Treatment of Diabetes in Older Adults: An Endocrine Society* Clinical Practice Guideline

A Qualitative Study of Older Adult Perspectives on Continuous Glucose Monitoring for Type 2 Diabetes

BACKGROUND

Continuous glucose monitoring (CGM) may improve self-management and reduce hypoglycemia risk among individuals with diabetes. However, little is known about how older adults with insulin-treated type 2 diabetes (T2D) experience and incorporate this technology into their daily lives.

OBJECTIVE

To explore experiences, preferences, barriers, and questions related to using CGM among older adults with insulin-treated T2D with and without experience using CGM.

DESIGN

Qualitative focus group study.

PARTICIPANTS

English-speaking older adults with T2D in a large, integrated healthcare delivery system. Groups included either experienced CGM users or adults who had not previously used CGM. Recruitment efforts prioritized individuals ≥ 75 years of age.

APPROACH

Transcripts were analyzed using the Framework Method to identify perspectives on CGM. Specific thematic categories were hypoglycemia-related benefits, general benefits, usefulness and ease of use concerns, and CGM questions.

KEY RESULTS

The study included 26 participants: 17 (65%) were experienced CGM users, 58% were female; median age was 74 (range 62-88) years. Participants perceived and anticipated these CGM benefits: informing behavior changes, reducing in-the-moment hypoglycemia risk, improving awareness and decision-making, and strengthening clinician collaboration. Perceived CGM barriers included challenges with wearability and reliability, burdens to others, distrust of technology, sensory and learning challenges, insufficient clinician support or engagement, and access and payer hurdles. Despite these downsides, experienced users perceived CGM as a worthwhile alternative to daily fingerstick glucose checks. Non-users were able to formulate many usability questions, providing a snapshot of informational needs for this age group.

CONCLUSIONS

Older adults with insulin-treated T2D experienced or anticipated benefits from CGM for diabetes management. Findings indicate a need for tailored education and self-management support for older adults to learn and gain maximal benefit from this technology.

Glucose Abnormalities Detected by Continuous Glucose Monitoring in Very Old Adults With and Without Diabetes

OBJECTIVE

To characterize the prevalence of continuous glucose monitoring (CGM)-defined glucose abnormalities in a large, community-based population of very old adults (>75 years).

RESEARCH DESIGN AND METHODS

A cross-sectional analysis of 1,150 older adults with and without diabetes who attended the Atherosclerosis Risk in Communities Study (2021-2022). Diabetes was based on a self-reported diagnosis of diabetes by a health care provider, use of diabetes medication, or a hemoglobin A1c (HbA1c) ≥6.5%. Prediabetes was defined as an HbA1c of 5.7% to <6.5% and normoglycemia as an HbA1c of <5.7%. We analyzed CGM metrics, including mean glucose, measures of hyperglycemia, and the coefficient of variation, by diabetes status.

RESULTS

Of the 1,150 participants (mean age 83 years, 59% women, 26% who are Black), 35.1% had normoglycemia, 34.5% had prediabetes, and 30.4% had diabetes. The summary 24-h ambulatory glucose profile for participants with prediabetes was very similar to those with normoglycemia. No participants with normoglycemia or prediabetes had a CGM mean glucose >140 mg/dL, while 32.7% of participants with diabetes had a CGM mean glucose >140 mg/dL.

CONCLUSIONS

In very old adults with normal or prediabetes HbA1c, hyperglycemia detected by CGM was rare. This suggests that HbA1c adequately captures the burden of hyperglycemia for most people in this population.

Patient and physician factors driving the gaps in use of drugs with cardiovascular and kidney benefits by medicare beneficiaries with type 2 diabetes treated by endocrinologists, nephrologists, and cardiologists: Population-based cohort study

AIMS

Endocrinologists, nephrologists, and cardiologists care for people with type 2 diabetes (T2D) and coexisting cardiovascular disease (CVD), heart failure (HF), and/or chronic kidney disease (CKD). Glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) should be preferentially used, but are underutilized. We examine patient and physician factors associated with GLP-1RA/SGLT2i use by patients treated by these subspecialists.

METHODS

Retrospective cohort study using linked 2022 Medicare and American Board of Internal Medicine data for adults >65 years with T2D and coexisting CVD, HF, and/or CKD and their treating endocrinologists, nephrologists, and cardiologists.

RESULTS

We identified 246,106/254,425/435,773 patients treated by 5,661/8,233/10,874 endocrinologists/nephrologists/cardiologists in 2022. Overall, 73.2 % of endocrinologist-treated patients filled diabetes medications prescribed by endocrinologists; 41.9 % filled GLP-1RA/SGLT2i. Patients of nephrologists and cardiologists were rarely prescribed diabetes medications by these subspecialists (9.8 % and 6.1 %, respectively); however, conditional on filling any diabetes medication, they were more likely to fill a GLP-1RA/SGLT2i (59.5 % and 48.2 %, respectively). Older patients of endocrinologists and nephrologists, and patients of older nephrologists and cardiologists, were less likely to fill GLP-1RA/SGLT2i.

CONCLUSIONS

Many, particularly older, patients with T2D treated by endocrinologists, nephrologists, and cardiologists should be, but are not, prescribed GLP-1RA/SGTL2i. Physician training may improve these statistics.

Management of Hypertension in Patients with Diabetes

Hypertension is a common comorbid condition among patients with diabetes, occurring in 71% to 80.6% of diabetes patients in the United States, and contributes to the development of cardiovascular disease. Screening for hypertension and a multifaceted treatment approach, including lifestyle management, pharmacologic therapy, and blood pressure targets are the key to reducing morbidity and mortality associated with uncontrolled blood pressure. Most patients require more than 1 medication to control their blood pressure, and clinicians should follow published guidelines to select the most appropriate and efficacious blood pressure agents for their patients.

Diabetes remission in newly diagnosed type 2 diabetes mellitus through short-term continuous subcutaneous insulin infusion intensive therapy combined with low-carbohydrate diet treatment

AIM/INTRODUCTION

To evaluate the therapeutic efficacy short-term continuous subcutaneous insulin infusion (CSII) intensive therapy combined with a low-carbohydrate diet (LCD) for diabetes remission in patients with newly diagnosed type 2 diabetes mellitus.

MATERIALS AND METHODS

This study included patients newly diagnosed with type 2 diabetes mellitus, who were randomly divided into two groups: conventional (conventional CSII + traditional lifestyle guidance); and intensive (intensive CSII + LCD lifestyle guidance). CSII was used for blood glucose control, with continuous glucose monitoring (CGM) used to monitor blood glucose levels. The primary outcome measure was hemoglobin A1c (HbA1c) level; secondary outcomes included body weight, body mass index (BMI), waist circumference, glycemic control, and biochemical indices.

RESULTS

The time in range (TIR) in the intensive treatment group was greater than that in the conventional treatment group (P < 0.05). There was no significant difference in the incidence of hypoglycemia between the two groups (P > 0.05). Compared with the conventional treatment group, diabetes remission rates were significantly greater in the intensive treatment group (P < 0.05). In the intensive treatment group, fasting plasma glucose (FPG), HbA1c, Homeostasis Model assessment of Insulin Resistance (HOMA-IR), triglycerides (TG), low-density lipoprotein cholesterol (LDL-c), and changes in body weight, BMI, visceral fat area (VFA), and subcutaneous fat area (SFA) decreased significantly (P < 0.05). FPG, HOMA-IR, TG, LDL-c, and changes in body weight, BMI, waist circumference, and VFA were significantly correlated with HbA1c levels (P < 0.05).

CONCLUSIONS

The combination of intensive CSII and LCD lifestyle guidance had been improved the remission rate in patients with newly diagnosed type 2 diabetes mellitus.

Realigning diabetes regimens in older adults: a 4S Pathway to guide simplification and deprescribing strategies

Treating older people with diabetes is challenging due to multiple medical comorbidities that might interfere with patients' ability to perform self-care. Most diabetes guidelines focus on improving glycaemia through addition of medications, but few address strategies to reduce medication burden for older adults-a concept known as deprescribing. Strategies for deprescribing might include stopping high-risk medications, decreasing the dose, or substituting for less harmful agents. Accordingly, glycaemic management strategies for older adults with type 1 and type 2 diabetes not responding to their current regimen require an understanding of how and when to realign therapy to meet patient's current needs, which represents a major clinical practice gap. With the gap in guidance on how to deprescribe or otherwise adjust therapy in older adults with diabetes in mind, the International Geriatric Diabetes Society, an organisation dedicated to improving care of older individuals with diabetes, convened a Deprescribing Consensus Initiative in May, 2023, to discuss Optimization of diabetes treatment regimens in older adults: the role of de-prescribing, de-intensification and simplification of regimens. The recommendations from this group initiative are discussed and described in this Review.

Pyroptosis-Mediator GSDMD in Plasma: A Promising Biomarker for Early Diagnosis of Type 2 Diabetes

Objective

This study investigates the potential of plasma Gasdermin D (GSDMD) as a novel biomarker for early diagnosis and monitoring of type 2 diabetes mellitus.

