Better glycemic control is associated with maintenance of lower-extremity function over time in Mexican American and European American older adults with diabetes

Response rates and associated factors after a multicomponent intervention in frail older adults with diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) and frailty are associated with functional decline in older population.

OBJECTIVE

To explore the individual response to a multimodal intervention on functional performance.

DESIGN

A cluster-randomised multicentre clinical trial.

SETTING

Outpatients in hospital or primary care.

SUBJECTS

843 (77.83 years, 50.65% men) prefrail and frail individuals ≥70 years with T2DM.

METHODS

Participants were allocated to usual care group (UCG) or a multicomponent intervention group (IG): 16-week progressive resistance training, seven nutritional and diabetological educational sessions and achievement of glycated haemoglobin (7-8%) and blood pressure (<150 mmHg) targets. Functional performance was assessed with the Short Physical Performance Battery (SPPB) at 1 year. We used multivariate binomial and multinomial logistic regression models to explore the effect of the IG, and adherence on the outcomes studied, in several adjusted models.

RESULTS

53.7% in the IG versus 38.0% in the UCG improved by at least 1 point in their SPPB score [OR (95% CI): 2.07 (1.43, 2.98), P value <0.001]. Age, SPPB score and number of frailty criteria met decreased the probability of improving the SPPB score. Factors associated with worsening were pertaining to IG (decreased), age, SPPB score and the number of frailty criteria (increased). An adherence ≥84% was needed to achieve benefits, reaching the peak in the probability of improving SPPB when this was ≥85% [OR(95%CI): 2.38 (1.29, 4.79), P value 0.014].

CONCLUSIONS

Factors predicting the likelihood of improvement in a multimodal programme in pre-frail and frail older adults with diabetes are age, basal SPPB score, the number of frailty criteria and adherence.

Group-Based Trajectory Modelling of Changes in Mobility over Six Years in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

To investigate temporal changes in mobility in community-based people with type 2 diabetes, Fremantle Diabetes Study Phase II (FDS2) data were analysed. The baseline assessment included the Timed Up and Go (TUG) test, which was repeated biennially for up to six years. Group-based trajectory modelling (GBTM) identified TUG trajectory groups in participants with ≥2 tests. Independent associates of group membership were assessed using multinomial regression. Of 1551 potential FDS2 participants, 1116 (72.0%; age 64.9 ± 11.0 years, 45.6% female) were included in the modelling. The best-fitting GBTM model identified two groups with linear, minimally changing trajectories (76.2% and 19.4% of participants; baseline TUG times 8 ± 2 and 12 ± 3 s, respectively), and a third (4.5%; baseline TUG 17 ± 5 s) with a TUG that increased over time then fell at Year 6, reflecting participant attrition. Both slower groups were older, more likely to be female, obese, and had greater diabetes-associated complications and comorbidities. Almost one-quarter of the FDS2 cohort had clinically relevant mobility impairment that persisted or worsened over six years, was multifactorial in origin, and was associated with excess late withdrawals and deaths. The TUG may have important clinical utility in assessing mobility and its consequences in adults with type 2 diabetes.

Data-Driven Identification of Long-Term Glycemia Clusters and Their Individualized Predictors in Finnish Patients with Type 2 Diabetes

Purpose

To gain an understanding of the heterogeneous group of type 2 diabetes (T2D) patients, we aimed to identify patients with the homogenous long-term HbA1c trajectories and to predict the trajectory membership for each patient using explainable machine learning methods and different clinical-, treatment-, and socio-economic-related predictors.

Patients and Methods

Electronic health records data covering primary and specialized healthcare on 9631 patients having T2D diagnosis were extracted from the North Karelia region, Finland. Six-year HbA1c trajectories were examined with growth mixture models. Linear discriminant analysis and neural networks were applied to predict the trajectory membership individually.

Results

Three HbA1c trajectories were distinguished over six years: "stable, adequate" (86.5%), "improving, but inadequate" (7.3%), and "fluctuating, inadequate" (6.2%) glycemic control. Prior glucose levels, duration of T2D, use of insulin only, use of insulin together with some oral antidiabetic medications, and use of only metformin were the most important predictors for the long-term treatment balance. The prediction model had a balanced accuracy of 85% and a receiving operating characteristic area under the curve of 91%, indicating high performance. Moreover, the results based on SHAP (Shapley additive explanations) values show that it is possible to explain the outcomes of machine learning methods at the population and individual levels.

Conclusion

Heterogeneity in long-term glycemic control can be predicted with confidence by utilizing information from previous HbA1c levels, fasting plasma glucose, duration of T2D, and use of antidiabetic medications. In future, the expected development of HbA1c could be predicted based on the patient's unique risk factors offering a practical tool for clinicians to support treatment planning.

Great diversity in the utilization and reporting of latent growth modeling approaches in type 2 diabetes: A literature review

Introduction

The progression of complications of type 2 diabetes (T2D) is unique to each patient and can be depicted through individual temporal trajectories. Latent growth modeling approaches (latent growth mixture models [LGMM] or latent class growth analysis [LCGA]) can be used to classify similar individual trajectories in a priori non-observed groups (latent groups), sharing common characteristics. Although increasingly used in the field of T2D, many questions remain regarding the utilization of these methods.

