Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study

Could poor glycaemic control be a predictor of walking speed decline in older adults? Evidence from the English Longitudinal Study of Ageing

AIM

Although diabetes is a risk factor for walking speed decline in older adults, it remains unclear how glycaemic control [assessed by glycated haemoglobin (HbA1c)] might affect the long-term trajectories of walking speed. We investigated whether the glycaemic control status accelerates the walking speed decline and whether this decline differs depending on previous mobility conditions.

MATERIALS AND METHODS

In total, 3202 individuals aged ≥60 years from the English Longitudinal Study of Ageing (ELSA) were classified at baseline and after 4 and 8 years of follow-up according to glycaemic control status as 'without diabetes' (no self-reported diabetes and HbA1c <6.5%), 'good glycaemic control' (self-reported diabetes and HbA1c ≥6.5% and <7.0%) and 'poor glycaemic control' (PGC) (self-reported diabetes and HbA1c ≥7.0%). The generalized linear mixed models verified the walking speed trajectories in m/s. A second analysis was performed, including only participants without slowness at baseline (>0.8 m/s).

RESULTS

Compared with the status 'without diabetes', the annual walking speed decline was -0.015 m/s for PGC and -0.011 m/s for good glycaemic control, totalling -0.160 and -0.130 m/s, respectively, over 8 years. Among those without slowness at baseline, only PGC had a significant walking speed decline, corresponding to -0.014 m/s per year and -0.222 m/s over 8 years.

CONCLUSIONS

Poor glycaemic control is a discriminator of walking speed decline in older adults, regardless of previous mobility conditions. It may serve as an early screening tool for those at risk of decreased functional performance later in life.

Digital gait measures, but not the 400-meter walk time, detect abnormal gait characteristics in people with Prediabetes

BACKGROUND AND AIM

Abnormal gait characteristics have been observed in people with diabetic neuropathy, but it is unclear if subtle changes in gait occur in prediabetic people with impaired fasting glucose (IFG). The aims of this study were: (1) to investigate if digital gait measures discriminate people with prediabetes from healthy control participants (HC) and (2) to investigate the relationship between gait measures and clinical scores (concurrent validity).

METHODS

108 people with prediabetes (71.20 ± 5.11 years) and 63 HC subjects (70.40 ± 6.25 years) wore 6 inertial sensors (Opals by APDM, Clario) while performing the 400-meter fast walk test. Fifty-five measures across 5 domains of gait (Lower Body, Upper Body, Turning, and Variability) were averaged. Analysis of Covariance was used to investigate the group differences, with body mass index as a covariate. Pearson's correlation coefficient assessed the association between the gait measures and the Short Physical Performance Battery (SPPB) score.

RESULTS

Nine gait measures were significantly different (p < 10-4) between IFG and HC groups. Step duration, cadence, and turn velocity were the most discriminative measures. In contrast, traditional stop-watch time was not significantly different between groups (p = 0.13), after controlling for BMI. Cadence (r = -0.37, p < 0.001), step duration (r = -0.39, p < 0.001), and turn velocity (r = 0.47, p < 0.001) showed a significant correlation with the SPPB score.

CONCLUSION

Body-worn inertial sensors detected gait impairments in people with prediabetes that related to clinical balance test performance, even when the traditional stop-watch time was not prolonged for the 400-meter walk test.

Comparing glycemic traits in defining diabetes among rural Chinese older adults

BACKGROUND

We sought to identify the optimal cut-off of glycated hemoglobin (HbA1c) for defining diabetes and to assess the agreements of fasting plasma glucose (FPG), fasting serum glucose (FSG), and HbA1c in defining diabetes among rural older adults in China.

METHODS

This population-based cross-sectional study included 3547 participants (age ≥61 years, 57.8% women) from the Multidomain Interventions to Delay Dementia and Disability in Rural China from 2018-2019; of these, 3122 had no previously diagnosed diabetes. We identified the optimal cut-off of HbA1c against FPG ≥7.0 mmol/L for defining diabetes by using receiver operating characteristic curve and Youden index. The agreements of FPG, FSG, and HbA1c in defining diabetes were assessed using kappa statistics.