Methods

We conducted a comparative analysis of clinical indicators among newly diagnosed diabetes patients, those with prediabetes, and healthy controls, finding significantly elevated plasma GSDMD levels in the diabetes group (P < 0.05).

Results

Correlation analyses revealed that GSDMD levels were positively associated with inflammatory markers and indicators of insulin resistance, while negatively correlating with HOMA-β (P < 0.001). Logistic regression analysis identified GSDMD, IL-6, and CRP as independent risk factors for type 2 diabetes (P < 0.001). The area under the ROC curve for plasma GSDMD was 0.988, indicating superior diagnostic capability compared to traditional markers like CRP (0.902) and IL-6 (0.857). With a threshold of 17.67 pg/mL, plasma GSDMD exhibited a sensitivity of 93.9% and specificity of 98.0%.

Conclusion

These findings suggest that plasma GSDMD not only reflects early metabolic abnormalities associated with type 2 diabetes but also holds promise as a therapeutic target to mitigate inflammatory responses and improve insulin resistance. Further large-scale clinical studies are warranted to validate its diagnostic utility and enhance clinical applications.

Nutritional intake of micronutrient and macronutrient and type 2 diabetes: machine learning schemes

BACKGROUND

Diabetes mellitus, an endocrine system disease, is a common disease involving many patients worldwide. Many studies are performed to evaluate the correlation between micronutrients/macronutrients on diabetes but few of them have a high statistical population and a long follow-up period. We aimed to investigate the relationship between intake of macro/micronutrients and the incidence of type 2 diabetes (T2D) using logistic regression (LR) and a decision tree (DT) algorithm for machine learning.

METHOD

Our research explores supervised machine learning models to identify T2D patients using the Mashhad Cohort Study dataset. The study population comprised 9704 individuals aged 35-65 years were enrolled regarding their T2D status, and those with T2D history. 15% of individuals are diabetic and 85% of them are non-diabetic. For ten years (until 2020), the participants in the study were monitored to determine the incidence of T2D. LR is a statistical model applied in dichotomous response variable modeling. All data were analyzed by SPSS (Version 22) and SAS JMP software.

RESULT

Nutritional intake in the T2D group showed that potassium, calcium, magnesium, zinc, iodine, carotene, vitamin D, tryptophan, and vitamin B12 had an inverse correlation with the incidence of diabetes (p < 0.05). While phosphate, iron, and chloride had a positive relationship with the risk of T2D (p < 0.05). Also, the T2D group significantly had higher carbohydrate and protein intake (p-value < 0.05).

CONCLUSION

Machine learning models can identify T2D risk using questionnaires and blood samples. These have implications for electronic health records that can be explored further.

Role of Psychological Distress in the Assessment of Chronic Illness Care and Self-Management Behaviors of Elderly Patients with T2DM Chronic Complications

Background

This study sought to explore the interrelationship between diabetes-related distress, patient evaluations of chronic illness management, and self-management practices among older adults diagnosed with T2DM and associated chronic complications.

Methods

This was a cross-sectional study including 264 older adults with T2DM in Shanghai, China. Chinese version of Problem Areas in Diabetes Scale (PAID-C), Patient Assessment of Chronic Illness Care (PACIC) and Diabetes Self-Management Behaviour for Older (DSMB-O) were employed. Student's t-test, one-way ANOVA or the nonparametric analysis (Mann-Whitney U-test), Pearson correlation coefficient and structural equation model (SEM) were used to analyse the data.

Results

A total of 264 participants (157 males [59.47%], with an average age of 71.07±6.47 years) were included in the study; their duration of T2DM ranged from 5 to 30 years, with a mean duration of 11.19±6.96 years. The DSMB-O scores exhibited a negative correlation with the PAID-C scores (r=-0.250, p<0.01), while showing a positive correlation with PACIC scores (r=0.348, p<0.01). Additionally, PAID-C scores demonstrated a negative correlation with PACIC scores (r=-0.182, p<0.01). The indirect effect of PAID-C on DSMB-O through PACIC was calculated as (-0.70*-0.39=0.27). Furthermore, the total effect of PAID-C on DSMB-O via PACIC was determined to be (0.27+0.22=0.49). Notably, the mediating effect accounted for 54.99%.

Conclusion

Psychological distress is intricately linked to self-management behaviour among elderly patients suffering from T2DM and chronic complications. Our findings carry significant implications for T2DM healthcare, indicating that addressing psychological distress may enhance the quality of chronic illnesses, ultimately fostering improved self-management practices and yielding better health outcomes.

Comparison of 1-Year Clinical Outcomes Between Ticagrelor Versus Clopidogrel in Type 2 Diabetes Patients After Implantation of Small Diameter Stents

BACKGROUND

Type 2 diabetes mellitus (T2DM) patients with small-diameter stents (SDS), that are equal to or less than 2.5 mm in diameter, face increased risks of restenosis and complications. This study aimed to evaluate the 1-year follow-up to assess the rate of major adverse cardiac events (MACE) and bleeding risk between ticagrelor and clopidogrel in T2DM patients after SDS implantation.

METHODS

The study was a single-center, prospective controlled registry trial, which included 332 T2DM patients who underwent percutaneous coronary intervention with SDS implantation. Follow-up was conducted for 1 year.

RESULTS

Following propensity score matching, the 1-year analysis revealed no significant difference in the risk of the composite MACE between clopidogrel and ticagrelor groups (P = .295). Male gender, history of ischemic heart disease, ejection fraction (EF), coronary lesion type, and chronic kidney disease (CKD) were identified as potential predictors for the composite endpoint. In a subanalysis of CKD patients, the 12-month rates of composites of cardiac death (CD), myocardial infarction (MI), stroke, and target vessel revascularization (TVR) were lower in the ticagrelor group than in the clopidogrel group (P = .024). However, the ticagrelor group was associated with a higher rate of bleeding compared to the clopidogrel group (20% vs. 9%) (P = .041).

CONCLUSION

Our study demonstrated that ticagrelor did not show improvement in the composite of CD, MI, stroke, TVR, or the risk of bleeding events defined by the BARC criteria in patients with T2DM and SDS compared with clopidogrel emphasizing the importance of individualized treatment decisions based on patient characteristics. However, the results may not be representative of the entire population.

Diabetes Fact Sheets in Korea 2024

BACKGRUOUND

This study aimed to investigate the prevalence, management, and comorbidities of diabetes mellitus among Korean adults.

METHODS

Data from the Korea National Health and Nutrition Examination Survey (2019-2022) were analyzed to assess the prevalence, treatment, risk factors, and comorbidities of diabetes. Comparisons between young and older adults with diabetes were emphasized.

RESULTS

Among Korean adults aged ≥30 years, the prevalence of diabetes is 15.5% during 2021-2022. Of these, 74.7% were aware of their condition, 70.9% received antidiabetic treatment, and only 32.4% achieved glycosylated hemoglobin (HbA1c) <6.5%. Moreover, 15.9% met the integrated management targets, which included HbA1c <6.5%, blood pressure <140/85 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL. In young adults aged 19 to 39 years, the prevalence of diabetes was 2.2%. Among them, 43.3% were aware of their condition, 34.6% received treatment, and 29.6% achieved HbA1c <6.5%. Obesity affected 87.1%, and 26.9% had both hypertension and hypercholesterolemia. Among adults aged ≥65 years, the prevalence of diabetes was 29.3%, with awareness, treatment, and control rates of 78.8%, 75.7%, and 31.2%, respectively. Integrated management targets (HbA1c <7.5%, hypertension, and lipids) were achieved by 40.1%.

CONCLUSION

Diabetes mellitus remains highly prevalent among Korean adults, with significant gaps in integrated glycemic, blood pressure, and lipid control. Older adults with diabetes show higher awareness and treatment rates but limited integrated management outcomes. Young adults with diabetes bear a significant burden of obesity and comorbidities, alongside low awareness and treatment rates. Therefore, early intervention programs, education, and strategies tailored to younger populations are urgently required.

Investigation of foot care knowledge and behaviour of older people with type 2 diabetes in Beijing community and analysis of influencing factors

Good foot care knowledge and behaviour are very important to prevent the occurrence of diabetic foot, but there are few reports on the foot care knowledge and behaviour of older people with diabetes in the community. The purpose of this study was to understand the foot care knowledge and behaviour of older people with type 2 diabetes in Beijing community, and analyse its influencing factors, so as to provide reference for further intervention. We investigated 254 older people with type 2 diabetes in Xinjiekou community, Beijing, including their general information, chronic complications, foot care knowledge and behaviour. The results showed that the average scores of foot care knowledge and behaviour were 73.38 ± 12.25 and 49.70 ± 8.70, respectively. Multiple stepwise regression analysis showed that the factors affecting the total score of foot nursing knowledge of older people with diabetes in community were gender, duration of diabetes and whether they had received foot nursing education (p < 0.05). The factors influencing the total score of foot nursing behaviour were gender, duration of disease, whether they had received foot nursing education and peripheral vascular disease (p < 0.05). In conclusion, the knowledge of foot care of older people with diabetes in community is in the middle level, and the foot care behaviour is not optimistic. Community healthcare workers can improve patients' knowledge of foot care and improve their compliance with foot care behaviour through foot care health education. At the same time, we should pay more attention to men, those with a shorter duration of diabetes and diabetic patients with peripheral vascular disease to reduce the occurrence of diabetic foot.

