Diabetes in the elderly

Blood pressure and the risk of diabetes: A longitudinal observational study based on Chinese individuals

BACKGROUND

With lifestyle changes, the incidence of diabetes has been steadily increasing, and hypertension remains a significant risk factor impacting cardiovascular health. Understanding the potential effects of blood pressure on diabetes risk is, therefore, crucial. This study aims to comprehensively explore the relationship between blood pressure and diabetes risk.

METHODS

A total of 211,809 individuals undergoing health check-ups were included in this analysis. Participants were divided into four groups based on the quartiles of systolic and diastolic blood pressure, with the primary outcome being the incidence of new-onset diabetes.

RESULTS

Over an average follow-up period of 3.1 years (±0.94 years), 3,000 men (1.42%) and 1,173 women (0.55%) were newly diagnosed with diabetes. Multivariable Cox regression analysis demonstrated that blood pressure is an independent predictor of new-onset diabetes (systolic blood pressure HR 1.07 per SD increase, 95% CI: 1.01-1.12, P for trend <0.001; diastolic blood pressure HR 1.11 per SD increase, 95% CI: 1.06-1.17, P for trend 0.001). The optimal cutoff for systolic blood pressure in predicting new-onset diabetes was found to be 123 mmHg (area under the curve 0.7014, sensitivity 0.65, specificity 0.64), which was superior to the predictive efficacy of diastolic blood pressure (area under the curve 0.6645, sensitivity 0.63, specificity 0.62). Subgroup analyses indicated that the risk of blood pressure-related diabetes was significantly higher in middle-aged individuals compared to older adults (P for interaction <0.05). Additionally, women showed a higher risk of systolic blood pressure-related diabetes than men, and normal-weight individuals exhibited a higher risk than those with obesity (P for interaction <0.05).

CONCLUSIONS

This cohort study within a Chinese population highlights that, after adjusting for other confounding factors, blood pressure is an independent risk factor for diabetes. This association is particularly pronounced among middle-aged individuals, women, and those of normal weight. Moreover, systolic blood pressure demonstrates superior predictive efficacy for diabetes compared to diastolic blood pressure.

Process evaluation of team-based care in people aged >65 years with type 2 diabetes mellitus

OBJECTIVE

The prevalence of type 2 diabetes mellitus (T2DM) is increasing globally and there is critical need develop interventions to improve health outcomes among older people. The Group Appointments in Primary Care (GAP) study was a randomised controlled trial designed to test the efficacy of a group and team-based medical visit programme to lower haemoglobin A1c among patients with T2DM. We aimed to understand the barriers and facilitators to implement the GAP intervention within a primary care setting, with an emphasis on patient experience.

RESEARCH DESIGN AND METHODS

This was a qualitative exploratory study. Data were gathered from semistructured interviews conducted with the first cohort of GAP study participants (n=15) at baseline and intervention completion. GAP participants were aged >65, diagnosed with T2DM and from one primary care clinic. The interview questions identified the patient perspectives and factors relating to their attendance at seven group medical visits that were part of the intervention programme. Data were analysed using framework analysis.

RESULTS

We identified four themes that captured participants' experiences: (1) Education: learning with professionals, learning with one another; (2) Social Support: common interests, common problems; (3) Setting: ease of location, ease of conversation and (4) Impact: expectations met, empowerment gained. The GAP intervention increased participants' self-reported diabetes literacy and self-management skills.

CONCLUSIONS

We learnt that: accessible community centres, not primary care offices, were the ideal location for GAP; the consistent leadership of the primary care physician was valued by participants; and, the content related to exercise and healthy diet were viewed as impactful. Also, learning was achieved through content delivered by clinical experts, and by T2DM experts with lived experience-the GAP peers. Our findings highlight the important role of group learning.

TRIAL REGISTRATION NUMBER

NCT02002143.