RESULTS

Among participants without previously diagnosed diabetes (n = 3122), the optimal HbA1c cut-off for defining diabetes was 6.5% (48 mmol/mol), with the sensitivity of 88.9%, specificity of 93.7%, and Youden index of 0.825. The correlation coefficients were 0.845 between FPG and FSG, 0.574 between FPG and HbA1c, and 0.529 between FSG and HbA1c in the total sample (n = 3547). The kappa statistic for defining diabetes was 0.962 between FSG and FPG, and 0.812 between HbA1c and FPG.

CONCLUSIONS

The optimal cut-off of HbA1c for diagnosing diabetes against FPG >7.0 mmol/L is ≥6.5% in Chinese rural-dwelling older adults. The agreement in defining diabetes using FPG, FSG, and HbA1c is nearly perfect. These results have relevant implications for diabetes research and clinical practice among older adults in China.

CLINICAL TRIAL REGISTRATION

The protocol of MIND-China was registered in the Chinese Clinical Trial Registry (ChiCTR, www.chictr.org.cn; registration no.: ChiCTR1800017758).

Cognitive function and cardiorespiratory fitness affect gait speed in type-2 diabetic patients without neuropathy

AIM

To identify physical, cognitive, and metabolic factors affecting gait speed in patients with type-2 diabetes mellitus (T2DM) without neuropathy.

METHODS

This cross-sectional study enrolled 71 diabetic patients without neuropathy (mean age 55.87±7.74 years, 85.9% women). Neuropathy status was assessed with Douleur Neuropathique 4. We used a cut-off point for gait speed of 1 m/s to classify the participants into two groups: slow walkers (SW) and average and brisk walkers (ABW). The groups were compared in terms of age, sex, body mass index (BMI), hemoglobin A1c (HbA1c), fasting glucose, systolic blood pressure, maximal aerobic capacity (VO2 max), percentage of muscle mass, percentage of lower extremity muscle mass, Mini-Mental State Examination (MMSE) score, and years of education.

RESULTS

Compared with the ABW group, the SW group had significantly lower VO2 max (14.49±2.95 vs 16.25±2.94 mL/kg/min) and MMSE score (25.01±3.21 vs 27.35±1.97), fewer years of education, and these patients were more frequently women (P<0.05). In the multivariate regression models, the combination of VO2 max, sex, and MMSE score explained only 23.5% of gait speed (P<0.001). MMSE score and VO2max independently determined gait speed after adjustment for age, BMI, HbA1c, fasting glucose, systolic blood pressure, percent of muscle mass, percent of lower extremity muscle mass, and years of education.

CONCLUSION

In diabetic patients without neuropathy, physical impairment and disability could be prevented by an improvement in aerobic capacity and cognitive function.

Gait Characteristics and Cognitive Function in Middle-Aged Adults with and without Type 2 Diabetes Mellitus: Data from ENBIND

Type 2 Diabetes Mellitus (T2DM) in midlife is associated with a greater risk of dementia in later life. Both gait speed and spatiotemporal gait characteristics have been associated with later cognitive decline in community-dwelling older adults. Thus, the assessment of gait characteristics in uncomplicated midlife T2DM may be important in selecting-out those with T2DM at greatest risk of later cognitive decline. We assessed the relationship between Inertial Motion Unit (IMUs)-derived gait characteristics and cognitive function assessed via Montreal Cognitive Assessment (MoCA)/detailed neuropsychological assessment battery (CANTAB) in middle-aged adults with and without uncomplicated T2DM using both multivariate linear regression and a neural network approach. Gait was assessed under (i) normal walking, (ii) fast (maximal) walking and (iii) cognitive dual-task walking (reciting alternate letters of the alphabet) conditions. Overall, 138 individuals were recruited (n = 94 with T2DM; 53% female, 52.8 ± 8.3 years; n = 44 healthy controls, 43% female, 51.9 ± 8.1 years). Midlife T2DM was associated with significantly slower gait velocity on both slow and fast walks (both p < 0.01) in addition to a longer stride time and greater gait complexity during normal walk (both p < 0.05). Findings persisted following covariate adjustment. In analyzing cognitive performance, the strongest association was observed between gait velocity and global cognitive function (MoCA). Significant associations were also observed between immediate/delayed memory performance and gait velocity. Analysis using a neural network approach did not outperform multivariate linear regression in predicting cognitive function (MoCA) from gait velocity. Our study demonstrates the impact of uncomplicated T2DM on gait speed and gait characteristics in midlife, in addition to the striking relationship between gait characteristics and global cognitive function/memory performance in midlife. Further studies are needed to evaluate the longitudinal relationship between midlife gait characteristics and later cognitive decline, which may aid in selecting-out those with T2DM at greatest-risk for preventative interventions.