A correlation study between blood glucose fluctuation and chronic pain in the older people with type 2 diabetes mellitus

OBJECTIVES

To investigate the correlation between blood glucose fluctuation parameters and other clinical data with chronic pain in older patients ( ≧ 60 years) with type 2 diabetes mellitus (T2DM), as well as evaluating the predictive value of risk of these parameters for chronic pain.

METHODS

Clinical data were collected from 60 older patients with T2DM undergoing chronic pain who were hospitalized in the Department of Geriatric Endocrinology at the First Affiliated Hospital of Anhui Medical University. Pain scores using the numeric rating scale (NRS) were administered to all study participants by a dedicated person. Based on their pain scores, patients were categorized into two groups: mild pain group (NRS ≤ 5, n = 28) and severe pain group (NRS > 5, n = 32). Blood glucose levels were continuously monitored using the Continuous Glucose Monitoring System (CGMS). Spearman correlation analysis was performed to investigate the correlation between pain scores and blood glucose fluctuation parameters, as well as other clinical data of concern. Comparing general clinical information and relevant data recorded by CGMS between the two groups. Binary logistic regression was used to identify factors influencing the severity of chronic pain in old patients with T2DM combined with chronic pain. Additionally, the predictive value of Mean Amplitude of Glycemic Excursions (MAGE), Coefficient of Variation (CV), and Time in Range (TIR) for chronic pain severity was assessed using Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Spearman correlation analysis revealed positive correlations between pain scores and the following variables: gender, age, duration of diabetes, duration of pain, MAGE, CV, mean blood glucose (MBG), standard deviation (SD), Mean of Daily Differences (MODD), and the highest glucose level. Conversely, pain scores were negatively correlated with red blood cell (RBC) count, hemoglobin (Hb), estimated glomerular filtration rate (eGFR). There were statistically significant differences in gender, age, disease duration, pain duration, Hb, eGFR, MAGE, CV, TIR, MBG, SD, MODD, and highest blood glucose values between the two groups. The gender, age, duration of diabetes, duration of pain, Hb, eGFR, MAGE, TIR, CV, MBG, SD, and MODD were identified as the risk factors for the severity of chronic pain in older T2DM patients by using binary logistic regression analysis. ROC curve analysis showed that the area under the curve for MAGE was 0.741 (sensitivity: 53.1%, specificity: 89.3%), for CV it was 0.668 (sensitivity: 40.6%, specificity: 89.3%), and for TIR it was 0.763 (sensitivity: 67.9%, specificity: 84%).

CONCLUSION

The chronic pain is strongly correlated with blood glucose fluctuation parameters in older patients with T2DM. This work shows that those indicators of blood glucose fluctuations can be used for predicting chronic pain level in older T2DM patients, providing a potential methodology for rapid evaluation of chronic pain.

CLINICAL TRIAL NUMBER

ChiCTR1800019107.

Individualized treatment of diabetes mellitus in older adults

The population of older adults with diabetes mellitus is growing but heterogeneous. Because geriatric syndromes, comorbidity or multimorbidity, the complexity of glucose dynamics, and socioeconomic conditions are associated with the risk of severe hypoglycemia and mortality, these factors should be considered in individualized diabetes treatment. Because cognitive impairment and frailty have similar etiologies and risk factors, a common strategy can be implemented to address them through optimal glycemic control, management of vascular risk factors, diet, exercise, social participation, and support. To prevent frailty or sarcopenia, optimal energy intake, adequate protein and vitamin intake, and resistance or multi-component exercise are recommended. For hypoglycemic drug therapy, it is important to reduce hypoglycemia, to use sodium glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, taking into account the benefits for cardiovascular disease and the risk of adverse effects, and to simplify treatment to address poor adherence. Glycemic control goals for older adults with diabetes should be set according to three categories, based on cognitive function and activities of daily living, using the Dementia Assessment Sheet for Community-based Integrated Care System 8-items. This categorization can be used to determine treatment strategies for diabetes when combined with the Comprehensive Geriatric Assessment (CGA). Based on the CGA, frailty prevention, treatment simplification, and social participation or services should be implemented for patients in Category II and above. Measures against hypoglycemia and for the prevention of cardiovascular disease and chronic kidney disease should also be promoted. Treatment based on categorization and CGA by multidisciplinary professionals would be an individualized treatment for older adults with diabetes. Geriatr Gerontol Int 2024; 24: 1257-1268.

Diabetes in residential aged care: Pharmacological management and concordance with clinical guidelines

OBJECTIVE

Existing studies have highlighted suboptimal diabetes management in residential aged care facilities (RACFs). However, understanding of diabetes management in Australian metropolitan RACFs has been limited. This retrospective cohort study aimed to explore the pharmacological management of diabetes in 25 RACFs in Sydney Australia and assess concordance with clinical practice guidelines (CPGs).

METHODS

Data from 231 permanent RACF residents aged ≥65 years and over with type 2 diabetes mellitus over the period from 1 July 2016 to 31 December 2019 were used. Concordance was measured by assessing the medications and medical history data for each individual resident for concordance with evidence-based CPGs. Multivariable logistic regression was used to estimate the effect of resident characteristics on concordance with CPGs.

RESULTS

Of the 231 residents with diabetes, 87 (38%) were not taking any antidiabetic medication. Pharmacological management inconsistent with CPG recommendations was observed for 73 (32%) residents, with the most common reason for non-concordance being the use of medications with significant adverse effects in older adults (47, 2%). Residents with hypertension or other heart diseases in addition to their diabetes had greater odds of their diabetes management being non-concordant with CPGs (OR = 2.84 95% CI = 1.54, 5.3 and OR = 2.64, 95% CI = 1.07, 6.41, respectively).

CONCLUSIONS

Pharmacological diabetes management in metropolitan Australian RACFs is suboptimal, with a high prevalence of inconsistency with CPGs (32%) observed. Additionally, having hypertension or heart diseases significantly increased the possibility of non-concordance among diabetic RACF residents. Further investigation into the underlying relationships with comorbidities is required to develop better strategies.

The effectiveness and safety of linagliptin within elderly type 2 diabetes mellitus: a meta-analysis and systematic review

INTRODUCTION

Linagliptin is a convenient and effective drug approved for glycemic management in type 2 diabetes mellitus (T2DM). However, the effectiveness and safety evidence of linagliptin remains unclear with the increasing prevalence of T2DM in elderly patients. The aim of this study was to evaluate the effectiveness and safety of linagliptin within T2DM cases who aged ≥60 years.

EVIDENCE ACQUISITION

The researchers pooled 4903 cases aged ≥60 years with T2DM from 5 published randomized clinical trials obtained from multiple databases. The safety was evaluated by the incidence and severity of adverse events which mainly focused on hypoglycemia. The major effectiveness end point was the change of glycated hemoglobin (HbA1c). Then the researchers made the qualitative and quantitative assessments of the investigation.

EVIDENCE SYNTHESIS

The level of HbA1c and fasting plasma glucose was significantly reduced by linagliptin (WMD=-0.63%, 95% CI: -0.81, -0.44; P<0.00001; Z=6.70) and (WMD=-15.58 mg/dL, 95% CI: -22.34, -8.82; P<0.00001; Z=4.52) relative to that in the placebo cohort. The incidences of overall (OR=1.01, 95% CI: 0.82, 1.25; P=0.91) and severe negative events (OR=0.88, 95% CI: 0.61, 1.25; P=0.46) were not significant increased in linagliptin cohorts compared to the placebo cohorts. There is insignificant difference in hypoglycemia between linagliptin and placebo cohorts for the 24 weeks' study (OR=1.12, 95% CI: 0.85, 1.48; P=0.41). Severe hypoglycemia had slightly descended incidence, whereas insignificant difference was shown in the linagliptin cohorts in contrast to placebo cohorts (OR=0.95, 95% CI: 0.68, 1.32, P=0.76).

CONCLUSIONS

Linagliptin is an effective drug with excellent safety for elderly T2DM.

Risk of Infection in Older Adults With Type 2 Diabetes With Relaxed Glycemic Control

OBJECTIVE

To compare the risk of hospitalization for infection among patients who achieve intensive versus relaxed glycemic control.

RESEARCH DESIGN AND METHODS

This retrospective cohort study included adults age ≥65 years with type 2 diabetes from an integrated health care delivery system. Negative binomial models were used to estimate incidence rates and relative risk (RR) of hospitalization for infections (respiratory; genitourinary; skin, soft tissue, and bone; and sepsis), comparing two levels of relaxed (hemoglobin A1c [HbA1c] 7% to <8% and 8% to <9%) with intensive (HbA1c 6% to <7%) glycemic control from 1 January 2019 to 1 March 2020.

