The risks and benefits of implementing glycemic control guidelines in frail older adults with diabetes mellitus

OBJECTIVES: To determine the hypo‐ and hyperglycemic outcomes associated with implementing the American Geriatrics Society (AGS) guideline for a glycosylated hemoglobin (HbA1c) level of less than 8% in frail older adults with diabetes mellitus (DM). DESIGN: Guideline implementation. SETTING: Program of All‐Inclusive Care for the Elderly. PARTICIPANTS: All participants in the before (October 2002–December 2004, n=338), early (January 2005–June 2006, n=289) and late (July 2006–December 2008, n=385) periods of guideline implementation with a diagnosis of DM and at least one HbA1c measurement. INTERVENTION: Clinician education in 2005 with annual monitoring of the proportion of each clinician's patients with DM with HbA1c less than 8%. MEASUREMENTS: Hypoglycemia (blood glucose<50 mg/dL), hyperglycemia (blood glucose>400 mg/dL), and severe hypoglycemia (emergency department (ED) visit for hypoglycemia). RESULTS: Participants in the before, early, and late periods were similar in age, race and ethnicity, comorbidities, and functional dependence. Antihyperglycemic medication use was greater in the late period, with more participants using metformin (28% before, 42% late, P<.001) and insulin (23% before, 34% late, P<.001) and achieving the AGS glycemic target of HbA1c of less than 8% (74% before, 84% late, P<.001). Episodes of hyperglycemia (per 100 person‐years) were dramatically lower in the late period (159 before, 46 late, P<.001), and episodes of hypoglycemia were similar (10.1 before, 9.3 late, P=.50). There were more episodes of severe hypoglycemia in the early period (1.1 before, 2.9 early, P=.03). CONCLUSION: Implementing the AGS glycemic control guideline for frail older adults led to fewer hyperglycemic episodes but more severe hypoglycemic episodes requiring ED visits in the early implementation period. Future glycemic control guideline implementation efforts should be coupled with close monitoring for severe hypoglycemia in the early guideline implementation period.     

Overtreatment of older patients with type 2 diabetes mellitus in primary care

Given that there are indications of overtreatment in older patients with type 2 diabetes in both the United States and Europe, we assessed the level of personalized diabetes treatment for older patients in primary care, focusing on overtreatment. Based on Dutch guidelines individuals aged ≥70 years were classified into 3 glycated haemoglobin (HbA1c) treatment target groups: 7% (53 mmol/mol), 7.5% (58 mmol/mol) and 8% (64 mmol/mol). In our cohort of 1002 patients (n = 319 aged ≥70 years), the 165 patients with HbA1c targets >7% had more micro‐ and macrovascular complications, more often used ≥5 medicines and were more often frail compared with those with an HbA1c target ≤7%. Of these 165 patients, 64 (38.8%) were overtreated; that is, 20% of all people aged ≥70 years. The majority of overtreated people were frail and used ≥5 medicines. Hypoglycaemia occurred in 20.3% of these patients and almost 30% reported accidents involving falls. Personalized treatment in older people with type 2 diabetes is not common practice. A substantial number of older people are overtreated, with probable harmful consequences. To prevent overtreatment, definition of lower HbA1c limits might be helpful.     

Individualizing glycemic targets in type 2 diabetes mellitus: implications of recent clinical trials

One of the first steps in the management of patients with type 2 diabetes mellitus is setting glycemic goals. Professional organizations advise setting specific hemoglobin A(1c) (HbA(1c)) targets for patients, and individualization of these goals has more recently been emphasized. However, the operational meaning of glycemic goals, and specific methods for individualizing them, have not been well-described. Choosing a specific HbA(1c) target range for a given patient requires taking several factors into consideration, including an assessment of the patient's risk for hyperglycemia-related complications versus the risks of therapy, all in the context of the overall clinical setting. Comorbid conditions, psychological status, capacity for self-care, economic considerations, and family and social support systems also play a key role in the intensity of therapy. The individualization of HbA(1c) targets has gained more traction after recent clinical trials in older patients with established type 2 diabetes mellitus failed to show a benefit from intensive glucose-lowering therapy on cardiovascular disease (CVD) outcomes. The limited available evidence suggests that near-normal glycemic targets should be the standard for younger patients with relatively recent onset of type 2 diabetes mellitus and little or no micro- or macrovascular complications, with the aim of preventing complications over the many years of life. However, somewhat higher targets should be considered for older patients with long-standing type 2 diabetes mellitus and evidence of CVD (or multiple CVD risk factors). This review explores these issues further and proposes a framework for considering an appropriate and safe HbA(1c) target range for each patient.     