Objective

To review the literature of longitudinal studies using latent growth modeling approaches to study T2D.

Methods

MEDLINE (Ovid), EMBASE, CINAHL and Wb of Science were searched through August 25th, 2021. Data was collected on the type of latent growth modeling approaches (LGMM or LCGA), characteristics of studies and quality of reporting using the GRoLTS-Checklist and presented as frequencies.

Results

From the 4,694 citations screened, a total of 38 studies were included. The studies were published beetween 2011 and 2021 and the length of follow-up ranged from 8 weeks to 14 years. Six studies used LGMM, while 32 studies used LCGA. The fields of research varied from clinical research, psychological science, healthcare utilization research and drug usage/pharmaco-epidemiology. Data sources included primary data (clinical trials, prospective/retrospective cohorts, surveys), or secondary data (health records/registries, medico-administrative). Fifty percent of studies evaluated trajectory groups as exposures for a subsequent clinical outcome, while 24% used predictive models of group membership and 5% used both. Regarding the quality of reporting, trajectory groups were adequately presented, however many studies failed to report important decisions made for the trajectory group identification.

Conclusion

Although LCGA were preferred, the contexts of utilization were diverse and unrelated to the type of methods. We recommend future authors to clearly report the decisions made regarding trajectory groups identification.

Sarcopenia is associated with the Geriatric Nutritional Risk Index in elderly patients with poorly controlled type 2 diabetes mellitus

AIMS/INTRODUCTION

Diabetes and sarcopenia have a two-way relationship with each other with advanced age. Additionally, malnutrition is correlated with a higher risk of sarcopenia in elderly patients. This study evaluated the association between sarcopenia and geriatric nutritional risk index (GNRI) in elderly patients with type 2 diabetes mellitus.

MATERIALS AND METHODS

Patients with type 2 diabetes mellitus aged ≥60 years were recruited from June 2018 to August 2020. This study analyzed 234 patients, who completed a physical performance test required for the diagnosis of sarcopenia. To investigate the effect of GNRI on sarcopenia, logistic regression analyses was used.

RESULTS

Patients with sarcopenia were significantly older with a lower body mass index (BMI) and GNRI compared with normal patients. The GNRI showed a positive correlation with the skeletal muscle index (SMI) and handgrip strength (SMI: R = 0.486, P < 0.001 for male; R = 0.589, P < 0.001 for female, handgrip strength: R = 0.470, P < 0.001 for male, R = 0.364, P < 0.001 for female). In the multivariate logistic regression model, a higher GNRI was associated with a lower risk of sarcopenia in older men and women with diabetes (adjusted odds ratio [OR], 0.892; 95% confidence interval [CI], 0.839-0.948 for male; adjusted OR, 0.928; 95% CI, 0.876-0.982 for female). One year of diabetes treatment improved the GNRI in the sarcopenia group with type 2 diabetes mellitus.

CONCLUSIONS

A low GNRI was associated with an increased risk of sarcopenia in elderly patients with type 2 diabetes mellitus. Treatment with glucose-lowering drugs improved the GNRI in the sarcopenia group.

Diabetes mellitus is associated with declines in physical function among men with and without HIV

OBJECTIVE

To determine the longitudinal relationships between abnormal glucose metabolism and physical function in persons with HIV (PWH) and without HIV.

DESIGN

Prospective cohort study of men with or at risk for HIV in four United States cities between 2006 and 2018.

METHODS

Men with or at risk for HIV from the Multicenter AIDS Cohort Study (MACS) had semi-annual assessments of glycemic status, grip strength, and gait speed. We used linear mixed models with random intercept to assess associations between glycemic status and physical function. Glycemic status was categorized as normal, impaired fasting glucose (IFG), controlled diabetes mellitus [hemoglobin A1C (HbA1C) <7.5%], or uncontrolled diabetes mellitus (HbA1C ≥ 7.5%).

RESULTS

Of 2240 men, 52% were PWH. Diabetes mellitus was similar among PWH (7.7%) vs. persons without HIV (6.7%, P = 0.36) at baseline. PWH had slower gait speed (1.17 vs. 1.20 m/s, P < 0.01) but similar grip strength (40.1 vs. 39.8 kg, P = 0.76) compared with persons without HIV at baseline. In multivariate models, gait speed decline was greater with controlled diabetes mellitus [-0.018 m/s (-0.032 to -0.005), P = 0.01] and grip strength decline was greater with controlled [-0.560 kg (-1.096 to -0.024), P = 0.04] and uncontrolled diabetes mellitus [-0.937 kg (-1.684 to -0.190), P = 0.01), regardless of HIV serostatus compared with normoglycemic individuals.

DISCUSSION

Abnormal glucose metabolism was associated with declines in gait speed and grip strength regardless of HIV serostatus. These data suggest that improvement in glucose control should be investigated as an intervenable target to prevent progression of physical function limitations among PWH.