Efficacy and Safety of Adding Sitagliptin in Type 2 Diabetes Patients on Insulin: Age-Stratified Comparison at One Year in the ASSIST-K Study

Background

Sitagliptin, the first dipeptidyl peptidase-4 inhibitor, has demonstrated efficacy and safety as monotherapy and as add-on therapy to oral antidiabetic agents or insulin. However, there have been few reports about sitagliptin in elderly patients. The ASSIST-K observational study was performed in patients with type 2 diabetes mellitus (T2DM) receiving sitagliptin as add-on therapy to insulin. Changes of hemoglobin A1c (HbA1c), body weight, and the estimated glomerular filtration rate (eGFR), as well as adverse events, were investigated over 12 months in age-stratified groups.

Methods

Among outpatients with T2DM treated at member institutions of Kanagawa Physicians Association, those starting sitagliptin as add-on therapy to insulin were followed for 12 months. HbA1c (National Glycohemoglobin Standardization Program), body weight, and eGFR were the efficacy endpoints, while adverse events were investigated to assess safety. Patients were stratified into three age groups (≤ 64 years, 65 - 74 years, and ≥ 75 years) for comparison of the endpoints.

Results

Among 937 patients on insulin before starting sitagliptin, 821 patients were analyzed after excluding those without HbA1c data at baseline and 12 months. The two groups of elderly patients (65 - 74 years and ≥75 years) had more complications and their HbA1c was lower at initiation of sitagliptin therapy. The dose of sitagliptin, daily number of insulin injections, and number of concomitant oral antidiabetic agents were all lower in the elderly patients. HbA1c showed a significant decrease after initiation of sitagliptin in all age groups, and there were no significant intergroup differences in the change of HbA1c at 12 months. Body weight did not change significantly in any group. eGFR decreased significantly in all groups, with no significant intergroup differences at 12 months. Regarding adverse events, there were no significant intergroup differences in the incidence of severe hypoglycemia, gastrointestinal symptoms, or constipation.

Conclusions

Despite baseline differences in demographic factors and medications, sitagliptin showed good efficacy and safety in all age groups of patients receiving it as add-on therapy to insulin during routine management of T2DM. Adding sitagliptin to insulin achieves similar efficacy and safety outcomes at 12 months in both elderly and non-elderly T2DM patients.

Testosterone, Dihydrotestosterone, Sex Hormone-Binding Globulin, and Incident Diabetes Among Older Men: The Cardiovascular Health Study

CONTEXT

Although sex hormone-binding globulin (SHBG) and testosterone (T) have been inversely associated with risk of diabetes, few studies have examined dihydrotestosterone (DHT), a more potent androgen than T, in older adults, whose glycemic pathophysiology differs from younger adults.

OBJECTIVE

To determine the associations of SHBG, T, and DHT with insulin resistance and incident diabetes in older adult men.

DESIGN

In a prospective cohort study, we evaluated baseline levels of SHBG, T, and DHT using liquid chromatography-tandem mass spectrometry among 852 men free of diabetes and cardiovascular disease in the Cardiovascular Health Study in 1994.

MAIN OUTCOME

Insulin resistance estimated by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) and insulin sensitivity estimated by the Gutt index in 1996, and incident diabetes (n = 112) ascertained over a mean follow-up of 9.8 years.

RESULTS

In linear regression models adjusted for demographics, alcohol consumption, current smoking, body mass index, and other androgens, SHBG [HOMA-IR 0.30 units lower per doubling; 95% confidence interval (CI), 0.08 to 0.52; P = 0.01] and total DHT (HOMA-IR 0.18 units lower per doubling; 95% CI, 0.06 to 0.30; P = 0.01), but not free T (P = 0.33), were inversely associated with insulin resistance. In corresponding Cox proportional hazards models, total DHT was again inversely associated with risk of diabetes (adjusted hazard ratio per doubling, 0.69; 95% CI, 0.52 to 0.92; P = 0.01), but SHBG (hazard ratio, 1.09; 95% CI, 0.74 to 1.59; P = 0.66) and free T (hazard ratio, 1.15; 95% CI, 0.92 to 1.43; P = 0.23) were not.

CONCLUSIONS

Among older men, higher levels of DHT were inversely associated with insulin resistance and risk of diabetes over the ensuing 10 years, whereas levels of T were not. Future studies are still needed to clarify the role of SHBG in risk of diabetes in this population.

