/16/2022] Open
Abstract
AIMS/INTRODUCTION Previously, a study using a narrowly defined (physical base) frailty scale reported that both good and bad (U-shaped curve) glycated hemoglobin (HbA1c) levels were frailty risk factors in patients with type 2 diabetes mellitus. However, no such studies in Japan have shown this. We aimed to evaluate the frailty risk factors including HbA1c in elderly Japanese patients with type 2 diabetes mellitus using a broadly defined (both physical and psychosocial base) frailty scale, the Clinical Frailty Scale (CFS). MATERIALS AND METHODS We randomly enrolled 132 elderly patients with type 2 diabetes mellitus (aged ≥65 years) and categorized the patients into nine stages of frailty using CFS. Because no patient had CFS 9, patients with a CFS score of 1-4 and 5-8 were defined as non-frail and frail, respectively. We attempted to identify the risk factors of frailty by investigating the association between CFS stage and various patient factors. RESULTS Multiple regression analysis showed that an increase in age, low levels of albumin, high-density lipoprotein cholesterol, systolic blood pressure, HbA1c, total cholesterol, and bodyweight were statistically significant and strong independent risk factors for frailty, suggesting that reverse metabolism owing to malnutrition in elderly type 2 diabetes mellitus patients might be involved. CONCLUSIONS HbA1c level was not a U-shaped risk for frailty, suggesting that relatively good glycemic control might be more important for frailty than poor control in elderly type 2 diabetes mellitus patients.
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Affiliation(s)
- Ikumi Yanagita
- Muta HospitalFukuokaJapan
- Department of Endocrinology and Diabetes MellitusFaculty of MedicineFukuoka UniversityFukuokaJapan
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Toshihiko Yanase
- Department of Endocrinology and Diabetes MellitusFaculty of MedicineFukuoka UniversityFukuokaJapan
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Abstract
Frailty is a state of vulnerability and a consequence of cumulative decline in multiple physiological systems over a lifespan. The occurrence of frailty depends on deterioration in muscle and nerve function, declining cardiopulmonary reserve and loss of executive function. Diabetes mellitus (DM) often causes functional impairment in each of the above systems, thus leading to a loss of whole body homeostasis and deterioration in physical function. Inability of self-management in DM patients may also have considerable impact on the development of sarcopenia/frailty. Thus, there may be positive feedback between the progression of diabetic complications and frailty/sarcopenia. While various factors are involved in this process, insulin resistance or insulin depletion may be an important factor in the progression of frailty in diabetes patients since insulin is well known to be an anabolic hormone in muscle. Interestingly, in our study targeting elderly DM patients, low HbA1c was a significant and independent risk factor for frailty, as assessed using a broad sense frailty scale, the Clinical Frailty Scale (CSF), suggesting that reverse metabolism due to malnutrition in elderly type 2 DM patients might be involved. Therefore, an intervention that includes proper nutrition and exercise training may be essential for the prevention of frailty. The pathogenesis of frailty in DM patients is extensively discussed in this review.