Association Between Long-Term HbA1c Variability and Functional Limitation in Individuals Aged Over 50 Years: A Retrospective Cohort Study

BACKGROUND

As mean HbA1c provides incomplete information regarding glycemic variability, there has been considerable interest in the emerging association between glycemic variability and macrovascular events and with microvascular complications and mortality in adults with and without diabetes. However, the association between long-term glycemic variability, represented by visit-to-visit HbA1c variability, and functional limitations has not been clarified in previous literature. The present study aimed to explore the longitudinal association between long-term glycemic variability, represented by visit-to-visit HbA1c variability and functional limitations.

METHODS

This cohort study included adults aged over 50 years who participated in the 2006 to 2016 waves of the Health and Retirement Study. Physical functions, including mobility, large muscle function, activities of daily living (ADLs), and instrumental ADLs (IADLs), were assessed at baseline and every 2 years, and HbA1c levels were assessed at baseline and every 4 years. Visit-to-visit HbA1c variability was calculated using the HbA1c variability score (HVS) during the follow-up period. Generalized estimating equation models were used to evaluate the longitudinal association between HbA1c variability and functional limitations with adjustment for a series of confounders.

RESULTS

A total of 5,544 participants having three HbA1c measurements from 2006 to 2016, having two or more physical function measures (including one at baseline), and age over 50 years were included in this analysis. The mean age at baseline was 66.13 ± 8.39 years. A total of 916 (16.5%) participants had an HVS = 100, and 35.1% had an HVS = 50. The highest HVS category (HVS =100) was associated with increased functional status score (β = 0.093, 95% CI: 0.021-0.165) in comparison with the lowest HVS category (HVS = 0). Sensitivity analyses using the CV and SD of HbA1c as measures of variability showed similar associations between HbA1c variability and functional limitation. An incremental increase in HbA1c-CV (β = 0.630, 95% CI: 0.127-1.132) or HbA1c-SD (β = 0.078, 95% CI: 0.006-0.150) was associated with an increase in functional limitation in the fully adjusted model.

CONCLUSIONS

HbA1c variability was associated with heightened difficulty in performing functional activities over time after adjusting for mean HbA1c levels and multiple demographics and comorbidities. This study provides further evidence regarding the detrimental effect of HbA1c variability and highlights the significance of steady glycemic control.

Gradual exacerbation of knee flexion angle after total knee arthroplasty in patients with diabetes mellitus

OBJECTIVES

This study aimed to investigate the effect of diabetes mellitus (DM) on knee extension/flexion angle and its early clinical course after total knee arthroplasty (TKA).

METHODS

Patients who received TKA were retrospectively divided into two groups based on haemoglobinA1c level; the DM group (23 knees) and the control group (23 knees matched for baseline characteristics). The passive knee extension/flexion angle, gait speed and Japanese Orthopaedic Association (JOA) score were evaluated preoperatively and at 1, 6 and 12 months postoperatively.

RESULTS

There was no significant difference in the passive knee flexion angle at 1 and 6 months postoperatively between the groups (p = .302, p = .160, respectively). The passive knee flexion angle was significantly lower at 12 months postoperatively in the DM group than the control group (p = .014). In the DM group, the passive knee flexion angle at 6 and 12 months significantly decreased compared with that at 1 month postoperatively (p = .021, p < .001, respectively). There were no significant differences in the knee extension angle, gait speed and JOA score between the groups.

CONCLUSION

Patients with DM are likely to experience passive knee flexion angle exacerbating from 1 to 6 months after TKA.

Joint trajectories of cognition and gait speed in Mexican American and European American older adults: The San Antonio longitudinal study of aging

OBJECTIVES

Cognitive decline and gait speed slowing are independent predictors of disability and mortality. While both factors increase in prevalence with advancing age, little is known about their combined patterns of change. The study goal was to identify joint trajectories of cognition and gait speed within an aging bi-ethnic cohort of Mexican Americans and European Americans.

METHODS/DESIGN

Participants included 182 Mexican Americans and 188 European Americans, ages 65 to 74, who were followed over a mean of 9.5 years. Cognition was assessed with the mini-mental state examination and gait speed was examined with a timed 10-ft walk. Joint trajectory classes of cognition and gait speed were identified with latent growth mixture modeling. Odd-ratios assessed predictors for trajectory classes.

RESULTS

Three latent trajectory classes were identified: (a) relatively stable cognition and gait (termed stable cognition and gait class, 65.4%); (b) deteriorating cognition and gait (termed cognitive and physical vulnerability class, 22.2%); (c) stable cognition and deteriorating gait (termed physical vulnerability class, 12.4%). The odds of classification in the cognitive and physical vulnerability class vs stable cognition and gait class was associated with Mexican American ethnicity (OR = 3.771, P = .016), age (OR = 1.186, P = .017), income (OR = 0.828, P = .029), education (OR = 0.703, P < .001), and diabetes (OR = 4.547, P = .010). The odds of classification in the physical vulnerability class was associated with female sex (OR = 6.481, P = .004) and body mass index (OR = 1.118, P = .025).

CONCLUSIONS

The trajectories of cognition and gait speed were generally parallel, suggesting the two domains may act synergistically to shape important health outcomes. Socioeconomic disparities and Mexican American ethnicity independently conferred risk for accelerated decline.