A study of non-obese diabetes mellitus in adults in a tertiary care hospital in Kerala, India

The term Latent Autoimmune Diabetes in Adults (LADA) was introduced to define adult diabetic patients initially non–insulin-requiring but with immune markers of type 1 diabetes that, in a number of cases, progress to insulin dependency. This term has been largely used in the last few years when referring to autoimmune forms of diabetes not requiring insulin initially. In the present study we looked for the clinical, biochemical and immunological parameters of non-obese type 2 diabetes mellitus in adults and studied the frequency of antibodies to glutamic acid decarboxylase (GAD) and pancreatic islet cell antibodies (PICA). Subjects of 30 years or older with a history of diabetes of duration not more than 36 months and body mass index (BMI) of less than 23 kg/m² were included. Fasting serum C-peptide, GAD antibody and islet cell auto antibody was estimated. GAD antibodies were positive in 25.81 %, ICA in 22.58 % and both in 9.70 % of lean diabetes. Fasting serum C-peptide was less than normal in 45.16 % of them.     

Duration of diabetes and glycemic control: impact on echocardiography findings in children and young adults with diabetes mellitus in Lagos

The influence of disease duration and glycemic control on cardiac function in type 1 diabetes mellitus (T1DM) patients remains controversial. There is little data on young patients in the Sub-Saharan continent. The aim of this study was to determine the effect of disease duration and glycemic control on the cardiac function of children and adolescents with diabetes using echocardiography. In this cross sectional study, 26 T1DM subjects and 33 matched controls had conventional echocardiography done. The relationship between their cardiac parameters, disease duration and glycated hemoglobin (HbA1c) level was assessed with correlation and regression analysis. Five (19.2 %) subjects had evidence of abnormal fractional shortening. There was no significant difference in systolic function between the diabetics and controls. The isovolumic relaxation time and Deceleration time were significantly prolonged in the diabetics (P?=?0.034, P?=?0.001 respectively). There was a significant correlation between disease duration and end diastolic diameter (EDD) (P?=?0.000) and Left ventricular mass (P?=?0.000). Disease duration was also an independent predictor of EDD (P?=?0.007), even after adjusting for age, body mass index and mean arterial pressure. There were no significant correlations between HbA1c and measures of cardiac structure or function. The right ventricular diastolic function was poorer in the T1DM subjects compared to the controls. Thus, the disease duration independently predicts left ventricular enlargement in this population of Sub-Saharan youths (who have relatively poor glycemic control).     

Depression and glycemic control in hispanic primary care patients with diabetes

CONTEXT: Maintaining optimal glycemic control is an important goal of therapy in patients with diabetes mellitus. Patients of Hispanic ancestry have been shown to have high rates of diabetes and poor glycemic control (PGC). Although depression is common in adults with diabetes, its relationship to glycemic control remains unclear, especially among Hispanics. OBJECTIVE: To assess the association of depression with PGC in Hispanics. DESIGN: Data from a cross-sectional mental health survey in primary care were crosslinked to the hospital's computerized laboratory database. SETTING: Urban general medicine practice at a teaching hospital. PATIENTS: Two hundred and nine patients (mean [standard deviation] age, 57.1 [10.3] years; 68% females) with recent International Classification of Diseases, Ninth Revision (ICD-9) codes for diabetes mellitus, and 1 or more hemoglobin A(1c) (HbA(1c)) tests. MAIN OUTCOME MEASURE: Probability of PGC (HbA(1c)>or=8%). RESULTS: Probability for PGC steadily increased with severity of depression. Thirty-nine (55.7%) of the 70 patients with major depression had HbA(1c)>or=8%, compared with 39/92 (42.4%) in the minimal to mild depression group, and 15/47 (31.9%) in the no depression group (P(trend)=.01; adjusted odds ratio, 3.27; 95% confidence interval, 1.23 to 8.64, for moderate or severe depression vs no depression). Only 29 (41.4%) of the patients with major depression received mental health treatment in the previous year. CONCLUSIONS: In this primary care sample of Hispanic patients with diabetes, we found a significant association between increasing depression severity and PGC. Yet, less than one half of the patients with moderate or severe depression received mental health treatment in the previous year. Improving identification and treatment of depression in this high-risk population might have favorable effects on diabetic outcomes.     