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Affiliation(s)
- Toshihiko Yanase
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
| | - Ikumi Yanagita
- Department of Endocrinology and Diabetes Mellitus, Faculty of Medicine, Fukuoka University, Fukuoka 814-0180, Japan
- Department of Diabetes and Metabolism, Muta Hospital, Fukuoka 814-0163, Japan
| | - Kazuo Muta
- Department of Diabetes and Metabolism, Muta Hospital, Fukuoka 814-0163, Japan
| | - Hajime Nawata
- Department of Diabetes and Metabolism, Muta Hospital, Fukuoka 814-0163, Japan
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Declining blood pressure and intensification of blood pressure management among people over 80 years: cohort study using electronic health records. J Hypertens 2017; 35:1276-1282. [PMID: 28441696 PMCID: PMC5404403 DOI: 10.1097/hjh.0000000000001291] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: Management of high blood pressure (BP) in people over 80 years is controversial, but there is limited information available concerning the uptake of hypertension treatment at this age. Objective: To evaluate use of antihypertensive drugs and changes in SBP and DBP from 2001 to 2014 in men and women aged 80 years and over. Methods: Cohort study using primary care electronic health records of 265 225 participants from the UK Clinical Practice Research Datalink. Records of BP and antihypertensive medications were analysed. Linear trends were estimated by frailty category in multiple regression models. Results: Data were analysed for 116 401 men and 148 824 women. The proportion with BP recorded increased from 51% in 2001 to 78% in 2014. The proportion of patients prescribed antihypertensive medications increased from 64 to 76%. Mean SBP declined from 150 (SD 20) mmHg in 2001 to 135 (16) mmHg in 2014. In ‘fit’ participants, the decline in SBP was 12.4 (95% confidence interval 11.9–13.0) mmHg/decade in those treated for hypertension and 8.5 (7.8–9.1) mmHg in those not treated. The decline in SBP was smaller as frailty increased. The proportion of all participants with BP less than 140/90 mmHg increased from 14 to 44% in the study period. Conclusion: In octogenarians, BP treatment has intensified between 2001 and 2014. BP values have declined in both treated and untreated participants, with a substantial increase in the proportion achieving conventional BP targets.
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Charlton J, Ravindrarajah R, Hamada S, Jackson SH, Gulliford MC. Trajectory of Total Cholesterol in the Last Years of Life Over Age 80 Years: Cohort Study of 99,758 Participants. J Gerontol A Biol Sci Med Sci 2017; 73:1083-1089. [DOI: 10.1093/gerona/glx184] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/26/2017] [Indexed: 02/01/2023] Open
Affiliation(s)
- Judith Charlton
- Department of Primary Care and Public Health Sciences, King’s College London, UK
| | - Rathi Ravindrarajah
- Department of Primary Care and Public Health Sciences, King’s College London, UK
| | - Shota Hamada
- Department of Primary Care and Public Health Sciences, King’s College London, UK
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan
| | | | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King’s College London, UK
- National Institute for Health Research Biomedical Research Centre at Guy’s and St Thomas’ National Health Service Foundation Trust, London, UK
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Meneilly GS, Berard LD, Cheng AYY, Lin PJ, MacCallum L, Tsuyuki RT, Yale JF, Nasseri N, Richard JF, Goldin L, Langer A, Tan MK, Leiter LA. Insights Into the Current Management of Older Adults With Type 2 Diabetes in the Ontario Primary Care Setting. Can J Diabetes 2017; 42:23-30. [PMID: 28583470 DOI: 10.1016/j.jcjd.2017.03.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 02/09/2017] [Accepted: 03/03/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The Goal Oriented controL of Diabetes in the Elderly populatioN (GOLDEN) Program assessed the management of older persons with type 2 diabetes in Canadian primary care. METHODS Data were extracted from the records of 833 consecutively identified persons 65 years of age or older who had type 2 diabetes and were taking 1 antihyperglycemic agent or more; they were managed by 64 physicians from 36 Ontario clinics. RESULTS More than half (53%) had glycated hemoglobin (A1C) levels of 7.0% or lower, 41% had blood pressure levels below 130/80 mm Hg, and 73% had low-density lipoprotein levels of 2.0 mmol/L or lower; 19% met all 3 criteria. Over the past year, 11% had been assessed for frailty, 16% for cognitive dysfunction and 19% for depression; 88% were referred for eye checkups, and 83% had undergone foot examinations. One-tenth were taking 4 or more antihyperglycemic agents, 87% statins and 52% an angiotensin-converting enzyme inhibitor. More than half of those with high clinical complexity had A1C levels of 7.0% or lower; of these, one-third were taking a sulfonylurea, and one-fifth were taking insulin. In the patients with A1C levels of 7.0% or above and low clinical complexity, there was often no up-titration or initiation of additional antihyperglycemic agents. CONCLUSIONS Older persons with type 2 diabetes often have multiple comorbidities. Unlike eye and foot examinations, there was less emphasis on evaluating for frailty, cognitive dysfunction and depression. The GOLDEN patients had generally well-controlled glycemic, blood pressure and cholesterol profiles, but whether these would be reflected in a "sicker" population is not known. Personalized strategies are necessary to avoid undertreatment of "healthy" older patients and overtreatment of the frail elderly.