Inertial Sensor Algorithm to Estimate Walk Distance

The “total distance walked” obtained during a standardized walking test is an integral component of physical fitness and health status tracking in a range of consumer and clinical applications. Wearable inertial sensors offer the advantages of providing accurate, objective, and reliable measures of gait while streamlining walk test administration. The aim of this study was to develop an inertial sensor-based algorithm to estimate the total distance walked using older subjects with impaired fasting glucose (Study I), and to test the generalizability of the proposed algorithm in patients with Multiple Sclerosis (Study II). All subjects wore two inertial sensors (Opals by Clario-APDM Wearable Technologies) on their feet. The walking distance algorithm was developed based on 108 older adults in Study I performing a 400 m walk test along a 20 m straight walkway. The validity of the algorithm was tested using a 6-minute walk test (6MWT) in two sub-studies of Study II with different lengths of a walkway, 15 m (Study II-A, n = 24) and 20 m (Study II-B, n = 22), respectively. The start and turn around points were marked with lines on the floor while smaller horizontal lines placed every 1 m served to calculate the manual distance walked (ground truth). The proposed algorithm calculates the forward distance traveled during each step as the change in the horizontal position from each foot-flat period to the subsequent foot-flat period. The total distance walked is then computed as the sum of walk distances for each stride, including turns. The proposed algorithm achieved an average absolute error rate of 1.92% with respect to a fixed 400 m distance for Study I. The same algorithm achieved an absolute error rate of 4.17% and 3.21% with respect to an averaged manual distance for 6MWT in Study II-A and Study II-B, respectively. These results demonstrate the potential of an inertial sensor-based algorithm to estimate a total distance walked with good accuracy with respect to the manual, clinical standard. Further work is needed to test the generalizability of the proposed algorithm with different administrators and populations, as well as larger diverse cohorts.

Frailty in Pancreas Transplantation

There are a variety of definitions and criteria used in clinical practice to define frailty. In the absence of a gold-standard definition, frailty has been operationally defined as meeting 3 out of 5 phenotypic criteria indicating compromised function: low grip strength, low energy, slowed walking speed, low physical activity, and unintentional weight loss. Frailty is a common problem in solid organ transplant candidates who are in the process of being listed for a transplant, as well as after transplantation. Patients with diabetes or chronic kidney disease (CKD) are known to be at increased risk of being frail. As pancreas transplantation is exclusively performed among patients with diabetes and the majority of them also have CKD, pancreas transplant candidates and recipients are at high risk of being frail. Sarcopenia, fatigue, low walking speed, low physical activity, and unintentional weight loss, which are some of the phenotypes of frailty, are very prevalent in this population. In various solid organs, frail patients are less likely to be listed or transplanted and have high waitlist mortality. Even after a transplant, they have increased risk of prolonged hospitalization, readmission, and delayed graft function. Given the negative impact of frailty on solid organ transplants, we believe that frailty would have a similar or even worse impact on pancreas transplantation. Due to the paucity of data specifically among pancreas transplant recipients, here we include frailty data from patients with CKD, diabetes, and various solid organ transplant recipients.

Longitudinal Associations Between Gait, Falls, and Disability in Community-Dwelling Older Adults With Type II Diabetes Mellitus: Findings From The Irish Longitudinal Study on Ageing (TILDA)

BACKGROUND

Diabetes is associated with gait deficits, future falls, and disability; however, it is unclear if associations remain after controlling for relevant confounders. This study investigated (i) the effects of type II diabetes on spatiotemporal gait parameters in community-dwelling older adults and (ii) if diabetes status was independently associated with future falls and disability, after controlling for gait and other confounders.

METHOD

Baseline data were obtained from 2608 community-dwelling adults (≥60 years) participating in The Irish Longitudinal Study on Ageing (TILDA). Diabetes was identified from self-reported doctors' diagnosis, medications, and glycated hemoglobin levels. Gait characteristics were obtained during single- and dual-task walking using a GAITRite mat (n = 2560). Incident falls and disability were collected over 4 years follow-up (n = 2473). Associations between diabetes status and gait (cross-sectional) and falls and disability (longitudinal) were investigated using regression analysis, adjusting for medications, cardiovascular health, neuropsychological function, and fall-related factors.