The relationship between glycemic control and falls in older adults

OBJECTIVES: To determine whether glycemic control contributes to fall risk in frail and nonfrail elderly adults with diabetes mellitus.
DESIGN: Retrospective, case-controlled design.
SETTING: Health maintenance organization in the Denver, Colorado, metropolitan area.
PARTICIPANTS: One hundred eleven community-dwelling adults aged 75 and older who receive care through Kaiser Permanente of Colorado. All subjects had been diagnosed with diabetes mellitus, had at least one hemoglobin A1C (HbA1c) measurement in the previous 12 months, and were using oral hypoglycemic medication or insulin to control their diabetes mellitus.
MEASUREMENTS: Measurements of risk factors (Vulnerable Elders Survey (VES-13) with a cutpoint of 3 to determine frailty status, self-reported number of falls over the prior 12-month period, HbA1c, fasting low-density lipoprotein cholesterol, average blood pressure, and other factors related to fall risk) were obtained through telephone interview and medical chart review. The outcome measure was falls.
RESULTS: Bivariate analyses to assess correlations between falls and risk factors determined that only HbA1c, frailty, and peripheral neuropathy were significantly associated with falls. A stepwise logistic regression determined that fall risk markedly increased when HbA1c was 7 or below, regardless of frailty status.
CONCLUSION: In this retrospective study of a convenience sample of frail older adults with diabetes mellitus, tighter glycemic control was associated with greater risk of falling. Prospective studies that further evaluate the risks and benefits of relaxed glucose control in high-risk older adults are needed to confirm this finding.     

Self-efficacy, self-management, and glycemic control in adults with type 2 diabetes mellitus

ObjectiveThe objective was to evaluate the relationships between diabetes management self-efficacy and diabetes self-management behaviors and glycemic control.MethodsA cross-sectional design was used. A convenience sample of 223 subjects with type 2 diabetes, ≥25 years old, who sought care at the National Diabetes Center in Amman, Jordan, was enrolled. A structured interview and medical records provided the data. The instruments included a sociodemographic and clinical questionnaire, a diabetes management self-efficacy scale, and a diabetes self-management behaviors scale. Glycosylated hemoglobin was used as an index for glycemic control. The analyses are presented as proportions, means (±S.D.), odds ratios, and 95% confidence intervals obtained from logistic regressions.ResultsDiet self-efficacy and diet self-management behaviors predicted better glycemic control, whereas insulin use was a statistically significant predictor for poor glycemic control. In addition, subjects with higher self-efficacy reported better self-management behaviors in diet, exercise, blood sugar testing, and taking medication. The findings showed that more than half of the subjects did not have their diabetes under control and that only 42% had attended diabetes education programs.ConclusionsThe majority of subjects did not have their diabetes controlled; their self-efficacy was low, and they had suboptimal self-management behaviors. Therefore, strategies to enhance and promote self-efficacy and self-management behaviors for patients are essential components of diabetes education programs. Furthermore, behavioral counseling and skill-building interventions are critical for the patients to become confident and be able to manage their diabetes.     

Parents matter: intergenerational influences of diabetes mellitus on glycemic control and morbidity in older type 2 diabetic males

In a cross-sectional study, the effects of disease duration of type 2 diabetes mellitus (DM) were examined along with parent history of DM on disease-related outcome variables. Specifically, the moderating role of parent history of DM on outcome variables was examined. Participants were 53 male veterans with DM. Chart reviews and self-reports were examined. Results showed that in those with a positive parent history of DM, hopelessness increased with diabetes duration. In the negative parent history group, glycemic control worsened with disease duration. These findings suggest parent history of DM should be considered in designing interventions to facilitate coping with type 2 diabetes.     

The psychosocial aspects of diabetes care. Using collaborative care to manage older adults with diabetes

Diabetes is a chronic disease that requires managing medications, adhering to dietary requirements, and engaging in age- and abilities appropriate physical activity. This article addresses the need for a collaborative care management approach that emphasizes a partnership between older adults and health care professionals. Such an approach recognizes that patients are the experts about their lives and primary care providers are experts about diabetes. A collaborative care management approach can help primary care providers assist older adults to address psychosocial concerns, cognitive functioning, and depression. We conclude this article with a brief discussion regarding a transdisciplinary approach that takes the collaborative care management approach one step further.     