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Affiliation(s)
- Graydon S Meneilly
- Department of Medicine, Vancouver Hospital and the University of British Columbia, Vancouver, British Columbia, Canada.
| | - Lori D Berard
- Winnipeg Regional Health Authority, Health Sciences Centre, Winnipeg Diabetes Research Group, Department of Medicine, Section of Endocrinology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alice Y Y Cheng
- Division of Endocrinology and Metabolism, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Peter J Lin
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lori MacCallum
- Banting and Best Diabetes Centre, Faculty of Medicine and Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Ross T Tsuyuki
- EPICORE Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jean-François Yale
- Division of Endocrinology and Metabolism, McGill University, Montréal, Québec, Canada
| | | | | | - Lianne Goldin
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Anatoly Langer
- Canadian Heart Research Centre, Toronto, Ontario, Canada; Terrence Donnelly Heart Centre, Division of Cardiology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mary K Tan
- Canadian Heart Research Centre, Toronto, Ontario, Canada
| | - Lawrence A Leiter
- Division of Endocrinology & Metabolism, Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Ontario, Canada
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Hazra NC, Gulliford M. Evolution of the "fourth stage" of epidemiologic transition in people aged 80 years and over: population-based cohort study using electronic health records. Popul Health Metr 2017; 15:18. [PMID: 28499387 PMCID: PMC5429583 DOI: 10.1186/s12963-017-0136-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 05/04/2017] [Indexed: 01/15/2023] Open
Abstract
Background In the “fourth stage” of epidemiological transition, the distribution of non-communicable diseases is expected to shift to more advanced ages, but age-specific changes beyond 80 years of age have not been reported. Methods This study aimed to evaluate demographic and health transitions in a population aged 80 years and over in the United Kingdom from 1990 to 2014, using primary care electronic health records. Epidemiological analysis of chronic morbidities and age-related impairments included a cohort of 299,495 participants, with stratified sampling by five-year age group up to 100 years and over. Cause-specific proportional hazards models were used to estimate hazard ratios for incidence rates over time. Results Between 1990 and 2014, nonagenarians and centenarians increased as a proportion of the over-80 population, as did the male-to-female ratio among individuals aged 80 to 95 years. A lower risk of coronary heart disease (HR 0.54, 95% confidence interval [CI]: 0.50–0.58), stroke (0.83, 0.76–0.90) and chronic obstructive pulmonary disease (0.59, 0.54–0.64) was observed among 80–84 year-olds in 2010–2014 compared to 1995–1999. By contrast, the risk of type II diabetes (2.18, 1.96–2.42), cancer (1.52, 1.43–1.61), dementia (2.94, 2.70–3.21), cognitive impairment (5.57, 5.01–6.20), and musculoskeletal pain (1.26, 1.21–1.32) was greater in 2010–2014 compared to 1995–1999. Conclusions Redistribution of the over-80 population to older ages, and declining age-specific incidence of cardiovascular and respiratory diseases in over-80s, are consistent with the “fourth stage” of epidemiologic transition, but increases in diabetes, cancer, and age-related impairment show new emerging epidemiological patterns in the senior elderly. Electronic supplementary material The online version of this article (doi:10.1186/s12963-017-0136-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nisha C Hazra
- Department of Primary Care and Public Health Sciences, King's College London, 3rd Floor Addison House, Guy's Campus, London, SE1 1UL, UK.