Efficacy of hypoglycemic treatment in type 2 diabetes stratified by age or diagnosed age: a meta-analysis

AIM

To compare the effects of blood glucose lowering regimens in groups of patients categorized by baseline age and diagnosed age.

METHODS

Placebo-controlled randomized trials in type 2 diabetes patients with a study length ≥12 weeks were included.

RESULTS

A total of 246 trials were included. HbA1c changes from baseline corrected by placebo were comparable in sulfonylurea treatment between older and younger patients' groups (weighted mean difference (WMD), -1.28% vs -0.92%, p > 0.05). Treatment with metformin between groups resulted in a comparable change in HbA1c levels (WMD, -0.97% vs -1.23%, p > 0.05). Treatment with α-glucosidase inhibitor (WMD, -0.68% vs -0.67%, p > 0.05), treatment with thiazolidinedione (WMD, -0.74% vs -1.01%, p > 0.05), treatment with DPP-4 inhibitors (WMD, -0.67% vs -0.67%, p > 0.05), and treatment with SGLT2 inhibitors (WMD, -0.54% vs -0.67%, p > 0.05) between groups also resulted in comparable HbA1c changes. Treatment with GLP-1 analogs between groups in HbA1c changes were also comparable (p > 0.05). Regression analysis indicated that the baseline age or diagnosed age was not associated with the HbA1c changes from baseline.

CONCLUSION

In each hypoglycemic treatment, the baseline age or diagnosed age was not associated with the HbA1c changes from baseline.

Two-year assessment of the efficacy and safety of sitagliptin in elderly patients with type 2 diabetes: Post hoc analysis of the ASSET-K study

BACKGROUND

There have only been a few reports about use of dipeptidyl peptidase 4 (DPP-4) inhibitors in elderly patients with type 2 diabetes mellitus (T2DM), suggesting that the safety of these agents has not been sufficiently demonstrated. We performed a comparative review of the efficacy and safety of sitagliptin for Japanese patients with T2DM managed in the real-world clinical setting.

METHODS

An age-stratified analysis was performed of 831 patients who were treated with sitagliptin for 2 years. Parameters assessed included the hemoglobin A1c (HbA1c), body weight, serum creatinine, and adverse events. HbA1c and the incidence of hypoglycemia were also evaluated in patients treated with sitagliptin and a sulfonylurea (SU), who were divided into three age groups (<65 years, 65-74 years, and ≥75 years).

RESULTS

Comparison of glycemic control parameters, laboratory values, and adverse events revealed significant improvement of HbA1c, casual postprandial plasma glucose, and fasting plasma glucose in each age group with no change in body weight. Serum creatinine increased significantly in all age groups. Hypoglycemia only occurred in patients who received combined treatment with an SU and sitagliptin, and there was no age-related difference in its incidence.

CONCLUSIONS

HbA1c was improved by 2 years of sitagliptin therapy in all three age groups, and age did not seem to influence the incidence of hypoglycemic events. These results confirm the efficacy and safety of sitagliptin in patients ≥ 75 years old, suggesting that it is also useful for treating elderly patients with T2DM.

Prevalence, Clinical Correlates, and Use of Glucose-Lowering Drugs among Older Patients with Type 2 Diabetes Living in Long-Term Care Facilities

Prevalence, clinical correlates, and use of glucose-lowering drugs were comprehensively evaluated among 863 nursing home older patients with diabetes (mean age 82.9 ± 2.1 years): functional dependence and cognitive impairment were present in 84.1% and 68% of patients, respectively, and 66.3% of patients had 2-4 comorbidities. HbA1c values < 7.0% were documented in 54.9% of diabetic; significantly lower HbA1c levels were observed in demented patients than in nondemented subjects. Documented hypoglycemic episodes were reported for 57 patients (6.6%), without significant association with age, functional dependence, cognitive impairment, or HbA1c levels. About one-fifth of older long-term facilities residents have diabetes, with concomitant poor health conditions and high prevalence of cognitive impairment and functional dependence. Roughly three-fourths of these older and frail diabetic patients have HbA1c values lower than optimal, suggesting a potential for hypoglycemic harm especially among patients with severe cognitive impairment.