RESULTS

Diabetes (prevalence = 9.1%) was cross-sectionally associated with shorter dual-task step length after adjusting for covariates (β = -1.59, 95% CI: -3.10, -0.08, p < .05). Diabetes was independently associated with increased risk of future instrumental activity of daily living (IADL) difficulty in those with no prior difficulty (incidence rate ratio [IRR] = 1.51, 95% CI: 1.08, 2.11, p < .05) although dual-task step length was an important confounder in all disability models. No independent associations between diabetes and falls were observed.

CONCLUSIONS

Diabetes was independently associated with shorter dual-task step length and increased risk of future IADL difficulty. Multidimensional interventions addressing poor health and function in those with diabetes may help reduce the risk of gait deficits and future disability.

Wearable Health Technology to Quantify the Functional Impact of Peripheral Neuropathy on Mobility in Parkinson's Disease: A Systematic Review

The occurrence of peripheral neuropathy (PNP) is often observed in Parkinson’s disease (PD) patients with a prevalence up to 55%, leading to more prominent functional deficits. Motor assessment with mobile health technologies allows high sensitivity and accuracy and is widely adopted in PD, but scarcely used for PNP assessments. This review provides a comprehensive overview of the methodologies and the most relevant features to investigate PNP and PD motor deficits with wearables. Because of the lack of studies investigating motor impairments in this specific subset of PNP-PD patients, Pubmed, Scopus, and Web of Science electronic databases were used to summarize the state of the art on PNP motor assessment with wearable technology and compare it with the existing evidence on PD. A total of 24 papers on PNP and 13 on PD were selected for data extraction: The main characteristics were described, highlighting major findings, clinical applications, and the most relevant features. The information from both groups (PNP and PD) was merged for defining future directions for the assessment of PNP-PD patients with wearable technology. We established suggestions on the assessment protocol aiming at accurate patient monitoring, targeting personalized treatments and strategies to prevent falls and to investigate PD and PNP motor characteristics.

Qualitative neurological gait abnormalities, cardiovascular risk factors and functional status in older community-dwellers without neurological diseases: The Healthy Brain Project

BACKGROUND

Neurologic gait abnormalities (NGA) increase risk for falls and dementia, but their pathophysiologic substrates or association with disability have been poorly investigated. We evaluated the association of NGA with clinical characteristics and functional status in older community-dwellers.

METHODS

Gait characteristics were measured in older community-dwellers without neurological or psychological diseases participating to the Health Aging Body Composition study. NGA were rated using standardized readings of video-recorded short walks, combined with standard neurological exam. We tested cross-sectional associations with demographics, vascular risk factors, comorbidities, cognitive function and disability.

RESULTS

Of 177 participants (median age [IQR] = 82 [4] years, 55% women, 58% Caucasian), 49 (27.7%) had NGA. The most prevalent sub-types were unsteady (10.7%), hemiparetic (4.5%) and parkinsonian (4%). In multivariable logistic regression models, diabetes was associated with higher risk (OR = 3.24, 95% CI = 1.38-7.59), whereas higher physical activity (OR = 0.89, 95% CI = 0.80-0.99) and gait speed (OR = 0.04, 95% CI = 0.005-0.27) with lower risk of NGA. Prevalence of NGA was associated with difficulty in at least 1 activity of daily living, adjusting for confounders (OR = 2.90, 95% CI = 1.11-7.58). After adjusting for gait speed, this association was attenuated to non-significance (OR = 2.13, 95% CI = 0.71-6.37).

CONCLUSIONS

In our sample of community-dwelling older adults without neurological diseases, NGA, detected with a standardized neurological exam, part of usual physicians' training, were common. The relationships with diabetes and reduced physical activity might suggest vascular dysfunction as an underlying contributor to NGA. These results, if confirmed by longitudinal studies, which should also disentangle the relationship between NGA, gait speed and disability, might add information for preventing and managing mobility disability.