Association Between Baseline Glycemic Markers (HbA1c) and 8-Year Trajectories of Functional Disability

BACKGROUND

This study assessed whether baseline (i) HbA1c (low [<5.7%], intermediate [5.7%-6.4%], and high [≥6.5%]) and (ii) glycemic control (7% HbA1c cutoff) in participants with self-reported diabetes were associated with differential 8-year functional disability trajectories.

METHODS

We used data from the 2006-2014 waves of the Health and Retirement Study for adults aged 50 years and older. Latent class mixture modeling was used to identify distinct functional disability trajectory classes. Multinomial logistic regression analysis examined the association between the newly constructed trajectories and baseline HbA1c levels, and glycemic control, respectively.

RESULTS

All participants (N = 5,966) were classified into four functional disability trajectory classes (no disability, low disability, low-increasing, and high-increasing). Participants with elevated HbA1c were at greater risk of being classified into the high-increasing (relative risk ratios = 1.63, 95% confidence interval [CI] = 1.25-2.11) trajectory class. Results showed significant effect modification by age and race. Three functional disability trajectories (no disability, low-increasing, and high-increasing) were identified for participants with self-reported diabetes (n = 1,119). There was no significant association between glycemic control in adults with self-reported diabetes and functional disability trajectory classes.

CONCLUSIONS

Participants with intermediate HbA1c and elevated HbA1c were more likely to be classified into the trajectories with progressing disability over the study period. More research is needed to better understand the association between glycemic markers and functional disability trajectories. Such research may provide insights into improvements for clinical care, self-management, and public health interventions for both conditions.

Inverse Correlation Between Grip Strength and Serum Phosphorus: A Retrospective Observational Study in Japanese Elderly with Poorly Controlled Type 2 Diabetes

The aim of this study was to investigate factors associated with sarcopenia among elderly patients with poorly controlled diabetes mellitus (DM). We retrospectively analyzed 41 patients with type 2 DM, aged ≥65 years who required diabetes education hospitalization. Patients were classified into two groups according to the presence or absence of a weakened hand grip, and clinical characteristics were compared. Patients with a weakened hand grip (n = 21) scored worse on a mini-mental state examination (24.3 vs. 26.5, p = 0.04), showed a higher prevalence of diabetic peripheral neuropathy (76% vs. 40%, p = 0.03), and had a higher serum phosphorus concentration (3.8 vs. 3.3 mg/dL, p < 0.01) compared to those without a weakened hand grip (n = 20). The serum phosphorus concentration was inversely correlated to hand grip strength (r = -0.501, p < 0.001) among the total of 41 patients. This inverse association was also confirmed after adjusting the effects of estimated glomerular filtration rate, age, and glycated hemoglobin. Thus, cognitive impairment, diabetic peripheral neuropathy, and high serum phosphorus concentrations are associated with hand grip weakness in elderly patients with type 2 DM.

Evidence gap on antihyperglycemic pharmacotherapy in frail older adults : A systematic review

Background

Although antihyperglycemic pharmacotherapy in frail older adults with type 2 diabetes mellitus (T2DM) is challenging, recommendations from international guidelines are mainly based on indirect evidence from trials not including frail participants.

Objective

This systematic review investigated the effectiveness and safety of pharmacotherapy in frail older adults with T2DM.

Material and methods

Randomized (RCT) and non-randomized prospective clinical trials (non-RCT) were searched in three electronic databases (Medline, Embase, Central) up to October 2018. Trials in older adults with T2DM who were assessed as significantly or severely impaired by defined cut-off scores of assessment instruments on frailty, activities of daily living or physical functional impairment were included.

Results

Two reviewers independently screened 17,391 references for inclusion and assessed risk of bias with ROBINS‑I. Five non-RCTs and no RCT were identified. Treatment of T2DM without insulin compared to insulin could be associated with increased improvement in cardiac functions in patients with cardiac resynchronization therapy and with decreased falls in frail older women. While better glycemic control with low variability and low HbA1c (hemoglobin A1c) values (<7%) was associated with better maintenance of physical function in community-dwelling older persons, higher HbA1c values (8–8.9%) were associated with a reduction in the composite outcome of death or functional decline in community-dwelling diabetic older adults with need for skilled assistance. Due to serious risk of bias in all studies, results should be considered with caution.

Conclusion

Well-designed, large-scale RCTs including this important group of patients are required to assess the effectiveness and safety of pharmacotherapy and HbA1c targets.

Electronic supplementary material

The online version of this article (10.1007/s00391-020-01724-3) contains supplementary material, which is available to authorized users.