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

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

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

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

Diabetes in long-term care facilities

With the aging of the population and longer life expectancies, the prevalence of population with multiple chronic medical conditions has increased. Difficulty managing these conditions as people age (because of changes in physical, functional, or cognitive abilities and the complexity of many treatment regimens), has led to more individuals with multiple medical conditions admitted to the long-term care facilities. Older adults with diabetes residing in the long-term facilities represent the most vulnerable of this cohort. Studies that specifically target diabetes management in older population are lacking and those that target diabetes management in the long-term care facilities are even fewer. The lack of knowledge regarding the care of the elderly residing in long-term care with diabetes may lead to treatment failure and higher risk of hyperglycemia, as well as hypoglycemia. In aging populations, hypoglycemia has the potential for catastrophic consequences. To avoid this, the management of older population with diabetes and other medical comorbidities residing in long-term care facilities requires a more holistic approach compared with focusing on individual chronic disease goal achievement.

Total and high-molecular-weight adiponectin and risk of incident diabetes in older people

OBJECTIVE

To delineate the associations of total adiponectin, high-molecular-weight (HMW) adiponectin, and the HMW-to-total adiponectin ratio with diabetes in older adults.

RESEARCH DESIGN AND METHODS

Total and HMW adiponectin were measured in a population-based study of older adults. The relations of total adiponectin, HMW adiponectin, and their ratio with incident diabetes (n = 309) were assessed in 3,802 individuals.

RESULTS

Total and HMW adiponectin were highly correlated (r = 0.94). Analysis using cubic splines revealed that the associations between total and HMW adiponectin and new-onset diabetes were not linear. Specifically, after adjustment for confounders, there were similar inverse relationships for total (hazard ratio per SD 0.49 [95% CI 0.39-0.63]) and HMW adiponectin (0.42 [0.32-0.56]) with diabetes up to values of 20 and 10 mg/L, respectively, above which the associations plateaued. These associations persisted after adjustment for potential mediators (blood pressure, lipids, C-reactive protein, and homeostasis model assessment of insulin resistance [HOMA-IR]). There was, however, evidence of interaction by HOMA-IR in the lower range of adiponectin, with stronger inverse associations among insulin-sensitive than insulin-resistant participants. HMW-to-total adiponectin ratio showed a linear adjusted association with outcome, but this was abolished by inclusion of mediating variables.

CONCLUSIONS

In this older cohort, increasing concentrations of total and HMW adiponectin were associated with comparably lower risks of diabetes, but these associations leveled off with further increases above concentrations of 20 and 10 mg/L, respectively. The more pronounced risk decreases at the lower range among participants without insulin resistance support a role for adiponectin that is independent of baseline hyperinsulinemia, but this will require further investigation.

Adequacy of diabetes care for older U.S. rural adults: a cross-sectional population based study using 2009 BRFSS data

Background

In the U.S. diabetes prevalence estimates for adults ≥ 65 years exceed 20%. Rural communities have higher proportions of older individuals and health disparities associated with rural residency place rural communities at risk for a higher burden from diabetes. This study examined the adequacy of care received by older rural adults for their diabetes to determine if older rural adults differed in the receipt of adequate diabetes care when compared to their non-rural counterparts.

Methods

Cross-sectional data from the 2009 Behavioral Risk Factor Surveillance Survey were examined using bivariate and multivariate analytical techniques.

Results

Logistic regression analysis revealed that older rural adults with diabetes were more likely to receive less than adequate care when compared to their non-rural counterparts (OR = 1.465, 95% CI: 1.454-1.475). Older rural adults receiving less than adequate care for their diabetes were more likely to be: male, non-Caucasian, less educated, unmarried, economically poorer, inactive, a smoker. They were also more likely to: have deferred medical care because of cost, not have a personal health care provider, and not have had a routine medical check-up within the last 12 months.

Conclusion

There are gaps between what is recommended for diabetes management and the management that older individuals receive. Older adults with diabetes living in rural communities are at greater risk for less than adequate care when compared to their non-rural counterparts. These results suggest the need to develop strategies to improve diabetes care for older adults with diabetes and to target those at highest risk.

