Prescribing for type 2 diabetes in the elderly: issues and solutions

Extensive researches have linked air pollutants with cardiovascular disease (CVD) and respiratory diseases (RD), however, there is limited evidence on causal effects of air pollutants on morbidity of CVD or RD with comorbidities, particularly diabetes mellitus in elder patients. We included hospital admissions for CVD or RD among elder (≥65 years) diabetic patients between 2014 and 2019 in Beijing. A time‐stratified case‐crossover design based on negative‐control exposure was used to assess causal associations of short‐term exposure to air pollutants with CVD and RD among diabetic patients with the maximum lag of 7 days. A random forest regression model was used to calculate the contribution magnitude of air pollutants. A total of 493,046 hospital admissions were recorded. Per 10 μg/m3 uptick in PM1, PM2.5, PM10, SO2, NO2, O3, and 1 mg/m3 in CO was associated with 0.29 (0.05, 0.53), 0.14 (0.02, 0.26), 0.06 (0.00, 0.12), 0.36 (0.01, 0.70), 0.21 (0.02, 0.40), −0.08 (−0.25, 0.09), and 4.59 (0.56, 8.61) causal effect estimator for admission of CVD among diabetic patients, corresponding to 0.12 (0.05, 0.18), 0.09 (0.05, 0.13), 0.05, 0.23 (0.06, 0.41), 0.10 (0.02, 0.19), −0.04 (−0.06, −0.01), and 3.91(1.81, 6.01) causal effect estimator for RD among diabetic patients. The effect of gaseous pollutants was higher than particulate pollutants in random forest model. Short‐term exposure to air pollution was causally associated with increased admission of CVD and RD among elder diabetic patients. Gaseous pollutants had a greater contribution to CVD and RD among elder diabetic patients.

Because of diversities of physical, mental, and psychological functions as well as clinical and social backgrounds, comprehensive geriatric assessment (CGA) is of great importance in treating elderly diabetic patients. We addressed three issues as to functions important for the CGA. First, we assessed several domains of cognitive function in 213 elderly diabetic patients. Attention and visual memory in diabetic patients without vascular disease were impaired compared with non-diabetic controls after adjusting for age and sex using analysis of covariance. Multivariate analysis revealed that age, hyperglycemia, and the presence of cerebral infarction were independent determinants for the impairment of attention in the diabetic patients. The results suggest that glucose control is important for the maintenance of cognitive function in elderly diabetic patients. Secondly, we assessed positive well-being as a measure of psychological function using a PGC morale scale in 197 elderly diabetic patients without cerebrovascular disease at baseline and examined whether the low well-being affect the development of cerebrovascular disease in a 3-year longitudinal study. The results indicate that low well-being was an independent risk factor for cerebrovascular disease after adjusting conventional risk factors in elderly diabetic patients. Thirdly, as a physical function, we assessed 5-m walking speed for both usual and maximum walking in 64 diabetic patients. The walking speed decreased with age and correlated significantly with the knee extension power and functional reach. The result suggests that muscle-strength exercise and balance training as well as endurance exercises are necessary to improve age-related decreases in walking speed and for effective exercise in elderly patients. From a gerontological point of view, new strategies of elderly diabetes treatment including muscle strength exercise and psychological approaches should be established to improve physical, mental, psychological, and social functions as assessed by the CGA.

This study describes the development and validation of Chinese, Malay and Tamil translations of the Positive Mental Health Instrument (PMHI) in a general population sample in Singapore. Translations were performed using two independent forward translations followed by expert panel discussions and tested for content, construct and language appropriateness using focus group discussions. The final translated tools were field-tested among 220 residents per language using self-administered questionnaires comprising the translated PMHI and other validity measures. Missing data, floor and ceiling effects, confirmatory factor analysis (CFA), internal consistency, item response theory differential item functioning (IRT-DIF) and criterion validity were assessed. A total of 10 PMHI-Chinese items, 26 PMHI-Malay items and six response categories and six PMHI-Tamil items were modified based on expert panel and focus group discussions. PMHI had low missing data and showed negative but acceptable skewness (<2) and kurtosis (<7) for all translations, except for the PMHI-Malay "spirituality" subscale (skewness: -2.8; kurtosis: 12.5). CFA showed that all three PMHI translations fulfilled the original six-factor-higher-order structure (RMSEA = 0.05, CFI = 0.962, TLI = 0.96). Cronbach's alpha coefficients for total PMHI were 0.958, 0.954, 0.945 and 0.949 in the overall sample and the Chinese, Malay and Tamil translations, respectively. The three translations of the PMHI showed expected and significant positive (r = 0.116 to 0.663) and negative correlations (r = -0.137 to -0.574) with established measures. The findings show that the Chinese, Malay and Tamil translations of the PMHI have high internal consistency and validity in this multi-ethnic population.