Hyponatremia Is Associated With Increased Osteoporosis and Bone Fractures in Patients With Diabetes With Matched Glycemic Control

Context

Patients with diabetes mellitus are at increased risk for bone fragility fracture secondary to multiple mechanisms. Hyperglycemia can induce true dilutional hyponatremia. Hyponatremia is associated with gait instability, osteoporosis, and increased falls and bone fractures, and studies suggest that compromised bone quality with hyponatremia may be independent of plasma osmolality. We performed a case-control study of patients with diabetes mellitus matched by median glycated hemoglobin (HbA1c) to assess whether hyponatremia was associated with increased risk of osteoporosis and/or fragility fracture.

Design

Osteoporosis (n = 823) and fragility fracture (n = 840) cases from the MedStar Health database were matched on age of first HbA1c ≥6.5%, sex, race, median HbA1c over an interval from first HbA1c ≥6.5% to the end of the encounter window, diabetic encounter window length, and type 1 vs type 2 diabetes mellitus with controls without osteoporosis (n = 823) and without fragility fractures (n = 840), respectively. Clinical variables, including coefficient of glucose variation and hyponatremia (defined as serum [Na⁺] <135 mmol/dL within 30 days of the end of the diabetic window), were included in a multivariate analysis.

Results

Multivariate conditional logistic regression models demonstrated that hyponatremia within 30 days of the outcome measure was independently associated with osteoporosis and fragility fractures (osteoporosis OR 3.09; 95% CI, 1.37 to 6.98; fracture OR, 6.41; 95% CI, 2.44 to 16.82).

Conclusions

Our analyses support the hypothesis that hyponatremia is an additional risk factor for osteoporosis and fragility fracture among patients with diabetes mellitus.

The effect of diabetes on prefrontal cortex activation patterns during active walking in older adults

BACKGROUND

Gait alterations were documented in diabetic patients. However, the effect of diabetes on cortical control of gait has not been reported. We evaluated the effect of diabetes on prefrontal cortex (PFC) Oxygenated Hemoglobin (HbO₂) levels during active walking in older adults.

METHODS

Of the total sample (n = 315; mean age = 76.84 ± 6.71ys; % female = 56.5) 43 participants (13.7%) had diabetes. The experimental paradigm consisted of two single tasks: Normal-Walk (NW); and Cognitive Interference (Alpha); and one dual-task condition consisting of the two single tasks, Walk-While-Talk (WWT). Functional Near-Infrared-Spectroscopy (fNIRS) was used to quantify PFC HbO₂ levels.

RESULTS

Older adults without diabetes showed higher PFC HbO₂ levels in WWT compared to both NW and Alpha. HbO₂ levels during NW were not different between the two groups. Consistent with Neural Inefficiency, older adults with diabetes exhibited higher HbO₂ levels during Alpha while performing significantly worse than those without diabetes. Moreover, the presence of diabetes was associated with attenuated HbO₂ levels during WWT. This pattern is consistent with Capacity Limitations suggesting a failure to recruit brain resources vis-à-vis the more cognitively challenging WWT condition.

CONCLUSIONS

A distinct functional neural signature of diabetes was established during active and attention demanding walking among older adults without overt neurological disease.

How tandem gait stumbled into the neurological exam: a review

Tandem gait testing is an integral part of the neurological exam. It is informative in a wide variety of disorders ranging from cerebellar disease to vestibular and peripheral neuropathies, parkinsonism, and other neurodegenerative conditions. We discuss the history and development of tandem gait testing as well as its technique, utility, and limitations in the assessment of neurological conditions. Tandem gait has emerged as a tool in the assessment of cerebellar disease, Huntington disease, idiopathic Parkinson's disease, atypical parkinsonism, peripheral neuropathies, and vestibulopathies. Its origin can be deduced from experimental observation and clinical experience as far back as the early nineteenth century. Despite the long history and ubiquitous performance of tandem gait testing, there is no standardized, guideline-based protocol to model for more homogenous research and clinical practices. Such a protocol should be developed using historical texts and manuscripts as well as the consensus of the medical research community. With standard protocols, further studies could define the sensitivity of abnormal tandem gait testing in cerebellar disorders, more diffuse neurodegeneration, and peripheral pathologies. Tandem gait can be a useful marker of dysfunction in neurologic conditions whose pathologies extend beyond the vermis or vestibulocerebellar module to include interconnected networks throughout the nervous system.