RESULTS

Among 103,242 older patients (48.5% with HbA1c 6% to <7%, 35.3% with HbA1c 7% to <8%, and 16.1% with HbA1c 8% to <9%), the rate of hospitalization for infections was 51.3 per 1,000 person-years. Compared with HbA1c 6% to <7%, unadjusted risk of hospitalization for infections was significantly elevated among patients with HbA1c 8% to <9% (RR 1.25; 95% CI 1.13, 1.39) but not among patients with HbA1c 7% to <8% (RR 0.99; 95% CI 0.91, 1.08), and the difference became nonsignificant after adjustment. Across categories of infections, the adjusted RR of hospitalization was significantly higher among patients with HbA1c 8% to <9% only for skin, soft tissue, and bone infection (RR 1.33; 95% CI 1.05, 1.69).

CONCLUSIONS

Older patients with type 2 diabetes who achieve relaxed glycemic control levels endorsed by clinical guidelines are not at significantly increased risk of hospitalization for most infections, but HbA1c 8% to <9% is associated with an increased risk of hospitalization for skin, soft tissue, and bone infections.

Association of diabetes risk with changes in memory, working memory, and processing speed among older adults

Background

This study investigated the risk of diabetes by examining changes in memory, working memory, and processing speed among older adults to provide evidence on how each cognitive domain is associated with the risk of diabetes in older adults.

Methods

This study used Health and Retirement Study data and tracked the respondents from 2012 to 2020 (n = 5,748). The Telephone Interview for Cognitive Status-27 includes three cognitive tests (recall, seven subtraction, and counting backward tests) to assess each cognitive domain. A Cox proportional hazard regression was used to calculate the changes in the odds ratio (OR) of diabetes by increasing each cognitive function and the parameter in covariates.

Results

We found that the OR of diabetes decreased with increasing universal cognitive function, increasing memory, working memory, and processing speed, and that age increased the OR in all analysis models.

Conclusion

The findings of this study contribute to filling gaps in the literature by exploring: (a) the association between each cognitive function and the decline in diabetes risk and (b) the varying patterns of change in diabetes risk with increasing cognitive function.

Systematic review of guideline recommendations for older and frail adults with type 2 diabetes mellitus

BACKGROUND

The application of clinical practice guidelines (CPGs) across the spectrum of individuals living with diabetes can be challenging, particularly in older adults, where factors such as frailty and multimorbidity exacerbate the complexity of management.

OBJECTIVE

This systematic review aimed to explore the guidance provided within diabetes CPGs for management of individuals who are older and/or frail, including recommendations for haemoglobin A1C (HbA1c) target and pharmacotherapeutic management.

METHODS

A systematic search was completed in Medline and Embase to identify national or international type 2 diabetes CPGs published in the last 10 years. Data extracted included recommendations for HbA1c targets and pharmacotherapy in older and frail adults, frailty screening and deprescribing. Quality of included CPGs was appraised with the AGREE II tool.

RESULTS

Twenty-three CPGs were included, within which older adults and frailty were discussed in 21 and 14 CPGs, respectively. Specific HbA1c targets for older and/or frail adults were provided by 15 CPGs, the majority of which suggested a strict target (<7.0%-7.5%) in healthier older adults and a more relaxed target (<8.0%-8.5%) in those who are frail or medically complex. Ten CPGs provided recommendations for insulin therapy and 16 provided recommendations for non-insulin antihyperglycaemic agents that were specific to older and/or frail populations, which primarily focused on minimising risk of hypoglycaemia.

CONCLUSION

Most diabetes CPGs recommend strict HbA1c targets in healthier older adults, with more relaxed targets in those living with frailty or medical complexity. However, significant variability exists in pharmacotherapy recommendations and there were proportionately less recommendations for individuals who are frail.

High prevalence of comorbidities in older adult patients with type 2 diabetes: a cross-sectional survey

BACKGROUND

Diabetes is a global health problem, and its incidence and complications increase with the duration of the disease and over time. This increase in complications in older patients can lead to disability and a lower quality of life. This study aimed to investigate the rate of diabetes control and complications in older adults.

METHOD

This was a cross-section of an ongoing cohort of patients with type 2 diabetes mellitus (T2DM) aged 65 years and older. The clinical and laboratory characteristics of older adult patients with T2DM in good and intermediate health conditions were collected between 2010 and 2022.

RESULTS

A total of 2,770 older adult patients with T2DM were enrolled, including 1,530(55.3%) female and 1,240 (44.7%) male participants. Metabolic syndrome, hypertension, and coronary artery disease were the most common comorbidities, affecting 1,889 (71.4%), 1,495 (54.4%), and 786 (29.2%) patients, respectively. Albuminuria was present in 626 (22.6%) patients, while retinopathy was detected in 408 (14.7%) patients, including 6% with proliferative retinopathy. Most patients were treated with oral antidiabetic agents (88.9%), with metformin being the most prescribed medication (85.6%). Statins were prescribed to 71.8% of the patients. The most prescribed antihypertensive medications were angiotensin receptor blockers and angiotensin-converting enzyme inhibitors, prescribed to 54% and 15% of patients, respectively. The hemoglobin A1c (HbA1c) goal (HbA1c < 7.5%) was achieved in 1,350 (56.4%) patients, and the low-density lipoprotein cholesterol (LDL-C) goal (LDL < 100) was achieved in 1,165 (45.6%) patients. Blood pressure control (BP < 140/90) was achieved in 1,755 (65.4%) patients. All three goals were achieved in 278 (10.3%) patients. There were no significant differences in clinical laboratory results and the patients' characteristics based on gender.

CONCLUSION

The rate of progression of complications in older adult patients is higher than the effectiveness of the treatment, indicating the need for increased social support for this age group.

Prevalence of tight glycemic control based on frailty status and associated factors in community-dwelling older adults

BACKGROUND

Tight control of type 2 diabetes (T2DM) in frail older adults has shown to be associated with adverse outcomes. The objective of this study is to determine the prevalence of tight glycemic control based on underlying frailty status and its association with functional and cognitive measures in community-dwelling older adults.

METHODOLOGY

Ancillary study of the Singapore Population Health Studies on older adults aged ≥65 years with T2DM. Tight glycemic control cut-offs were based on the 2019 Endocrine Society guideline using HbA1c target range based on a patient's overall health status measured by the FRAIL scale. Data on basic demographics, frailty, cognitive, and functional statuses were collected. Multivariable regression was used to assess potential factors associated with tight glycemic control.

RESULTS

Of 172 community-dwelling older adults with diabetes mellitus and HbA1c done, frail (65%) and pre-frail (64.4%) participants were more likely to have tight glycemic control than robust participants (31.6%, P < 0.001). In multi-variate analysis, frailty (OR 6.43, 95% CI 1.08-38.1, P = 0.041), better cognition (OR 1.15, 95% CI 1.02-1.32, P = 0.028), and multi-morbidity (OR 7.36, 95% CI 1.07-50.4, P = 0.042) were found to be significantly associated with increased odds of tight glycemic control.

CONCLUSION

Tight glycemic control was highly prevalent in frail and pre-frail older adults, especially in those with multi-morbidity and better cognition. Future prospective longitudinal studies are required to evaluate effectiveness of frailty screening in making treatment decisions and long-term outcomes. Key messages What is already known on this topic:  There is growing recognition that glycemic targets should be adjusted based on health or frailty status. However, there is no consensus on how health status or frailty should be defined when determining glycemic control targets. What this study adds:  Our study found that tight glycemic control was highly prevalent in frail and pre-frail older adults. Our findings highlight the importance of assessing for tight glycemic control based on frailty status and further work is needed to aid implementation of screening and intervention policies to avoid the attendant harms of tight glycemic control.

Management of older adults with diabetes mellitus: Perspective from geriatric medicine

Advances in diabetes medication and population aging are lengthening the lifespans of people with diabetes mellitus (DM). Older patients with diabetes mellitus often have multimorbidity and tend to have polypharmacy. In addition, diabetes mellitus is associated with frailty, functional decline, cognitive impairment, and geriatric syndrome. Although the numbers of patients with frailty, dementia, disability, and/or multimorbidity are increasing worldwide, the accumulated evidence on the safe and effective treatment of these populations remains insufficient. Older patients, especially those older than 75 years old, are often underrepresented in randomized controlled trials of various treatment effects, resulting in limited clinical evidence for this population. Therefore, a deeper understanding of the characteristics of older patients is essential to tailor management strategies to their needs. The clinical guidelines of several academic societies have begun to recognize the importance of relaxing glycemic control targets to prevent severe hypoglycemia and to maintain quality of life. However, glycemic control levels are thus far based on expert consensus rather than on robust clinical evidence. There is an urgent need for the personalized management of older adults with diabetes mellitus that considers their multimorbidity and function and strives to maintain a high quality of life through safe and effective medical treatment. Older adults with diabetes mellitus accompanied by frailty, functional decline, cognitive impairment, and multimorbidity require special management considerations and liaison with both carers and social resources.