Association of Lifelong Intake of Barley Diet with Healthy Aging: Changes in Physical and Cognitive Functions and Intestinal Microbiome in Senescence-Accelerated Mouse-Prone 8 (SAMP8)

Barley intake reportedly reduces the risk of cardiovascular disease, but effects on the systemic phenotypes during healthy aging have not yet been examined. Therefore, we examined the effects of barley on the lifespan; behavioral phenotypes, such as locomotor activity, and cognitive functions, and intestinal microbiome in the senescence-accelerated mouse-prone 8 (SAMP8) mouse. We prepared two mild high-fat diets by adding lard, in which the starch components of AIN-93G were replaced by rice or barley "Motchiriboshi." SAMP8 (four weeks old, male) mice were fed AIN-93G until eight weeks old, and then rice (rice group) or barley diet (rice: barley = 1:4, barley group) until death. Changes in aging-related phenotypes, object and spatial recognition, locomotor and balancing activities, and the intestinal microbiome were recorded. Moreover, plasma cholesterol levels were analyzed at 16 weeks old. Barley intake prolonged the lifespan by approximately four weeks, delayed locomotor atrophy, and reduced balancing ability and spatial recognition. Barley intake significantly increased the medium and small particle sizes of high-density lipoprotein (HDL) cholesterol, which is associated with a reduced risk of total stroke. The Bacteroidetes to Firmicutes ratio in the barley group was significantly higher than that in the rice group during aging. Thus, lifelong barley intake may have positive effects on healthy aging.

Paradoxical Relationship Between Glycated Hemoglobin and Longitudinal Change in Physical Functioning in Older Adults: A Prospective Cohort Study

BACKGROUND

Hyperglycemia with high hemoglobin A1c (HbA1c) levels is associated with significant health risks. However, the relationship between HbA1c levels and the physical functioning status in later life remains uncertain and so is the possible underlying mechanism.

METHODS

We conducted a prospective study of 2,565 initially well-functioning community-dwelling older adult aged 55 years and older from the Healthy Aging Longitudinal Study in Taiwan. Each participant received baseline measurements of blood HbA1c and inflammatory markers levels and repeated assessments of physical functioning over a mean follow-up period of 5.3 years. We used generalized linear mixed-effects regression to estimate the adjusted changes in the odds ratio for self-reported physical functioning impairment and Short Physical Performance Battery (SPPB) score according to baseline HbA1c levels (categorized into 0.5% increments from <5.5% to ≥7.0%).

RESULTS

HbA1c levels showed a U-shaped relationship with changes in the odds ratio for physical functioning impairment and SPPB score (p for quadratic term < .001). Compared with participants with an HbA1c of 5.5% to <6.0%, those with an HbA1c of <5.5% or ≥7.0% had a higher annual increase in the odds ratio for physical functioning impairment (odds ratio [95% confidence interval] per year, 1.25 [1.04-1.50] and 1.21 [1.04-1.41]) and a higher annualized decrease in SPPB score (coefficient [95% confidence interval], -0.05 [-0.10 to 0.00] and -0.04 [-0.08 to 0.00]). These relationships were nonlinear only in participants with high soluble interleukin-6 receptor levels (>48,124 pg/mL; p for interaction < .05).

CONCLUSIONS

High and low HbA1c levels at baseline are associated with faster physical functioning decline, particularly among individuals with elevated circulating soluble interleukin-6 receptor, a sign of enhanced interleukin-6 trans-signaling.

Importance of physical evaluation using skeletal muscle mass index and body fat percentage to prevent sarcopenia in elderly Japanese diabetes patients

AIMS/INTRODUCTION

To investigate the prevalence of sarcopenia, its related factors and indicators of physical evaluation in elderly diabetes patients.

MATERIALS AND METHODS

This was a cross-sectional observation study. A total of 267 diabetes patients (159 men, 108 women) aged >65 years were recruited in the present study. Skeletal muscle mass index, grip strength and usual gait speed were measured to diagnose sarcopenia according to the Asian Working Group for Sarcopenia. Body composition was measured using bioelectrical impedance analysis. Body mass index (BMI) and body fat percentage were evaluated in quartiles to investigate the relationship with sarcopenia. A multiple logistic regression analysis examined sarcopenia-related factors.

RESULTS

The prevalence of sarcopenia in all participants was 18.7% and increased with age. Sarcopenia decreased as BMI increased (P < 0.01, Cochran-Armitage test). In contrast, the third quartile body fat percentage group showed the lowest prevalence of sarcopenia. A strong positive correlation was observed between body mass and skeletal muscle mass indices (R = 0.702-0.682). Multiple logistic regression analysis showed that sarcopenia was associated with lower BMI, non-use of metformin and lower bone mineral content in men (P < 0.05), and lower bone mineral content, lower serum levels of albumin and older age in women (P < 0.05).

CONCLUSIONS

The present study suggests that diabetes patients with a high body fat percentage in addition to low BMI might develop sarcopenia. It is suggested that physical management in elderly diabetes patients should be carried out based on the evaluation of BMI and body fat percentage to prevent sarcopenia.

Sex-related differences in frailty factors in older persons with type 2 diabetes: a cross-sectional study

BACKGROUND

This cross-sectional study aimed to describe sex-related differences in diabetes-specific factors underlying the development of frailty in older persons with type 2 diabetes.

METHODS

Older persons aged 60-80 years were sequentially enrolled. Frailty and sarcopenia were evaluated using the validated Kihon checklist (KCL) and Asian Working Group for Sarcopenia algorithm, respectively. Physical function and characteristics were measured by trained nurses independently.