| | - Martin Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, 3rd Floor Addison House, Guy's Campus, London, SE1 1UL, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust, Great Maze Pond, London, SE1 9RT, UK
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Hamada S, Gulliford MC. Drug prescribing during the last year of life in very old people with diabetes. Age Ageing 2017; 46:147-151. [PMID: 28181655 PMCID: PMC5388282 DOI: 10.1093/ageing/afw174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 10/05/2016] [Indexed: 12/24/2022] Open
Abstract
Objective to evaluate primary care drug utilisation during the last year of life, focusing on antidiabetic and cardiovascular drugs, in patients of advanced age with diabetes. Design population-based cohort study. Setting primary care database in the UK. Subjects patients with type 2 diabetes who died at over 80 years of age between 2011 and 13. Methods main outcome measures included proportions of patients prescribed different classes of drugs, comparing the first (Q1) and the fourth quarters (Q4) of the last year of life. Results the study included 5,324 patients, with the median age 86 years and 50% female. Three-fourths of the patients received five or more drugs, and the total number of drugs prescribed was almost stable at 6.2 ± 3.1 (mean ± SD) during the last year of life. Substantial proportions of patients were treated with antidiabetic drugs (78%), antihypertensive drugs (76%), statins (62%) and low-dose aspirin (46%) in Q1. Prescribing of these drugs slightly decreased by 3–8% in Q4. There were increases in prescribing of anti-infectives (35% in Q1 to 50% in Q4), drugs for nervous system (63% to 73%), drugs for respiratory system (24% to 33%) and systemic hormonal drugs (22% to 27%). Conclusion patients of advanced age with type 2 diabetes were often treated with antidiabetic and cardiovascular drugs even when approaching death. More research is needed to generate evidence to guide optimal drug utilisation for older people with a limited life expectancy.
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Affiliation(s)
- Shota Hamada
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- Address correspondence to: S. Hamada, Department of Primary Care and Public Health Sciences, King's College London, 3rd floor, Addison House, London SE1 1UL, UK. Tel: +44 (0)20 7848 6426; Fax: +44 (0)20 7848 6620.
| | - Martin C. Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas’ NHS Foundation Trust, London, UK
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Hamada S, Gulliford MC. Mortality in Individuals Aged 80 and Older with Type 2 Diabetes Mellitus in Relation to Glycosylated Hemoglobin, Blood Pressure, and Total Cholesterol. J Am Geriatr Soc 2016; 64:1425-31. [PMID: 27295278 PMCID: PMC6680323 DOI: 10.1111/jgs.14215] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objectives To evaluate whether low glycosylated hemoglobin (HbA1c), blood pressure (BP), and total cholesterol (TC) are associated with lower risk of all‐cause mortality in very old individuals with type 2 diabetes mellitus. Design Population‐based cohort study. Setting Primary care database in the United Kingdom. Participants Individuals aged 80 and older with type 2 diabetes mellitus (N = 25,966). Measurements Associations between baseline HbA1c, BP, and TC and all‐cause mortality were evaluated in Cox proportional hazards models. Analyses were adjusted for sex, age, duration of diabetes mellitus, lifestyle variables, HbA1c, BP, TC, comorbidities, prescribing of antidiabetic and cardiovascular drugs, and participants’ general practice. Results There were 4,490 deaths during follow‐up (median 2.0 years; mortality 104.7 per 1,000 person‐years). Mortality in participants with low (<6.0% (<42 mmol/mol)) or high (≥8.5% (≥69 mmol/mol)) HbA1c was similar to that in those with the reference HbA1c (8.0–8.4% (64–68 mmol/mol)). Mortality was lowest in individuals with HbA1c of 7.0–7.4% (53–57 mmol/mol) (80.9 per 1,000 person‐years, adjusted hazard ratio (aHR) = 0.80, 95% confidence interval (CI) = 0.70–0.91, P = .001). Mortality was higher in individuals with lower BP (e.g., <130/70 mmHg, 151.7 per 1,000 person‐years, aHR = 1.52, 95% CI = 1.34–1.72, P < .001 vs reference BP <150/90 mmHg) and in the lowest TC category (<3.0 mmol/L, 138.7 per 1,000 person‐years, aHR = 1.42, 95% CI = 1.24–1.64, P < .001 vs reference TC 4.5–4.9 mmol/L). The relationship between TC and mortality varied according to sex and prescription of lipid‐lowering drugs. Conclusion Low HbA1c, BP, and TC may be associated with higher mortality in very old adults with type 2 diabetes mellitus. Further research is required to understand these associations and to identify optimal treatment targets in this population.
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Affiliation(s)
- Shota Hamada
- Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom.,National Institute for Health Research, Biomedical Research Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
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