Prognostic effect of exercise capacity on mortality in older adults with diabetes mellitus

OBJECTIVES: To investigate the prognostic effect of exercise capacity in older individuals with diabetes mellitus. DESIGN: Retrospective data review in a clinic‐based cohort. SETTING: Veterans Affairs Medical Centers in Washington, District of Columbia, and Palo Alto, California. PARTICIPANTS: Two thousand eight hundred sixty‐seven men aged 50 to 87 with type 2 diabetes mellitus. MEASUREMENTS: Exercise tolerance testing with fitness categories based on peak metabolic equivalents of task (METs) achieved adjusted for age. All‐cause mortality in age groups 50 to 65 (Group 1; n=1,658) and older than 65 (Group 2; n=1,209) was analyzed using adjusted Cox proportional hazards models. RESULTS: After a mean ± standard deviation follow‐up period of 7.8 ± 5.1 years, there were 324 deaths in Group 1 (20%) and 464 in Group 2 (38%). For each 1‐MET increase in exercise capacity, mortality was 18% lower for the entire cohort (hazard ratio (HR)=0.82, 95% confidence interval (CI)=0.79–0.86), 23% lower for Group 1 (HR=0.77, 95% CI=0.73–0.82), and 16% lower for Group 2 (HR=0.84, 95% CI=0.8–0.89). When fitness categories were considered, the mortality risk was 30% to 80% lower for those who achieved more than 4 METs in both age groups. CONCLUSION: Augmented exercise capacity is associated with lower risk of mortality in people with type 2 diabetes mellitus aged 50 to 65 as well as in those older than 65. Thus, physical fitness, as represented by exercise capacity, lowers mortality risk in people with diabetes mellitus irrespective of age. These findings suggest that healthcare providers should be cognizant of the level of exercise capacity in individual patients and encourage a physically active lifestyle regardless of age.     

Cognitive dysfunction in older subjects with diabetes mellitus: impact on diabetes self-management and use of care services

Objective: To determine whether cognitive impairment is associated with changes in self-care behaviour and use of health and social services in older subjects with diabetes mellitus. Research design and methods: This was a community based, case-control study of subjects registered with general practices participating in the All Wales Research into Elderly (AWARE) Diabetes Study. The 396 patients aged 65 years or older with known diabetes mellitus were compared with 393 age- and sex-matched, non-diabetic controls. Adjusted odds ratio estimates of normal performance on Mini-Mental State Examination (MMSE) and Clock Drawing Test (numbers and hands) were determined. Information on self-care behaviours and use of services was obtained. Results: A total of 283 (71%) diabetic subjects scored 24 or more on MMSE, compared with 323 (88%) of controls (OR 0.54, P<0.0005). The mean (S.D.) scores were 24.5 (5.1) and 25.7 (4.3), respectively (difference between means 1.22; 95% CI 0.56, 1.88; P<0.001). Clock testing demonstrated that 257 (65%) and 286 (72%) diabetic subjects correctly placed the numbers and hands, respectively, compared with 299 (76%) and 329 (84%) of controls (OR 0.59, P<0.001 and P<0.52, P<0.0005, respectively). Both test scores declined with increasing age, earlier school leaving age and deteriorating visual acuity. Of other variables examined, only need for oral hypoglycaemic drugs or insulin, history of stroke, dementia or Parkinson's disease and symptoms of autonomic neuropathy significantly impaired one or more cognitive test scores. The odds ratios (95% CI) for normal cognitive test results in subjects with diabetes after adjusting for all significant variables was 0.74 (0.56, 0.97), P=0.029 for MMSE scores and 0.63 (0.44, 0.93), P=0.019, and 0.58 (0.38, 0.89), P=0.013, for the numbers and hands parts of the clock test, respectively. In comparison with diabetic subjects with no evidence of cognitive impairment, diabetic subjects with an MMSE score <23 were significantly less likely to be involved in diabetes self-care (P<0.001) and diabetes monitoring (P<0.001). A low MMSE score was also significantly associated with higher hospitalisation in the previous year (P=0.001), reduced ADL (activities of daily living) ability (P<0.001) and increased need for assistance in personal care (P=0.001). Conclusions: Elderly subjects with predominantly Type 2 diabetes mellitus display significant excess of cognitive dysfunction, associated with poorer ability in diabetes self-care and greater dependency. Routine screening of cognition in older subjects with diabetes is recommended.     

Prevalence and determinants of diabetes distress in patients of diabetes mellitus in a tertiary care centre

Background

Patients of diabetes mellitus experience psychological difficulties associated with their disease which remains unrecognized involving several states related to coping with diabetes. Diabetes distress is a distinct condition which is often mistaken for depression and is related to adverse disease outcomes.