RESULTS

This study included 213 participants. The mean age, body mass index (BMI), and glycated hemoglobin (HbA1c) level were 70.4 years, 24.3 kg/m², and 7.4%, respectively. Prevalence of frailty was higher in women. Social and cognitive functions were lower in the prefrailty stage, while physical function was lower in the frailty stage, although there was no decrease in skeletal muscle mass. After adjustment for age, the KCL score was significantly associated with peripheral neuropathy, diet score, and coronary artery disease (CAD); frailty, with CAD and inoccupation; prefrailty, with diet score; and sarcopenia, with living alone in men. Meanwhile, the KCL score was significantly associated with living alone and skeletal muscle percentage; prefrailty, with peripheral neuropathy; and sarcopenia, with diabetes duration, LDL-cholesterol level, diet score, and irregular lifestyle in women.

CONCLUSIONS

Sex differences in the risk factors of frailty should be considered when selecting preventive strategies for older persons with type 2 diabetes, early in the prefrailty stage. In particular, it is important to evaluate social participation and diet therapy in men and skeletal muscle mass and psychosocial function in women.

Longitudinal trends in HbA1c patterns and association with outcomes: A systematic review

BACKGROUND

This study aimed to review studies that identified patterns of longitudinal HbA1c trends in patients with diabetes and to summarize factors and outcomes associated with distinct trajectory patterns.

METHODS

PubMed and Web of Science were systematically searched for studies examining HbA1c trends among patients with diabetes from database inception through September 2017. Articles were included if they met the following inclusion criteria: (a) longitudinal study of subjects with diabetes only, (b) use of serial measurements of HbA1c , and (c) analysis of the trend of HbA1c using group-based trajectory approaches.

RESULTS

Twenty studies were included, 11 on type 1 diabetes and 9 on type 2 diabetes. These studies identified 2 to 6 HbA1c trajectory patterns. The most commonly identified patterns included stable HbA1c around 7.0% and at levels between 8.0% and 9.9%, which usually captured the HbA1c pattern among the majority of subjects in the study population. Unstable patterns identified included increasing HbA1c trend, decreasing HbA1c trend, and non-linear patterns. These patterns were associated with differential risk of disease outcomes, over and beyond single-point HbA1c measures. Age, gender, ethnicity, diabetes duration, disease management frequency, cardiovascular risk factors, insulin treatment, family environment, and psychosocial factors were the most frequently reported factors associated with membership of specific HbA1c pattern groups.

CONCLUSION

Common patterns of longitudinal HbA1c trends were identified despite heterogeneity among the studies. A better understanding of what underlies these different patterns may provide opportunities to tailor therapies and care for these patients to reduce adverse outcomes.

Frailty and sarcopenia - newly emerging and high impact complications of diabetes

Diabetes increases the risk of physical dysfunction and disability. Diabetes-related complications and coexisting morbidities partially explain the deterioration in physical function. The decline in muscle mass, strength and function associated with diabetes leads to sarcopenia, frailty and eventually disability. Frailty acts as a mediator in the pathogenesis of disability in older people with diabetes and its measurement in routine daily practice is recommended. Frailty is a dynamic process which progresses from a robust condition to a pre-frail stage then frailty and eventually disability. Therefore, a multimodal intervention which includes adequate nutrition, exercise training, good glycaemic control and the use of appropriate hypoglycemic medications may help delay or prevent the progression to disability.

Tighter glycemic control is associated with ADL physical dependency losses in older patients using sulfonylureas or mitiglinides: Results from the DIMORA study

BACKGROUND

There is growing evidence that tight glycemic control may be more harmful than beneficial in older persons with Type 2 diabetes (T2DM). It remains controversial if tight glycemic control (lower glycated hemoglobin A1c (A1c)) is associated with functional impairments in older frail patients with T2DM. We explored associations between A1c and losses in Activities of Daily Living (ADLs) in diabetic nursing home (NH) patients and tested for differences according to anti-diabetic treatment: diet, anti-diabetic oral drug (AOD), insulin, combined insulin+AOD.

METHODS

We conducted a cross-sectional study on 1845 older NH patients with T2DM from 150 sites across Italy. Complete evaluations on ADLs, glycemic control, anti-diabetic treatments, comorbidities, and clinical data were recorded. ANOVA was applied to compare clinical characteristics across A1c tertiles. Multivariate regression models evaluated associations between A1c and ADL losses.

RESULTS

Patients had a mean age [SD]=82 [8] years; BMI=25.5 kg/m(2) [4.7]; Fasting Plasma Glucose (FPG)=7.4 [3.0] mmol/l; Post-prandial glucose (PPG)=10.3 [3.6] mmol/l; A1c=7.0% (54 mmol/mol), ADL losses=3.7 [1.8]. Compared to higher A1c tertiles, patients in the lower tertile had greater ADL losses, were more likely to use AODs, while less likely to use insulin or insulin+AOD. After adjusting for multiple confounders, impairments in ADLs were associated with tighter A1c levels (B=-0.014; p=0.002). Regression models according to anti-diabetic treatment showed that tighter A1c levels continued as independent determinants of ADL losses in patients using AODs (B=-0.023; p=0.001), particularly in those using sulfonylureas (B=-0.043; p<0.001) or mitiglinides (B=-0.044; p=0.050).