This study was performed to describe the patterns of healthcare switching with overlapping use of anti-diabetic medication in the elderly using the Korea Health Insurance Review and Assessment Service's claims data. The study subjects were ambulatory elderly diabetic patients (ICD-10, E10-14) receiving at least one oral anti-diabetic drug or insulin, and visiting healthcare facilities more than two times between January and December 2005. A total of 457,975 elderly diabetic ambulatory care patients were identified. The mean of visiting frequencies was 9.0 ( ± 3.6) and switching frequencies was 1.5 ( ± 0.8) during 2005. Switching group consisted of 33% of total study subject. Healthcare switching was common in female patients who were older, and had treated polytherapy more in rural areas. The movement among primary care medical services was very common among the patients in the switching group (52.6%). A statistically significant correlation was observed between the healthcare switching and concomitant drug use (rho = 0.96), and overlapping days (rho = 0.57). The use of overlapping anti-diabetic medication increased with the extent of healthcare switching. Further, frequent switching of healthcare between primary clinics was observed. Efforts should be made to establish continuity for the elderly diabetic patients with the identification of frequent switching with overlapping medication.

Background: The purpose of the present study was to investigate the possible contribution of plasma homocysteine to asymptomatic cerebral infarction (CI) or leukoaraiosis.Methods: The relationship between plasma homocysteine concentrations and cerebral lesions was investigated in 233 elderly diabetic patients (mean age: 74 years) who were divided into three groups based on the neurological and brain MR findings: asymptomatic cerebral infarction (CI), symptomatic CI, and a control group with no evidence of cerebrovascular disease. Plasma total homocysteine concentrations were measured by high‐performance liquid chromatography. The C677T polymorphism in the methylene tetrahydrofolate reductase (MTHFR) gene was assessed by PCR‐RFLP. The total score of T2 high‐intensity lesions on the brain MR images was summed from the focal T2 high‐intensity scores in 24 areas of the brain.Results: Diabetic patients with asymptomatic or symptomatic CI had significantly higher homocysteine concentrations in plasma than the control group. The plasma homocysteine concentration was more strongly associated with the presence and number of small infarctions or infarction of the putamen, which may explain the association between increased plasma homocysteine concentrations and asymptomatic CI in elderly diabetic patients. In the diabetic patients, high plasma homocysteine concentrations were also significantly associated with high scores of total T2 high‐intensity lesions or focal T2 high‐intensity scores in some periventricular regions. Although there was no significant relationship between the MTHFR TT genotype and CI, a significant association was found between the MTHFR TT genotype and total T2 high‐intensity scores.Conclusion: An elevated plasma homocysteine concentration is independently associated with asymptomatic CI and T2 high‐intensity lesions on brain MR images in elderly patients with diabetes mellitus. The association between the MTHFR TT genotype and periventricular T2 high‐intensity lesions, but not with CI, suggests an important effect of C677T MTHFR gene mutation on leukoaraiosis, independent of hyperhomocysteinemia in elderly diabetic patients.

Constipation is quite common and has impact on life quality in the elderly diabetic patients; therefore it is important to seek better treatments. The aim of this study is to evaluate the effect of Chang Run Tong (CRT) decoction on constipation in elderly diabetic patients in comparison with the effect of Macrogol 4000 powder (Forlax). This study was designed as a prospective study consisting of two parallel arms: CRT group and Forlax group. The study was conducted in China-Japan Hospital. Subject interventions: Eighty elderly diabetic patients with constipation were evaluated, among them 52 patients were treated with CRT and 28 patients were treated with Forlax. The patients were interviewed for Bristol stool scale, spontaneous complete bowel movements (SCBM) and symptoms of defecation feeling, defecation weakness, feeling of incomplete evacuation, bloating, and flatulence at different time points. The changes of all above parameters from treatment for 2 and 4 weeks and follow-up for 1 and 2 months with reference to the baseline (before treatment) were compared between CRT and Forlax treatments. The treatment efficiency was evaluated and compared between two different treatments. For the improvement of Bristol stool scale, SCBM and feeling of incomplete evacuation, CRT was significantly better than Forlax at different time points (p < 0.01, p < 0.001). For the symptoms of defecation feeling, defecation weakness, bloating, and flatulence, CRT was significantly better than Forlax for follow-up improvement (p < 0.01, p < 0.001); whereas no difference was found at other time points of the treatment (p > 0.05). Furthermore, CRT had a significantly better treatment efficiency than Forlax (p < 0.001). Both CRT and Forlax treatment could effectively improve bowel habits and symptoms of constipation in elderly diabetic patients. CRT was better than Forlax to treat constipation in elderly diabetic patients and had better follow-up improvement after stopping drugs.