National burden and risk factors of diabetes mellitus in China from 1990 to 2021: Results from the Global Burden of Disease study 2021

BACKGROUND

In recent years, the prevalence and mortality rates of diabetes have been rising continuously, posing a significant threat to public health and placing a heavy burden on the population. This study was conducted to describe and analyze the burden of diabetes in China from 1990 to 2021 and its attributable risk factors.

METHODS

Utilizing data from the Global Burden of Disease Study 2021, we analyzed the incidence, prevalence, and disability-adjusted life years (DALYs) of type 1 diabetes (T1DM) and type 2 diabetes (T2DM) in China from 1990 to 2021. We extracted sex- and age-specific data on diabetes, focusing on DALYs, years lived with disability, and years of life lost. Bayesian meta-regression and spatiotemporal Gaussian process regression were used to estimate disease parameters. Age-standardized rates (ASRs) and estimated annual percentage changes (EAPC) were calculated using direct standardization and log-linear regression. The population-attributable fractions were also determined for each risk factor.

RESULTS

In 2021, the absolute number of incident diabetes mellitus (DM) cases was estimated at 4003543.82, including 32 000 T1DM and 3971486.24 T2DM cases. The ASRs were 244.57 for DM, 2.67 for T1DM, and 241.9 for T2DM (per 100 000 population). The absolute number of prevalent DM cases was 117288553.93, including 1442775.09 T1DM and 115845778.84 T2DM cases. The ASRs were 6142.29 for DM, 86.78 for T1DM, and 6055.51 for T2DM (per 100 000 population). In 2021, there were 178475.73 deaths caused by DM, with an ASR of mortality of 8.98 per 100 000 population. The DALYs due to DM in 2021 were 11713613.86, with an ASR of 585.43 per 100 000 population and an EAPC of 0.57. This increase can be attributed to several factors, including high body mass index, air pollution, and dietary habits.

CONCLUSIONS

The burden of diabetes is considerable, with high prevalence and incidence rates, highlighting the urgent need for public health interventions. Addressing factors like high fasting plasma glucose, body mass index, air pollution, and dietary risks through effective interventions is critical.

Ageing well with diabetes: the role of technology

Over the past two decades there has been a substantial rise in the adoption of diabetes therapeutic technology among children, adolescents and younger adults with type 1 diabetes, and its use is now also advocated for older individuals. Older people with diabetes are more prone to experience hypoglycaemia because of numerous predisposing factors and are at higher risk of hypoglycaemic events requiring third-party assistance as well as other adverse sequelae. Hypoglycaemia may also have long-term consequences, including cognitive impairment, frailty and disability. Diabetes in older people is often characterised by marked glucose variability related to age-associated changes such as variable appetite and levels of physical activity, comorbidities and polypharmacotherapy. Preventing hypoglycaemia and mitigating glucose excursions may have considerable positive impacts on physical and cognitive function and general well-being and may even prevent or improve frailty. Technology for older people includes continuous glucose monitoring systems, insulin pumps, automated insulin delivery systems and smart insulin pens. Clinical trials and real-world studies have shown that older people with diabetes benefit from technology in terms of glucose management, reductions in hypoglycaemic events, emergency department attendance and hospital admissions, and improvement in quality of life. However, ageing may bring physical impairments and other challenges that hinder the use of technology. Healthcare professionals should identify older adults with diabetes who may benefit from therapeutic technology and then adopt an individualised approach to education and follow-up for individuals and their caregivers. Future research should explore the impact of diabetes technology on outcomes relevant to older people with diabetes.

The influence of insulin on diabetic retinopathy and retinal vessel parameters in diabetes

AIM

To investigate the associations between insulin use and diabetic retinopathy (DR), and retinal vascular parameters in type 2 diabetes (T2DM).

METHODS

A total of 6,374 T2DM patients, consisting of 2,231 patients receiving insulin alone and 4143 patients without any hypoglycemic medication, were included in cross-sectional analyses. Among those without DR at baseline, 791 patients were followed for three years in longitudinal analyses. Fundus photography was taken to diagnose DR and calculate central retinal arteriolar equivalent (CRAE), central retinal venular equivalent (CRVE), arteriolar-to-venular ratio (AVR), and vascular tortuosity. Inverse probability treatment-weighted analyses were performed.

RESULTS

After adjusting for gender, age, body mass index, blood pressure, blood glucose, T2DM duration, smoking, and alcohol use, insulin users showed a higher risk of DR (odds ratio (OR) = 2.27, 95% confidence interval (95%CI) = 2.08-2.48, P < 0.001), larger CRVE (β = 3.92, 95%CI = 2.46-5.37, P < 0.001), smaller AVR (β=-0.0083, 95%CI=-0.0121- -0.0046, P < 0.001), and larger vascular curvature (β = 0.19, 95%CI = 0.05-0.33, P = 0.008). After 3 years, insulin users had a higher risk of developing DR (OR = 1.94; 95% CI = 1.37-2.73, P = 0.002), and greater change in CRVE (β = 3.92, 95%CI = 0.96-6.88, P = 0.009).

CONCLUSIONS

The impact of insulin on the retinal microvasculature provides support for linking insulin to the increased risk of DR, as well as cardiovascular events in T2DM.

SGLT2 inhibitors for the treatment of diabetes: a patent review (2019-23)

INTRODUCTION

The sodium-glucose co-transporter 2 (SGLT2) inhibitors are FDA-approved class of drugs for diabetes management. They improve glycemic control by inducing glucosuria. Notwithstanding with potent anti-hyperglycemic activity, SGLT2 inhibitors are emerging as drugs with multifaceted therapeutic potential, evidenced for cardioprotective, renoprotective, antihypertensive, and neuroprotective activities. Continuous attempts are being accomplished through structural modification, development of new formulation, or combination with other drugs, to enhance the bioactivity spectrum of SGLT2 inhibitors for better management of diabetes and related complications.

AREAS COVERED

This review comprises a summary of patent applications, acquired using the Espacenet Patent Search database, concerning SGLT2 inhibitors from 2019 to 2023, with focus on improving therapeutic potentials in management of diabetes and metabolic complications.

EXPERT OPINION

SGLT2 inhibitors have provided an exciting treatment option for diabetes. Originally developed as anti-hyperglycemic agents, SGLT2 inhibitors exert pleiotropic metabolic responses and have emerged as promising antidiabetic agents with cardio-protective and reno-protective activities. Given their distinct therapeutic profile, SGLT2 inhibitors have revolutionized the management of diabetes and associated complications. Emerging evidences on their therapeutic potential against cancer, male reproductive dysfunctions, and neurodegenerative diseases indicate that further research in this field may unfold novel prospective on their plausible use in the management of other chronic conditions.

Nutritional Status, Dietary Intake, and Nutrition-Related Interventions Among Older Adults With Type 1 Diabetes: A Systematic Review and Call for More Evidence Toward Clinical Guidelines

There is an emerging population of older adults (≥65 years) living with type 1 diabetes. Optimizing health through nutrition during this life stage is challenged by multiple and ongoing changes in diabetes management, comorbidities, and lifestyle factors. There is a need to understand nutritional status, dietary intake, and nutrition-related interventions that may maximize well-being throughout the life span in type 1 diabetes, in addition to nutrition recommendations from clinical guidelines and consensus reports. Three reviewers used Cochrane guidelines to screen original research (January 1993-2023) and guidelines (2012-2023) in two databases (MEDLINE and CENTRAL) to characterize nutrition evidence in this population. We found limited original research explicitly focused on nutrition and diet in adults ≥65 years of age with type 1 diabetes (six experimental studies, five observational studies) and meta-analyses/reviews (one scoping review), since in the majority of analyses individuals ≥65 years of age were combined with those age ≥18 years, with diverse diabetes durations, and also individuals with type 1 and type 2 diabetes were combined. Further, existing clinical guidelines (n = 10) lacked specificity and evidence to guide clinical practice and self-management behaviors in this population. From a scientific perspective, little is known about nutrition and diet among older adults with type 1 diabetes, including baseline nutrition status, dietary intake and eating behaviors, and the impact of nutrition interventions on key clinical and patient-oriented outcomes. This likely reflects the population's recent emergence and unique considerations. Addressing these gaps is foundational to developing evidence-based nutrition practices and guidelines for older adults living with type 1 diabetes.

Lifestyle Changes in Aging and their Potential Impact on POAG

Primary open angle glaucoma is a primary mitochondrial disease with oxidative stress triggering neuroinflammation, eventually resulting in neurodegeneration. This affects many other areas of the brain in addition to the visual system. Aging also leads to inflammaging - a low-grade chronic inflammatory reaction in mitochondrial dysfunction, so these inflammatory processes overlap in the aging process and intensify pathophysiological processes associated with glaucoma. Actively counteracting these inflammatory events involves optimising treatment for any manifest systemic diseases while maintaining chronobiology and improving the microbiome. Physical and mental activity also provides support. This requires a holistic approach towards optimising neurodegeneration treatment in primary open angle glaucoma in addition to reducing intraocular pressure according personalised patient targets.