Role of vildagliptin in managing type 2 diabetes mellitus in the elderly

BACKGROUND

The prevalence of type 2 diabetes (T2DM) increases with age. Older patients have an increased likelihood for T2DM-related morbidity and mortality. The objective of this review is to provide an overview of the challenges in managing T2DM in the elderly, with an emphasis on prevention of hypoglycaemia and the role of the DPP-4 inhibitor vildagliptin in this patient population.

METHODS

A search of PubMed was conducted (from 2003 to 2010) to identify English-language articles relevant to the management of elderly patients with T2DM, with an emphasis on vildagliptin treatment. A limitation of this review is that it does not provide an overview of the entire class of dipeptidyl-peptidase-4 (DPP-4) inhibitors.

FINDINGS

Management of T2DM in elderly patients is complicated by numerous factors, including a high prevalence of cardiovascular risk factors and other comorbidities and a high frequency of polypharmacy issues. Hypoglycaemia may pose the greatest barrier to optimal glycaemic control in elderly patients, who are less likely to recognise and respond to hypoglycaemic episodes, leading to increased frequency and severity of events. Data on the DPP-4 inhibitor vildagliptin indicate that reductions in A1C in elderly patients are at least as good as those observed in younger patients and are achieved with minimal risk of hypoglycaemia. T2DM in older individuals is associated with relative hyperglucagonaemia and elevated postprandial glucose (PPG). Vildagliptin treatment appears to address both these defects. Vildagliptin improves the ability of alpha- and beta-cells to respond appropriately to changes in plasma glucose levels. This, in the face of high glucose levels, results in reduced inappropriate glucagon secretion and PPG excursions. In the face of low glucose, however, the protective glucagon response is well-preserved. These factors help explain the efficacy and minimal risk of hypoglycaemia observed with vildagliptin in elderly patients.

CONCLUSION

The elderly population with T2DM poses unique treatment challenges and have not been particularly well-represented in clinical trials, highlighting the need for additional studies to better define appropriate glucose targets and to ascertain the best strategies for achieving and maintaining appropriate glycaemic levels. Because vildagliptin does not expose patients to hypoglycaemic risk, it seems particularly suited to oral therapy of T2DM in the elderly.

Nutritional considerations for older adults with type 2 diabetes

As Western populations age, the burden of associated chronic diseases, including diabetes, cardiovascular disease (CVD), and cancer will increase dramatically. In the United States in the next 50 years, it is projected that the percentage of adults with type 2 diabetes will exceed 30%, with the vast majority older than 65 years. It is therefore important to determine the best possible dietary and lifestyle modifications to prevent and control this disease and its associated complications. Although few data are available regarding the optimal nutritional regimen for the elderly with type 2 diabetes, as a general rule, the use of nutrient-dense, low glycemic index, high-dietary fiber foods with possibly higher protein intake is recommended.

Importance of cultural issues in managing a patient with diabetes

Diabetes is highly prevalent in different ethnic groups. In the Hispanic population there are unique health care beliefs and practices that may affect diabetes care and management. It is important for pharmacists to understand these beliefs and other cultural issues in providing care to these persons with diabetes.

Antihyperglycaemic therapy in elderly patients with type 2 diabetes: potential role of incretin mimetics and DPP-4 inhibitors

Management of elderly patients with type II diabetes is complicated by age-related changes in physiology, comorbidities, polypharmacy and heterogeneity of functional status. A minimum goal in antidiabetic treatment in this population is to achieve a level of glycaemic control that avoids acute complications of diabetes, adverse effects and reduction in quality of life. Hypoglycaemia is a particular problem in elderly patients, and many antidiabetic agents pose increased risk for hypoglycaemia. In addition, many standard agents pose risks for older patients because of reduced renal function and common comorbidities. Newer agents based on enhancing incretin activity, including the glucagon-like peptide-1 mimetics exenatide and liraglutide and the oral dipeptidyl peptidase-4 inhibitors sitagliptin and vildagliptin, may offer particular advantages in elderly patients with diabetes.