Salient symptoms and course of depression in elderly diabetes mellitus patients in South Indian populationBackground -Depression and diabetes have a bidirectional relationship . Due to high prevalence and immense hidden burden for both conditions , the association should be considered as an important public health concern .Characteristics of depression in diabetes patients remains poorly studied . A clear understanding of the qualitative nature of depression in a highly vulnerable population like the elderly will provide promising avenues for reducing the disease burden for both entities .Aim -To explore the salient features and course of depression in elderly diabetes patients in south indiaMaterials and Methods -Elderly diabetic patients with scores of >5 (N= 52) on the Patient Health Questionnaire-9 were evaluated . Hamilton depression and anxiety ( HAM-A , HAM -D ) scales along with Montgomery and Asberg Depression Rating Scale (MADRS) were administered . Qualitative aspects were obtained via detailed clinical interview by a psychiatrist .Results -80% individuals (N=42) had ‘mild to moderate’ symptoms with multiple recurrences or a long ( >1yr) course for 86.5 % (N= 45) individuals . Fatigue , insomnia , somatic anxiety and inner tension dominated the clinical picture. Persistent symptoms were positively correlated with higher HbA1c , higher BMI and multimorbid state .Discussion -Elderly diabetes patients had a chronic and recurrent course with milder nature of symptoms with multiple factors influencing the clinical picture . Regular patients at the medicine OPD were found to have depressive features on incidental screening , emphasising the importance of physicians in tackling the burden .

As the global population ages, cardiovascular diseases, particularly heart failure (HF), have become leading causes of mortality and disability among elderly patients. Diabetes and hypertension are major risk factors for cardiovascular diseases, making this group especially vulnerable to HF. Current clinical tools for predicting HF risk are often complex, requiring extensive clinical parameters and laboratory tests, which limit their practical application. Therefore, a need exists for a predictive model that is both simple and effective in assessing HF risk in elderly patients with diabetes and hypertension. This study utilized data from the National Health and Nutrition Examination Survey, spanning seven cycles from 2003 to 2016, including 71 058 subjects. The study focused on elderly patients (aged 65 and above) diagnosed with both diabetes and hypertension, ultimately including 1445 participants. We examined seven novel composite indices: a body shape index (ABSI), atherogenic index of plasma (AIP), BARD score, body fat percentage (BFP), body roundness index (BRI), fatty liver index (FLI), and prognostic nutritional index (PNI). These indices were selected for their simplicity and ease of calculation from routine clinical assessments. The primary outcome was HF status, and data pre-processing included imputation for missing values using random forest algorithms. Various machine learning models were applied, including random forest, logistic regression, XGBoost, and others, with model performance assessed through metrics like accuracy, precision, recall, F1 score, and receiver operating characteristic-area under the curve (ROC AUC). The best-performing model was further analysed using SHAP (SHapley Additive exPlanations) values to determine feature importance. The study found that the XGBoost model demonstrated superior performance across all evaluation metrics, with an area under the curve (AUC) value of 0.96. Significant predictors of HF included BRI and PNI, which had the highest SHAP values, indicating their substantial influence on model predictions. The study also highlighted the robust predictive capabilities of AIP, particularly in assessing cardiovascular events in elderly patients. The study demonstrates that novel composite indices like ABSI, AIP, BARD score, BFP, BRI, FLI, and PNI have significant potential in predicting HF risk among elderly diabetic and hypertensive patients. These indices offer clinicians new tools for cardiovascular risk assessment that are simpler and potentially more effective in clinical practice. Future research should focus on validating these findings in different populations and exploring their longitudinal predictive power. This study explores simple and effective ways to predict heart failure risk in elderly patients with diabetes and hypertension by using novel, easy-to-calculate indices.Indices like ABSI, AIP, BARD score, BFP, BRI, FLI, and PNI are highly effective in predicting heart failure risk in elderly diabetic and hypertensive patients.The XGBoost machine learning model, which uses these indices, demonstrated strong predictive power with an AUC of 0.96, highlighting its clinical applicability.