Should dietary restrictions be imposed on Alzheimer's Disease patients affected by type 2 diabetes?

INTRODUCTION

Antidiabetic drugs, reduction of carbohydrates intake, maintaining normal weight and physical activity are the cornerstone of diabetes 2 treatment.

METHODS

This opinion article is not intended to challenge hundreds of studies unequivocally demonstrating the benefits of a healthy lifestyle including appropriate diet in controlling the consequences of T2DM. The article questions whether the benefits of dietary restrictions for the management of T2D in older adults who are already demented, are worth the potential detrimental effects on quality of life for the patients and their caregivers, as well as the effects of dietary restrictions on frailty, sarcopenia.

DISCUSSION

However, the benefit of dietary restrictions including carbohydrates restrictions, might not manifest in elderly Alzheimer and vascular dementia patients with type 2 diabetes. On the contrary, such restrictions might hinder the patients' and caregiver's quality of life and encumber attempts to maintain normal weight in a population which tends to be underweight. Therefore, the benefit/risk ratio of dietary restriction should be weighed in this population on an individual basis.

Out of Sight, Out of Mind: A Call to Action for the Treatment of Hypoglycemia

Hypoglycemia will inevitably occur. Being prepared and implementing a treatment plan should help to restore euglycemia and resolve hypoglycemia symptoms. The plan comprises fast-acting carbohydrates and, importantly, ready-to-use glucagon for self-administration when carbohydrates are not working or for third-party administration when the affected person is unwilling or unable to swallow (e.g., unconscious or in a coma).

Medical database analysis of the association between kidney function and achievement of glycemic control in older Japanese adults with type 2 diabetes who started with oral antidiabetic drugs

AIMS/INTRODUCTION

Despite the emergence of new drugs with novel mechanisms of action, treatment options for older people and those with chronic kidney disease are still limited.

MATERIALS AND METHODS

Using a medical database compiled from Diagnostic Procedure Combination hospitals, we retrospectively analyzed treatment status, glycemic control and kidney function over 3 years after the first oral antidiabetic drugs in Japanese adults with type 2 diabetes who were aged ≥65 years.

RESULTS

Among 5,434 study participants, 3,246 (59.7%) were men, the median age was 72.0 years, the baseline median hemoglobin A1c was 7.1% and the baseline median estimated glomerular filtration rate was 66.6 mL/min/1.73 m2. Treatment was intensified in 40.0% of people during the 3-year observation period, and the median time to the first treatment intensification was 198 days. Insulin was the most commonly used agent for treatment intensification (36.9%, 802/2,175). Hemoglobin A1c of <7.0% was achieved in 3,571 (65.7%) at 360 ± 90 days. Multivariable logistic regression analysis found that baseline age, hemoglobin A1c and estimated glomerular filtration rate were negatively associated with achieving hemoglobin A1c of <7.0% at 360 ± 90 days.

CONCLUSIONS

In older Japanese adults with type 2 diabetes, those with a lower estimated glomerular filtration rate were more likely to achieve hemoglobin A1c of <7.0%. To safely manage blood glucose levels in older adults with chronic kidney disease, physicians should remain vigilant about the risk of iatrogenic hypoglycemia.

HbA1c variability associated with dementia risk in people with type 2 diabetes

INTRODUCTION

Although poor glycemic control is associated with dementia, it is unknown if variability in glycemic control, even in those with optimal glycosylated hemoglobin A1c (HbA1c) levels, increases dementia risk.

METHODS

Among 171,964 people with type 2 diabetes, we evaluated the hazard of dementia association with long-term HbA1c variability using five operationalizations, including standard deviation (SD), adjusting for demographics and comorbidities.

RESULTS

The mean baseline age was 61 years (48% women). Greater HbA1c SD was associated with greater dementia hazard (adjusted hazard ratio = 1.15 [95% confidence interval: 1.12, 1.17]). In stratified analyses, higher HbA1c SD quintiles were associated with greater dementia hazard among those with a mean HbA1c < 6% (P = 0.0004) or 6% to 8% (P < 0.0001) but not among those with mean HbA1c ≥ 8% (P = 0.42).

DISCUSSION

Greater HbA1c variability is associated with greater dementia risk, even among those with HbA1c concentrations at ideal clinical targets. These findings add to the importance and clinical impact of recommendations to minimize glycemic variability.

HIGHLIGHTS

We observed a cohort of 171,964 people with type 2 diabetes (mean age 61 years). This cohort was based in Northern California between 1996 and 2018. We examined the association between glycosylated hemoglobin A1c (HbA1c) variability and dementia risk. Greater HbA1c variability was associated with greater dementia hazard. This was most evident among those with normal-low mean HbA1c concentrations.

The Association Between Depressive Symptoms, Access to Diabetes Care, and Glycemic Control in Five Middle-Income Countries

OBJECTIVE

The relationship between depression, diabetes, and access to diabetes care is established in high-income countries (HICs) but not in middle-income countries (MICs), where contexts and health systems differ and may impact this relationship. In this study, we investigate access to diabetes care for individuals with and without depressive symptoms in MICs.

RESEARCH DESIGN AND METHODS

We analyzed pooled data from nationally representative household surveys across Brazil, Chile, China, Indonesia, and Mexico. Validated survey tools Center for Epidemiologic Studies Depression Scale Revised, Composite International Diagnostic Interview, Short Form, and Patient Health Questionnaire identified participants with depressive symptoms. Diabetes, defined per World Health Organization Package of Essential Noncommunicable Disease Interventions guidelines, included self-reported medication use and biochemical data. The primary focus was on tracking diabetes care progression through the stages of diagnosis, treatment, and glycemic control. Descriptive and multivariable logistic regression analyses, accounting for gender, age, education, and BMI, examined diabetes prevalence and care continuum progression.

RESULTS

The pooled sample included 18,301 individuals aged 50 years and above; 3,309 (18.1%) had diabetes, and 3,934 (21.5%) exhibited depressive symptoms. Diabetes prevalence was insignificantly higher among those with depressive symptoms (28.9%) compared with those without (23.8%, P = 0.071). Co-occurrence of diabetes and depression was associated with increased odds of diabetes detection (odds ratio [OR] 1.398, P < 0.001) and treatment (OR 1.344, P < 0.001), but not with higher odds of glycemic control (OR 0.913, P = 0.377).

CONCLUSIONS

In MICs, individuals aged 50 years and older with diabetes and depression showed heightened diabetes identification and treatment probabilities, unlike patterns seen in HICs. This underscores the unique interplay of these conditions in different income settings.

Design, Synthesis, and Biological Evaluation of 1,4-Dihydropyridine-Indole as a Potential Antidiabetic Agent via GLUT4 Translocation Stimulation

In the quest for the discovery of antidiabetic compounds, a series of 27 1,4-dihydropyridine-indole derivatives were synthesized using a diversity approach. These compounds were systematically evaluated for their antidiabetic activity, starting with an in vitro assessment for GLUT4 translocation stimulation in L6-GLUT4myc myotubes, followed by in vivo antihyperglycemic activity evaluation in a streptozotocin (STZ)-induced diabetic rat model. Among the synthesized compounds, 12, 14, 15, 16, 19, 27, and 35 demonstrated significant potential to stimulate GLUT4 translocation in skeletal muscle cells. Compound 19 exhibited the highest potency and was selected for in vivo evaluation. A notable reduction of 21.6% (p < 0.01) in blood glucose levels was observed after 5 h of treatment with compound 19 in STZ-induced diabetic rats. Furthermore, pharmacokinetic studies affirmed that compound 19 was favorable to oral exposure with suitable pharmacological parameters. Overall, compound 19 emerged as a promising lead compound for further structural modification and optimization.

Management of Type 2 Diabetes Mellitus: Synopsis of the Department of Veterans Affairs and Department of Defense Clinical Practice Guideline

The US Department of Veterans Affairs (VA) and the US Department of Defense (DoD) approved a joint clinical practice guideline for the management of type 2 diabetes. This was the product of a multidisciplinary guideline development committee composed of clinicians from both the VA and the DoD and was overseen by the VA/DoD Evidence Based Practice Work Group. The development process conformed to the standards for trustworthy guidelines as established by the National Academy of Medicine. The guideline development committee developed 12 key questions to guide an evidence synthesis. An independent third party identified relevant randomized controlled trials and systematic reviews that were published from January 2016 through April 2022. This evidence synthesis served as the basis for drafting recommendations. Twenty-six recommendations were generated and rated by the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system. Two algorithms were developed to guide clinical decision-making. This synopsis summarizes key aspects of the VA/DoD Clinical Practice Guideline for diabetes in 5 areas: prediabetes, screening for co-occurring conditions, diabetes self-management education and support, glycemic treatment goals, and pharmacotherapy. The guideline is designed to help clinicians and patients make informed treatment decisions to optimize health outcomes and quality of life and to align with patient-centered goals of care.

