Depression in type 1 diabetes and risk of dementia

Objective: Depression afflicts 14% of individuals with type 1 diabetes (T1D). Depression is a robust risk factor for dementia but it is unknown if this holds true for individuals with T1D, who recently started living to an age conferring dementia risk. We examined if depression is a dementia risk factor among elderly individuals with T1D.

Methods: 3,742 individuals with T1D age ≥50 were followed for dementia from 1/1/96-9/30/2015. Depression, dementia, and comorbidities were abstracted from electronic medical records. Cox proportional hazard models estimated the association between depression and dementia adjusting for demographics, glycosylated hemoglobin, severe dysglycemic epidsodes, stroke, heart disease, nephropathy, and end stage renal disease. The cumulative incidence of dementia by depression was estimated conditional on survival dementia-free to age 55.

Results: Five percent (N = 182) were diagnosed with dementia and 20% had baseline depression. Depression was associated with a 72% increase in dementia (fully adjusted HR = 1.72; 95% CI:1.12-2.65). The 25-year cumulative incidence of dementia was more than double for those with versus without depression (27% vs. 12%).

Conclusions: For people with T1D, depression significantly increases dementia risk. Given the pervasiveness of depression in T1D, this has major implications for successful aging in this population recently living to old age.     

Employing computational linguistics techniques to identify limited patient health literacy: Findings from the ECLIPPSE study

ObjectiveTo develop novel, scalable, and valid literacy profiles for identifying limited health literacy patients by harnessing natural language processing.Data SourceWith respect to the linguistic content, we analyzed 283 216 secure messages sent by 6941 diabetes patients to physicians within an integrated system''s electronic portal. Sociodemographic, clinical, and utilization data were obtained via questionnaire and electronic health records.Study DesignRetrospective study used natural language processing and machine learning to generate five unique “Literacy Profiles” by employing various sets of linguistic indices: Flesch‐Kincaid (LP_FK); basic indices of writing complexity, including lexical diversity (LP_LD) and writing quality (LP_WQ); and advanced indices related to syntactic complexity, lexical sophistication, and diversity, modeled from self‐reported (LP_SR), and expert‐rated (LP_Exp) health literacy. We first determined the performance of each literacy profile relative to self‐reported and expert‐rated health literacy to discriminate between high and low health literacy and then assessed Literacy Profiles’ relationships with known correlates of health literacy, such as patient sociodemographics and a range of health‐related outcomes, including ratings of physician communication, medication adherence, diabetes control, comorbidities, and utilization.Principal FindingsLP_SR and LP_Exp performed best in discriminating between high and low self‐reported (C‐statistics: 0.86 and 0.58, respectively) and expert‐rated health literacy (C‐statistics: 0.71 and 0.87, respectively) and were significantly associated with educational attainment, race/ethnicity, Consumer Assessment of Provider and Systems (CAHPS) scores, adherence, glycemia, comorbidities, and emergency department visits.ConclusionsSince health literacy is a potentially remediable explanatory factor in health care disparities, the development of automated health literacy indicators represents a significant accomplishment with broad clinical and population health applications. Health systems could apply literacy profiles to efficiently determine whether quality of care and outcomes vary by patient health literacy; identify at‐risk populations for targeting tailored health communications and self‐management support interventions; and inform clinicians to promote improvements in individual‐level care.     

Pioglitazone initiation and subsequent hospitalization for congestive heart failure.

AIMS: Thiazolidinediones (TZD) have been associated with an expansion in plasma volume and the development of peripheral oedema. A recent study reported an association between the use of TZDs and development of congestive heart failure (CHF). The objective of this study was to determine if short-term use of pioglitazone, a TZD, is associated with increased risk of admission to hospital because of CHF in a well-characterized, community-based cohort of Type 2 diabetic patients without prevalent CHF. METHODS: A cohort study of all patients in the Kaiser Permanente Medical Care Program with Type 2 diabetes (Kaiser Permanente Northern California Diabetes Registry) who initiated any diabetes pharmacotherapy (n = 23 440) between October 1999 and November 2001. Only patients initiating single new therapies ('new users') were included to reduce confounding and create mutually exclusive exposure groups. We constructed Cox proportional hazards models (with sulphonylureas initiators specified as the reference group) to evaluate the impact of initiating new diabetes therapies on time-to-incident admission to hospital because of CHF, defined by primary hospital discharge diagnosis. RESULTS: Patients initiated pioglitazone (15.2%), sulphonylureas (25.3%), metformin (50.9%), and insulin (8.6%) alone, or as additions to pre-existing or maintained therapies. Three hundred and twenty admissions for CHF were observed during the follow-up (mean 10.2 months) after drug initiation. Relative to patients initiating sulphonylureas, there were no significant increases in the incidence of hospitalization for CHF in those initiating pioglitazone [hazard ratio (HR) = 1.28; 95% confidence interval (CI): 0.85-1.92] after adjusting for demographic, behavioural and clinical factors. There was a significantly higher incidence among those initiating insulin (HR = 1.56; 95% CI: 1.00-2.45) and lower incidence among those initiating metformin (HR = 0.70; 95% CI: 0.49-0.99). CONCLUSIONS: This study of patients with Type 2 diabetes failed to find evidence that short-term pioglitazone use was associated with an elevated risk of hospitalization for CHF relative to the standard, first-line diabetes therapy.     