Aims: Using specials wearable sensors, we explored changes in gait and balance parameters, over time, in elderly patients at high risk of diabetic foot, wearing different types of footwear. This assessed the relationship between gait and balance changes in elderly diabetic patients and the development of foot ulcers, in a bid to uncover potential benefits of wearable devices in the prognosis and management of the aforementioned complication. Methods: A wearable sensor-based monitoring system was used in middle-elderly patients with diabetes who recently recovered from neuropathic plantar foot ulcers. A total of 6 patients (age range: 55–80 years) were divided into 2 groups: the therapeutic footwear group (n = 3) and the regular footwear (n = 3) group. All subjects were assessed for gait and balance throughout the study period. Walking ability and gait pattern were assessed by allowing participants to walk normally for 1 min at habitual speed. The balance assessment program incorporated the “feet together” standing test and the instrumented modified Clinical Test of Sensory Integration and Balance. Biomechanical information was monitored at least 3 times. Results: We found significant differences in stride length (p < 0.0001), stride velocity (p < 0.0001), and double support (p < 0.0001) between the offloading footwear group (OG) and the regular footwear group on a group × time interaction. The balance test embracing eyes-open condition revealed a significant difference in Hip Sway (p = 0.004), COM Range ML (p = 0.008), and COM Position (p = 0.004) between the 2 groups. Longitudinally, the offloading group exhibited slight improvement in the performance of gait parameters over time. The stride length (odds ratio 3.54, 95% CI 1.34–9.34, p = 0.018) and velocity (odds ratio 3.13, 95% CI 1.19–8.19, p = 0.033) of OG patients increased, converse to the double-support period (odds ratio 6.20, 95% CI 1.97–19.55, p = 0.002), which decreased. Conclusions: Special wearable devices can accurately monitor gait and balance parameters in patients in real time. The finding reveals the feasibility and effectiveness of advanced wearable sensors in the prevention and management of diabetic foot ulcer and provides a solid background for future research. In addition, the development of foot ulcers in elderly diabetic patients may be associated with changes in gait parameters and the nature of footwear. Even so, larger follow-up studies are needed to validate our findings.

Poor glycemic control impairs the cardioprotective effects of red blood cells on myocardial ischemia/reperfusion injury

Aims/IntroductionTo investigate the prevalence of sarcopenia, its related factors and indicators of physical evaluation in elderly diabetes patients.Materials and MethodsThis 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.ResultsThe 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).ConclusionsThe 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.

Background: Diabetic foot ulcer is a serious complication of diabetes and a major cause of morbidity and mortality among diabetic elderly patients, and good prevention guideline programs will inhibit the diabetic foot ulcer and further complication. Aims: This study aimed to evaluate the effect of a foot ulcer prevention guideline program for elderly diabetic patients at EL- Fayoum General Hospital. Research design: A quasi-experimental research design was used to utilize this study. Setting: The study was conducted at the medicine outpatient clinic in EL- Fayoum General Hospital. Subjects: A purposive sample was used to choose 300 elderly diagnosed with diabetes. Tools for data collection: Two tools for data collection were used. 1st tool: Structured interviewing questionnaire included demographic characteristics of elderly patients, past and current medical history, knowledge assessment questionnaire, patients reported practice questionnaire. 2nd tool: Observational checklist to assess foot ulcer risk included neurological foot assessment and peripheral vascular assessment. Results: It was revealed that there was a highly statistically significant improvement in total knowledge, good score and satisfactory reported practice represented as (7% to 85.3%) and (40.3% to 93.30%) respectively pretest versus posttest. In addition, there was a highly statistically significant improvement in total neurological foot items and total right and left peripheral vascular items represented as (14.23±3.004 to 16.97±1.800), (11.38±2.57 to 12.22±2.11) and (11.32±2.63 to 12.15±2.14) respectively pretest versus posttest. Conclusion: The current study concluded that after applying the foot ulcer prevention guideline program, level of knowledge, reported practice and foot ulcer risk scale of elderly diabetic patients improved. Recommendation: Periodic prevention guideline program and reduction sessions regarding the prevention of foot ulcer in diabetic elderly patients.