Receipt of Diabetes Specialty Care and Management Services by Older Adults With Diabetes in the U.S., 2015-2019: An Analysis of Medicare Fee-for-Service Claims

OBJECTIVE

We characterized the receipt of diabetes specialty care and management services among older adults with diabetes.

RESEARCH DESIGN AND METHODS

Using a 20% random sample of fee-for-service Medicare beneficiaries aged ≥65 years, we analyzed cohorts of type 1 diabetes (T1D) or type 2 diabetes (T2D) with history of severe hypoglycemia (HoH), and all other T2D annually from 2015 to 2019. Outcomes were receipt of office-based endocrinology care, diabetes education, outpatient diabetes health services, excluding those provided in primary care, and any of the aforementioned services.

RESULTS

In the T1D cohort, receipt of endocrinology care and any service increased from 25.9% and 29.2% in 2015 to 32.7% and 37.4% in 2019, respectively. In the T2D with HoH cohort, receipt of endocrinology care and any service was 13.9% and 16.4% in 2015, with minimal increases. Age, race/ethnicity, residential setting, and income were associated with receiving care.

CONCLUSIONS

These findings suggest that many older adults may not receive specialty diabetes care and underscore health disparities.

Holistic and Personalized Strategies for Managing in Elderly Type 2 Diabetes Patients

Due to increased life expectancy and lifestyle changes, the prevalence of diabetes among the elderly in Korea is continuously rising, as is the associated public health burden. Diabetes management in elderly patients is complicated by age-related physiological changes, sarcopenia characterized by loss of muscle mass and function, comorbidities, and varying levels of functional, cognitive, and mobility abilities that lead to frailty. Moreover, elderly patients with diabetes frequently face multiple chronic conditions that elevate their risk of cardiovascular diseases, cancer, and mortality; they are also prone to complications such as hyperglycemic hyperosmolar state, diabetic ketoacidosis, and severe hypoglycemia. This review examines the characteristics of and management approaches for diabetes in the elderly, and advocates for a comprehensive yet personalized strategy.

Willingness to take less medication for type 2 diabetes among older patients: The Diabetes & Aging Study

BACKGROUND

To examine the willingness of older patients to take less diabetes medication (de-intensify) and to identify characteristics associated with willingness to de-intensify treatment.

METHODS

Survey conducted in 2019 in an age-stratified, random sample of older (65-100 years) adults with diabetes on glucose-lowering medications in the Kaiser Permanente Northern California Diabetes Registry. We classified survey responses to the question: "I would be willing to take less medication for my diabetes" as willing, neutral, or unwilling to de-intensify. Willingness to de-intensify treatment was examined by several clinical characteristics, including American Diabetes Association (ADA) health status categories used for individualizing glycemic targets. Analyses were weighted to account for over-sampling of older individuals.

RESULTS

A total of 1337 older adults on glucose-lowering medication(s) were included (age 74.2 ± 6.0 years, 44% female, 54.4% non-Hispanic white). The proportions of participants willing, neutral, or unwilling to take less medication were 51.2%, 27.3%, and 21.5%, respectively. Proportions of willing to take less medication varied by age (65-74 years: 54.2% vs. 85+ years: 38.5%) and duration of diabetes (0-4 years: 61.0% vs. 15+ years: 44.2%), both p < 0.001. Patients on 1-2 medications were more willing to take less medication(s) compared with patients on 10+ medications (62.1% vs. 46.6%, p = 0.03). Similar proportions of willingness to take less medications were seen across ADA health status, and HbA1c. Willingness to take less medication(s) was similar across survey responses to questions about patient-clinician relationships.

CONCLUSIONS

Clinical guidelines suggest considering treatment de-intensification in older patients with longer duration of diabetes, yet patients with these characteristics are less likely to be willing to take less medication(s).

The optimal second-line therapy for older adults with type 2 diabetes mellitus: protocol for a systematic review and network meta-analysis using individual participant data (IPD)

BACKGROUND

Due to increasing life expectancy, almost half of people with type 2 diabetes are aged 65 years or over worldwide. When metformin alone does not control blood sugar, the choice of which second-line therapy to prescribe next is not clear from currently available evidence. The existence of frailty and comorbidities in older adults further increases the complexity of medical decision-making. As only a relatively small proportion of trials report results separately for older adults, the relative efficacy and safety of second-line therapies in older adults with type 2 diabetes mellitus are unknown and require further investigation. This individual participant data (IPD) network meta-analysis evaluates the relative efficacy and safety of second-line therapies on their own or in combination in older adults with type 2 diabetes mellitus.

METHODS

All relevant published and unpublished trials will be identified. Studies published prior to 2015 will be identified from two previous comprehensive aggregate data network meta-analyses. Searches will be conducted in CENTRAL, MEDLINE, and EMBASE from 1st January 2015 onwards, and in clinicaltrials.gov from inception. Randomised controlled trials with at least 100 estimated older adults (≥ 65 years) receiving at least 24 weeks of intervention that assess the effects of glucose-lowering drugs on mortality, glycemia, vascular and other comorbidities outcomes, and quality of life will be eligible. The screening and data extraction process will be conducted independently by two researchers. The quality of studies will be assessed using the Cochrane risk of bias tool 2. Anonymised IPD of all eligible trials will be requested via clinical trial portals or by contacting the principal investigators or sponsors. Received data will be reanalysed where necessary to standardise outcome metrics. Network meta-analyses will be performed to determine the relative effectiveness of therapies.

DISCUSSION

With the increasing number of older adults with type 2 diabetes worldwide, an IPD network meta-analysis using data from all eligible trials will provide new insights into the optimal choices of second-line antidiabetic drugs to improve patient management and reduce unnecessary adverse events and the subsequent risk of comorbidities in older adults.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021272686.

Global burden of type 1 diabetes in adults aged 65 years and older, 1990-2019: population based study

OBJECTIVES

To estimate the burden, trends, and inequalities of type 1 diabetes mellitus (T1DM) among older adults at global, regional, and national level from 1990 to 2019.

DESIGN

Population based study.

POPULATION

Adults aged ≥65 years from 21 regions and 204 countries and territories (Global Burden of Disease and Risk Factors Study 2019)from 1990 to 2019.

MAIN OUTCOME MEASURES

Primary outcomes were T1DM related age standardised prevalence, mortality, disability adjusted life years (DALYs), and average annual percentage change.

RESULTS

The global age standardised prevalence of T1DM among adults aged ≥65 years increased from 400 (95% uncertainty interval (UI) 332 to 476) per 100 000 population in 1990 to 514 (417 to 624) per 100 000 population in 2019, with an average annual trend of 0.86% (95% confidence interval (CI) 0.79% to 0.93%); while mortality decreased from 4.74 (95% UI 3.44 to 5.9) per 100 000 population to 3.54 (2.91 to 4.59) per 100 000 population, with an average annual trend of -1.00% (95% CI -1.09% to -0.91%), and age standardised DALYs decreased from 113 (95% UI 89 to 137) per 100 000 population to 103 (85 to 127) per 100 000 population, with an average annual trend of -0.33% (95% CI -0.41% to -0.25%). The most significant decrease in DALYs was observed among those aged <79 years: 65-69 (-0.44% per year (95% CI -0.53% to -0.34%)), 70-74 (-0.34% per year (-0.41% to -0.27%)), and 75-79 years (-0.42% per year (-0.58% to -0.26%)). Mortality fell 13 times faster in countries with a high sociodemographic index versus countries with a low-middle sociodemographic index (-2.17% per year (95% CI -2.31% to -2.02%) v -0.16% per year (-0.45% to 0.12%)). While the highest prevalence remained in high income North America, Australasia, and western Europe, the highest DALY rates were found in southern sub-Saharan Africa, Oceania, and the Caribbean. A high fasting plasma glucose level remained the highest risk factor for DALYs among older adults during 1990-2019.

CONCLUSIONS

The life expectancy of older people with T1DM has increased since the 1990s along with a considerable decrease in associated mortality and DALYs. T1DM related mortality and DALYs were lower in women aged ≥65 years, those living in regions with a high sociodemographic index, and those aged <79 years. Management of high fasting plasma glucose remains a major challenge for older people with T1DM, and targeted clinical guidelines are needed.

Use of systems thinking and adapted group model building methods to understand patterns of technology use among older adults with type 1 diabetes: a preliminary process evaluation

BACKGROUND

A growing number of older adults (ages 65+) live with Type 1 diabetes. Simultaneously, technologies such as continuous glucose monitoring (CGM) have become standard of care. There is thus a need to understand better the complex dynamics that promote use of CGM (and other care innovations) over time in this age group. Our aim was to adapt methods from systems thinking, specifically a participatory approach to system dynamics modeling called group model building (GMB), to model the complex experiences that may underlie different trajectories of CGM use among this population. Herein, we report on the feasibility, strengths, and limitations of this methodology.