Preventable Major Cardiovascular Events Associated With Uncontrolled Glucose,Blood Pressure,and Lipids and Active Smoking in Adults With Diabetes With and Without Cardiovascular Disease: A Contemporary Analysis

OBJECTIVEThe objective of this study was to assess the incidence of major cardiovascular (CV) hospitalization events and all-cause deaths among adults with diabetes with or without CV disease (CVD) associated with inadequately controlled glycated hemoglobin (A1C), high LDL cholesterol (LDL-C), high blood pressure (BP), and current smoking.RESULTSMean (SD) age at baseline was 59 (14) years; 48% of subjects were female, 45% were white, and 31% had CVD. Mean follow-up was 59 months. Event rates per 100 person-years for adults with diabetes and CVD versus those without CVD were 6.0 vs. 1.7 for MI/ACS, 5.3 vs. 1.5 for stroke, 8.4 vs. 1.2 for HF, 18.1 vs. 40 for all CV events, and 23.5 vs. 5.0 for all-cause mortality. The percentages of CV events and deaths associated with inadequate risk factor control were 11% and 3%, respectively, for those with CVD and 34% and 7%, respectively, for those without CVD.CONCLUSIONSAdditional attention to traditional CV risk factors could yield further substantive reductions in CV events and mortality in adults with diabetes.     

Symptom Burden of Adults with Type 2 Diabetes Across the Disease Course: Diabetes & Aging Study

BACKGROUND

Reducing symptom burden is paramount at the end-of-life, but typically considered secondary to risk factor control in chronic disease, such as diabetes. Little is known about the symptom burden experienced by adults with type 2 diabetes and the need for symptom palliation.

OBJECTIVE

To examine pain and non-pain symptoms of adults with type 2 diabetes over the disease course ?C at varying time points before death and by age.

DESIGN

Survey follow-up study.

PARTICIPANTS

13,171 adults with type 2 diabetes, aged 30?C75?years, from Kaiser Permanente, Northern California, who answered a baseline symptom survey in 2005?C2006.

MAIN MEASURES

Pain and non-pain symptoms were identified by self-report and medical record data. Survival status from baseline was categorized into ??6, >6?C24, or alive >24?months.

KEY RESULTS

Mean age was 60?years; 48?% were women, and 43?% were non-white. Acute pain was prevalent (41.8?%) and 39.7?% reported chronic pain, 24.6?% fatigue, 23.7?% neuropathy, 23.5?% depression, 24.2?% insomnia, and 15.6?% physical/emotional disability. Symptom burden was prevalent in all survival status categories, but was more prevalent among those with shorter survival, p?<?.001. Adults ??60?years who were alive >24?months reported more physical symptoms such as acute pain and dyspnea, whereas participants <60?years reported more psychosocial symptoms, such as depressed mood and insomnia. Adjustment for duration of diabetes and comorbidity reduced the association between age and pain, but did not otherwise change our results.

CONCLUSIONS

In a diverse cohort of adults with type 2 diabetes, pain and non-pain symptoms were common among all patients, not only among those near the end of life. However, symptoms were more prevalent among patients with shorter survival. Older adults reported more physical symptoms, whereas younger adults reported more psychosocial symptoms. Diabetes care management should include not only good cardiometabolic control, but also symptom palliation across the disease course.     

Use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk clinical and ethnic groups with diabetes

BACKGROUND: Diabetes causes 45% of incident end-stage renal disease (ESRD). Risk of progression is higher in those with clinical risk factors (albuminuria and hypertension), and in ethnic minorities (including blacks, Asians, and Latinos). Angiotensin-converting enzyme inhibitors (ACE) and angiotensin receptor blockers (ARB) slow the progression of diabetic nephropathy, yet little is known about their use among patients at high risk for progression to ESRD. OBJECTIVES: To examine the prevalence of ACE or ARB (ACE/ARB) use overall and within patients with high-risk clinical indications, and to assess for ethnic disparities in ACE/ARB use. DESIGN: Observational cohort study. SETTING: Kaiser Permanente Northern California (KPNC) Diabetes Registry, a longitudinal registry that monitors quality and outcomes of care for all KPNC patients with diabetes. PATIENTS: Individuals (N= 38887) with diabetes who were continuously enrolled with pharmacy benefits during the year 2000, and had self-reported ethnicity data on survey. INTERVENTIONS AND MEASUREMENTS: Pharmacy dispensing of ACE/ARB. RESULTS: Forty-one percent of the cohort had both hypertension and albuminuria, 30% had hypertension alone, and 12% had albuminuria alone. Fourteen percent were black, 11% Latino, 13% Asian, and 63% non-Latino white. Overall, 61% of the cohort received an ACE/ARB. ACE/ARB was dispensed to 74% of patients with both hypertension and albuminuria, 64% of those with hypertension alone, and 54% of those with albuminuria alone. ACE/ARB was dispensed to 61% of whites, 63% of blacks, 59% of Latinos, and 60% of Asians. Among those with albuminuria alone, blacks were significantly (P =.0002) less likely than whites to receive ACE/ARB (47% vs 56%, respectively). No other ethnic disparities were found. CONCLUSIONS: In this cohort, the majority of eligible patients received indicated ACE/ARB therapy in 2000. However, up to 45% to 55% of high-risk clinical groups (most notably individuals with isolated albuminuria) were not receiving indicated therapy. Additional targeted efforts to increase use of ACE/ARB could improve quality of care and reduce ESRD incidence, both overall and in high-risk ethnic groups. Policymakers might consider use of ACE/ARB for inclusion in diabetes performance measurement sets.