Objective To investigate the effect of glycated albumin on recurrent cerebral infarction in elderly patients with diabetes mellitus. Methods All of 252 elderly acute cerebral infarction patients with diabetes mellitus were chosen from clinics. They were divided into 2 groups: A group (glycated albumin <19.0% , 117 patients) and B group (glycated albumin ≥ 19.0%, 135 patients). The clinical characteristics and the recurrent rate of cerebral infarction were compared between two groups. Results The levels of glycated albumin, fasting blood glucose, total cholesterol, low-density lipoprotein cholesterol and triglycerides in B group were significantly higher than those in A group: (21.00 ± 4.93)% vs. (16.75±1.72)%, (9.84 ± 2.89) mmol/L vs. (5.36 ± 1.00) mmol/L, (5.44 ± 1.30) mmol/L vs. (4.57 ± 1.00) mmol/L, (3.13±0.81) mmol/L vs. (2.58 ± 0.74) mmol/L, (2.34 ± 1.61) mmol/L vs. (1.74 ± 1.47) mmol/L, P<0.01 or <0.05. The recurrent rate of cerebral infarction in B group was significantly higher than that in A group: 53.3% (72/135) vs.36.7% (43/117), χ2 = 6.946, P = 0.008. Logistic regression analysis showed that the increase of glycated albumin was the independent risk factor of recurrent cerebral infarction in elderly patients with diabetes mellitus (P = 0.048). Conclusions The recurrent rate of cerebral infarction is increased in elderly diabetes patients with high glycated albumin. The increase of glycated albumin is the independent risk factor of recurrent cerebral infarction. Key words: Aged; Diabetes mellitus; Cerebral infarction; Glycated albumin

The novel myokine myonectin is predominantly expressed in skeletal muscle and is involved in the regulation of metabolic homeostasis. A putative association between myonectin and type 2 diabetes mellitus (T2DM) has been discussed controversially in current literature. The association between myonectin and T2DM at different ages is still obscure and thus is addressed in the present study. We measured myonectin in 410 vascular risk patients with a mean age of 66 years. Myonectin did not correlate with age (r=-0.19; p=0.697). Half of our patients (53%) were elderly (≥66 years; n=219) with a mean age of 74 years. The younger ones (≤65 years; n=191) had a mean age of 57 years. 40.6% (n=89) of elderly patients had T2DM and 42.4% (n=81) of the younger ones. Myonectin concentrations were significantly decreased in elderly patients with T2DM compared to nondiabetic ones (1.8 vs, 4.2 ng/ml; p=0.002), whereas no significant difference was seen in younger patients (2.6 vs. 2.3 ng/ml; p=0.183). Regression analysis revealed an unadjusted odds ratio (OR) of 0.24 [0.07-0.81] (p=0.021) for the association between myonectin and T2DM in elderly patients but not in younger patients (OR=1.08 [0.80-1.45]; p=0.609). This association remained significant after adjusting for sex, body mass index, LDL-cholesterol, HDL-cholesterol, current smoking, as well as statin intake in elderly but not in younger patients (OR=0.23 [0.07-0.81]; p=0.021 vs. OR=1.05 [0.76-1.46]; p=0.769). We conclude that plasma myonectin levels are significantly associated with T2DM particularly in elderly vascular risk patients. Disclosure A. Leiherer: None. P. Fraunberger: None. H. Drexel: None. A. Muendlein: None. K. Geiger: None. C. H. Saely: None. B. Larcher: None. A. Mader: None. M. Maechler: None. L. Sprenger: None. B. Mutschlechner: None.

The novel myokine myonectin is predominantly expressed in skeletal muscle and is involved in the regulation of metabolic homeostasis. A putative association between myonectin and type 2 diabetes mellitus (T2DM) has been discussed controversially in current literature. The purpose of this study was to investigate the association between myonectin and T2DM at different ages. We measured myonectin in 410 vascular risk patients with a mean age of 66 years. Myonectin did not correlate with age (r=−0.19; p=0.697). From our patients 219 (53%) were &amp;gt;65 years, with a mean age of 74 years and 191 ≤65 years, with a mean age of 57 years. The prevalence of T2DM was 40.6% vs. 42.4% in the older as compared to the younger age group. Myonectin concentrations were significantly decreased in elderly patients with T2DM compared to non-diabetic subjects (1.8 vs. 4.2 ng/ml; p=0.002), whereas no significant difference was observed in younger patients (2.6 vs. 2.3 ng/ml; p=0.183). Concordantly, regression analysis revealed an unadjusted odds ratio (OR) of 0.24 [0.07–0.81] (p=0.021) for the association between myonectin and T2DM in elderly patients but not in younger patients (OR=1.08 [0.80–1.45]; p=0.609). The association between myonectin and T2D; remained significant after adjusting for sex, body mass index, LDL cholesterol, HDL cholesterol, current smoking, as well as statin intake in elderly but remained non-significant in younger patients (OR=0.23 [0.07–0.81]; p=0.021 vs. OR=1.05 [0.76–1.46]; p=0.769). We conclude that plasma myonectin levels are significantly associated with T2DM, particularly in elderly vascular risk patients. Funding Acknowledgement Type of funding sources: None.