METHODS

We conducted a series of GMB workshops and validation interviews to collect data in the form of questionnaires, diagrams, and recordings of group discussion. Data were integrated into a conceptual diagram of the "system" of factors associated with uptake and use of CGM over time. We evaluate the feasibility of each aspect of the study, including the teaching of systems thinking to older adult participants. We collected participant feedback on positive aspects of their experiences and areas for improvement.

RESULTS

We completed nine GMB workshops with older adults and their caregivers (N = 33). Each three-hour in-person workshop comprised: (1) questionnaires; (2) the GMB session, including both didactic components and structured activities; and (3) a brief focus group discussion. Within the GMB session, individual drawing activities proved to be the most challenging for participants, while group activities and discussion of relevant dynamics over time for illustrative (i.e., realistic but not real) patients yielded rich engagement and sufficient information for system diagramming. Study participants liked the opportunity to share experiences with peers, learning and enhancing their knowledge, peer support, age-specific discussions, the workshop pace and structure, and the systems thinking framework. Participants gave mixed feedback on the workshop duration.

CONCLUSIONS

The study demonstrates preliminary feasibility, acceptability, and the value of GMB for engaging older adults about key determinants of complex health behaviors over time. To our knowledge, few studies have extended participatory systems science methods to older adult stakeholders. Future studies may utilize this methodology to inform novel approaches for supporting health across the lifespan.

A nurse driven care management program to engage older diabetes patients in personalized goal setting and disease management

Background and Aims

Multiple diabetes care guidelines have called for the personalization of risk factor goals, medication management, and self-care plans among older patients. Study of the implementation of these recommendations is needed. This study aimed to test whether a patient survey embedded in the Electronic Healthcare Record (EHR), coupled with telephonic nurse care management, could engage patients in personalized goal setting and chronic disease management.

Methods

We conducted a single-center equal-randomization delayed comparator trial at the primary care clinics of the University of Chicago Medicine from 2018.6 to 2019.12. Patients over the age of 65 years with type 2 diabetes with an active patient portal account were recruited and randomized to receive an EHR embedded goal setting and preference survey immediately in the intervention arm or after 6 months in the delayed intervention control arm. In the intervention arm, nurses reviewed American Diabetes Association recommendations for A1C goals based on health status class, established personalized goals, and provided monthly telephonic care management phone calls for a maximum of 6 months. Our primary outcome was the documentation of a personalized A1C goal in the EHR.

Results

A total of 100 patients completed the trial (mean age, 72.51 [SD, 5.22] years; mean baseline A1C, 7.14% [SD, 1.06%]; 68% women). The majority were in the Healthy (59%) followed by Complex (30%) and Very Complex (11%) health status classes. Documentation of an A1C goal in the EHR increased from 42% to 90% (p < 0.001) at 6 months in the intervention group and from 54% to 56% in the control group. Across health status classes, patients set similar A1C goals.

Conclusions

Older patients can be engaged in personalized goal setting and disease management through an embedded EHR intervention. The clinical impact of the intervention may differ if deployed among older patients with more complex health needs and higher glucose levels.

Trial Registration

ClinicalTrials.gov Identifier: NCT03692208.

Chinese Guidelines for Medical Nutrition Therapy for Patients with Diabetes (2022 Edition)

Medical nutrition therapy (MNT) is the foundation of the comprehensive treatment of patients with diabetes. In 2010, the Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association developed the first Chinese guideline on MNT for patients with diabetes, and it was updated in 2015. Since then, new evidence has emerged in the field of MNT and metabolic therapy in patients with diabetes. The Nutrition and Metabolic Management Branch of the China International Exchange and Promotive Association for Medical and Health Care organized a team of experts from related institutions, including the Clinical Nutrition Branch of the Chinese Nutrition Society, Chinese Diabetes Society, Chinese Society for Parenteral and Enteral Nutri-tion, and Chinese Clinical Nutritionist Center of the Chinese Medical Doctor Association. Their task was to develop the Chinese Guidelines of Medical Nutrition Therapy in Diabetes (2022 Edition) in accordance with the requirements of the Guidelines for the Formulation/Revision of Clinical Guidelines in China (2022 Edition) by combining the questions raised and evidence gathered in clinical practices in China, to guide and standardize the clinical MNT.

Diabetes mellitus in older persons with neurocognitive disorder: overtreatment prevalence and associated structural brain MRI findings

BACKGROUND

Tight diabetes control is often applied in older persons with neurocognitive disorder resulting in increased hypoglycemic episodes but little is known about the pattern of brain injury in these overtreated patients. This study aims to: (a) quantify the prevalence of diabetes overtreatment in cognitively impaired older adults in a clinical population followed in an academic memory clinic (b) identify risk factors contributing to overtreatment; and (c) explore the association between diabetes overtreatment and specific brain region volume changes.

METHODS

Retrospective study of older patients with type 2 diabetes and cognitive impairment who were diagnosed in a memory clinic from 2013 to 2020. Patients were classified into vulnerable and dependent according to their health profile. Overtreatment was defined when glycated hemoglobin was under 7% for vulnerable and 7.6% for dependent patients. Characteristics associated to overtreatment were examined in multivariable analysis. Grey matter volume in defined brain regions was measured from MRI using voxel-based morphometry and compared in patients over- vs. adequately treated.

RESULTS

Among 161 patients included (median age 76.8 years, range 60.8-93.3 years, 32.9% women), 29.8% were considered as adequately treated, 54.0% as overtreated, and 16.2% as undertreated. In multivariable analyses, no association was observed between diabetes overtreatment and age or the severity of cognitive impairment. Among patients with neuroimaging data (N = 71), associations between overtreatment and grey matter loss were observed in several brain regions. Specifically, significant reductions in grey matter were found in the caudate (adj β coeff: -0.217, 95%CI: [-0.416 to -0.018], p = .033), the precentral gyri (adj βcoeff:-0.277, 95%CI: [-0.482 to -0.073], p = .009), the superior frontal gyri (adj βcoeff: -0.244, 95%CI: [-0.458 to -0.030], p = .026), the calcarine cortex (adj βcoeff:-0.193, 95%CI: [-0.386 to -0.001], p = .049), the superior occipital gyri (adj βcoeff: -0.291, 95%CI: [-0.521 to -0.061], p = .014) and the inferior occipital gyri (adj βcoeff: -0.236, 95%CI: [-0.456 to - 0.015], p = .036).

CONCLUSION

A significant proportion of older patients with diabetes and neurocognitive disorder were subjected to excessively intensive treatment. The association identified with volume loss in several specific brain regions highlights the need to further investigate the potential cerebral damages associated with overtreatment and related hypoglycemia in larger sample.

Continuous Glucose Monitoring-Guided Insulin Administration in Long-Term Care Facilities: A Randomized Clinical Trial

OBJECTIVES

To evaluate the efficacy of real-time continuous glucose monitoring (rt-CGM) in adjusting insulin therapy in long-term care facilities (LTCF).

DESIGN

Prospective randomized clinical trial.

SETTINGS AND PARTICIPANTS

Insulin-treated patients with type 2 diabetes (T2D) admitted to LTCF.

METHODS

Participants in the standard of care wore a blinded CGM with treatment adjusted based on point-of-care capillary glucose results before meals and bedtime (POC group). Participants in the intervention (CGM group) wore a Dexcom G6 CGM with treatment adjusted based on daily CGM profile. Treatment adjustment was performed by the LTCF medical team, with a duration of intervention up to 60 days. The primary endpoint was difference in time in range (TIR 70-180 mg/dL) between treatment groups.

RESULTS

Among 100 participants (age 74.73 ± 11 years, 80% admitted for subacute rehabilitation and 20% for nursing home care), there were no significant differences in baseline clinical characteristics between groups, and CGM data were compared for a median of 17 days. There were no differences in TIR (53.38% ± 30.16% vs 48.81% ± 28.03%, P = .40), mean daily mean CGM glucose (184.10 ± 43.4 mg/dL vs 190.0 ± 45.82 mg/dL, P = .71), or the percentage of time below range (TBR) <70 mg/dL (0.83% ± 2.59% vs 1.18% ± 3.54%, P = .51), or TBR <54 mg/dL (0.23% ± 0.85% vs 0.56% ± 2.24%, P = .88) between rt-CGM and POC groups.

CONCLUSIONS AND IMPLICATIONS

The use of rtCGM is safe and effective in guiding insulin therapy in patients with T2D in LTCF resulting in a similar improvement in glycemic control compared to POC-guided insulin adjustment.

A National Survey of Physicians' Views on the Importance and Implementation of Deintensifying Diabetes Medications

BACKGROUND

Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.

OBJECTIVE

To understand physicians' decision-making around deintensifying diabetes treatment.

DESIGN

National physician survey.

PARTICIPANTS

US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.

MAIN MEASURES

Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.

KEY RESULTS

There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).

CONCLUSIONS

While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.