CONCLUSIONS

Tighter glycemic control was associated with ADL physical dependency losses, especially in those using sulfonylureas and mitiglinides.

Risk factors associated with falls in elderly patients with type 2 diabetes

AIMS

This study investigated risk factors of falls in elderly patients with type 2 diabetes mellitus.

METHODS

A total of 211 patients aged ≧60years (168 diabetic patients and 43 non-diabetic control subjects) were studied. Factors associated with falls in the past year were retrospectively examined using multiple logistic regression analysis.

RESULTS

The prevalence of patients who had a history of falls in the past year was twice as high as in diabetic patients compared in control subjects (36.9% vs. 18.6%, P<0.05). When diabetic patients were exclusively analyzed, the presence of any level of hypoglycemia and the Timed Up and Go test (TUG) scores correlated with patients' falls. The presence of hypoglycemia (OR 3.62, 95% CI: 1.242-10.534, P=0.018), cognitive impairment (OR 3.63, 95% CI: 1.227-10.727, P=0.020), and high Fall Risk Index scores (OR 1.2, 95% CI: 1.010-1.425, P=0.039) was independently correlated with the presence of multiple falls. When the diabetic patients were divided into three groups according to the frequency of hypoglycemia episodes, the prevalence of falls increased as the frequency of hypoglycemia increased.

CONCLUSION

Hypoglycemia was a risk factor of falls in elderly type 2 diabetic patients.

Diet soda intake is associated with long-term increases in waist circumference in a biethnic cohort of older adults: the San Antonio Longitudinal Study of Aging

OBJECTIVES

To examine the relationship between diet soda (DS) intake (DSI) and long-term waist circumference (WC) change (ΔWC) in the biethnic San Antonio Longitudinal Study of Aging (SALSA).

DESIGN

Prospective cohort study.

SETTING

San Antonio, Texas, neighborhoods.

PARTICIPANTS

SALSA examined 749 Mexican-American and European-American individuals aged 65 and older at baseline (baseline, 1992-96); 474 (79.1%) survivors completed follow-up 1 (FU1, 2000-01), 413 (73.4%) completed FU2 (2001-03), and 375 (71.0%) completed FU3 (2003-04). Participants completed a mean of 2.64 follow-up intervals, for 9.4 total follow-up years.

MEASUREMENTS

DSI, WC, height, and weight were measured at outset and at the conclusion of each interval: baseline, FU1, FU2, and FU3.

RESULTS

Adjusted for initial WC, demographic characteristics, physical activity, diabetes mellitus, and smoking, mean interval ΔWC of DS users (2.11 cm, 95% confidence interval (CI) = 1.45-2.76 cm) was almost triple that of nonusers (0.77 cm, 95% CI = 0.29-1.23 cm) (P < .001). Adjusted interval ΔWCs were 0.77 cm (95% CI = 0.29-1.23 cm) for nonusers, 1.76 cm (95% CI = 0.96-2.57 cm) for occasional users, and 3.04 cm (95% CI = 1.82-4.26 cm) for daily users (P = .002 for trend). This translates to ΔWCs of 0.80 inches for nonusers, 1.83 inches for occasional users, and 3.16 for daily users over the total SALSA follow-up. In subanalyses stratified for selected covariates, ΔWC point estimates were consistently higher in DS users.

CONCLUSION

In a striking dose-response relationship, increasing DSI was associated with escalating abdominal obesity, a potential pathway for cardiometabolic risk in this aging population.

Dipeptidyl peptidase-4 inhibitors can minimize the hypoglycaemic burden and enhance safety in elderly people with diabetes

The prevalence of type 2 diabetes mellitus (T2DM) among elderly people is increasing. Often associated with disabilities/comorbidities, T2DM lowers the chances of successful aging and is independently associated with frailty and an increased risk of hypoglycaemia, which can be further exacerbated by antihyperglycaemic treatment. From this perspective, the clinical management of T2DM in the elderly is challenging and requires individualization of optimum glycaemic targets depending on comorbidities, cognitive functioning and ability to recognize and self-manage the disease. The lack of solid evidence-based medicine supporting treatment guidelines for older people with diabetes further complicates the matter. Several classes of medicine for the treatment of T2DM are currently available and different drug combinations are often required to achieve individualized glycaemic goals. Many of these drugs, however, carry disadvantages such as the propensity to cause weight gain or hypoglycaemia. Dipeptidyl peptidase-4 (DPP-4) inhibitors, a recent addition to the pharmacological armamentarium, have become widely accepted in clinical practice because of their efficacy, low risk of hypoglycaemia, neutral effect on body weight, and apparently greater safety in patients with kidney failure. Although more information is needed to reach definitive conclusions, growing evidence suggests that DPP-4 inhibitors may become a valuable component in the pharmacological management of elderly people with T2DM. The present review aims to delineate the potential advantages of this pharmacological approach in the treatment of elderly people with T2DM.

Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options

The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.

Causal inference in longitudinal comparative effectiveness studies with repeated measures of a continuous intermediate variable

We propose a principal stratification approach to assess causal effects in nonrandomized longitudinal comparative effectiveness studies with a binary endpoint outcome and repeated measures of a continuous intermediate variable. Our method is an extension of the principal stratification approach originally proposed for the longitudinal randomized study "Prevention of Suicide in Primary Care Elderly: Collaborative Trial" to assess the treatment effect on the continuous Hamilton depression score adjusting for the heterogeneity of repeatedly measured binary compliance status. Our motivation for this work comes from a comparison of the effect of two glucose-lowering medications on a clinical cohort of patients with type 2 diabetes. Here, we consider a causal inference problem assessing how well the two medications work relative to one another on two binary endpoint outcomes: cardiovascular disease-related hospitalization and all-cause mortality. Clinically, these glucose-lowering medications can have differential effects on the intermediate outcome, glucose level over time. Ultimately, we want to compare medication effects on the endpoint outcomes among individuals in the same glucose trajectory stratum while accounting for the heterogeneity in baseline covariates (i.e., to obtain 'principal effects' on the endpoint outcomes). The proposed method involves a three-step model estimation procedure. Step 1 identifies principal strata associated with the intermediate variable using hybrid growth mixture modeling analyses. Step 2 obtains the stratum membership using the pseudoclass technique and derives propensity scores for treatment assignment. Step 3 obtains the stratum-specific treatment effect on the endpoint outcome weighted by inverse propensity probabilities derived from Step 2.

Physical disability in the elderly with diabetes: epidemiology and mechanisms

Diabetes mellitus is a common chronic condition worldwide, especially in the elderly population. Several epidemiologic studies in the last 2 years have consistently associated diabetes with physical disability, a condition that may profoundly affect the quality of life of older people. Although in older people with diabetes, the pathogenesis of functional limitation and disability has not been completely elucidated, it is certainly complex and involves multiple potential pathways. In this narrative review, we described the most recent epidemiologic and clinical evidence supporting the association between diabetes and impaired physical function in older persons focusing on emerging biological mechanisms explaining the excess risk of disability associated with diabetes.

The Hispanic paradox and predictors of mortality in an aging biethnic cohort of Mexican Americans and European Americans: the san antonio longitudinal study of aging

OBJECTIVES

To examine predictors of mortality in aging Mexican Americans (MAs) and European Americans (EAs).

DESIGN

Longitudinal, observational cohort study.

SETTING

Socioeconomically diverse neighborhoods in San Antonio, Texas.

PARTICIPANTS

Community-dwelling adults aged 65 and older (394 MA; 355 EA) who completed the baseline examination (1992-96) of the San Antonio Longitudinal Study of Aging (SALSA) and for whom vital status was ascertained over an average 8.2 years of follow-up.

MEASUREMENTS

Ethnic group was classified using a validated algorithm. Hazard ratios (HRs) for mortality were estimated using Cox proportional hazards models with age, sex, ethnic group, education, income, frailty, diabetes mellitus with and without complications, comorbidity, cognition, depressive symptoms, and body mass index included as predictors in sequential models.

RESULTS

At baseline, MAs had a higher prevalence of diabetes mellitus and frailty and lower socioeconomic status (SES) than EAs. The age- and sex-adjusted ethnic HR (MA vs EA) for mortality was 1.54 (95% confidence interval (CI) = 1.17-2.03). After adjusting for SES, the ethnic HR was no longer significant (HR = 1.16, 95% CI = 0.83-1.61). In the final model, comorbidity, diabetes mellitus with complications, depressive symptoms, and cognitive impairment were significant independent risk factors for mortality.

CONCLUSION

Contrary to the Hispanic paradox, MAs were at greater risk of mortality than EAs. SES differences largely explained this ethnic disparity. Significant independent predictors of mortality, regardless of ethnic group, were diabetes mellitus with complications, comorbidity, depressive symptoms, and cognitive impairment. Mortality reduction in older MAs requires attention to socioeconomic disparities and disease factors.

Management of type 2 diabetes mellitus in older adults

In the near future, the majority of patients with diabetes will be adults aged 65 or older. Unlike young adults with diabetes, elderly diabetic people may be affected by a variety of comorbid conditions such as depression, cognitive impairment, muscle weakness (sarcopenia), falls and fractures, and physical frailty. These geriatric syndromes should be considered in the establishment of treatment goals in older adults with diabetes. Although there are several guidelines for the management of diabetes, only a few are specifically designed for the elderly with diabetes. In this review, we present specific conditions of elderly diabetes which should be taken into account in the management of diabetes in older adults. We also present advantages and disadvantages of various glucose-lowering agents that should be considered when choosing a proper regimen for older adults with diabetes.

Disability in older people with diabetes: issues for the clinician

Diabetes may become a disabling disease due to diverse mechanisms. Many patients have evidence of physical or cognitive impairments that can markedly influence their ability to diabetes self manage and adversely affect possible outcomes of diabetes care. A screening process for impairment is therefore needed and in frail patients a comprehensive gerontological assessment should be used to improve the efficiency of care. A diabetes educational programme adapted to this population, which has involved the main care-giver has shown its efficacy to improve risk factor control and quality of life in a safer way. The experience of case-managers according to a model of heart failure may be promising for the future.