Current Diabetes Reviews - Volume 12, Issue 2, 2016

Aging is one of the most important societal challenges that western societies face, as a result of longer life expectancy and reduced natality rates. Aging is a success story of our health and social systems, but raises sustainability issues that are linked to the increased need for services of older adults, due to the reduction of their independence and to the co-existence of multiple chronic diseases. The metabolic syndrome can be considered an age-related disease, since its prevalence increases with age. Current demographic trends in the population highlight aging-related dysfunctions that contribute to the onset of several metabolic diseases, and the need for innovative, effective and sustainable approaches. This review describes the correlation between the metabolic syndrome and aging, and the underlying common molecular mechanisms, focusing on calcium signaling and its crosstalks.

The natural process of aging determinates several cardiac modifications with increased susceptibility to heart diseases and ultimately converging on development of chronic heart failure as final stage. These changes mainly include left ventricular hypertrophy, diastolic dysfunction, valvular degeneration, increased cardiac fibrosis, increased prevalence of atrial fibrillation, and decreased maximal exercise capacity, as demonstrated in several humans and animal models of aging. While different theories have been proposed to explain the natural process of aging, it is clear that most of the alterations affect mechanisms involved in cell homeostasis and maintenance. Latest research studies have in particular focused on role of mitochondrial oxidative stress, energy production and mitochondria quality control. This article reviews the central role played by this organelle in aging and the role of new molecular players involved into the progression toward heart failure and potentially susceptible of new “anti-aging” strategies.

The treatment of diabetes in the elderly is a major challenge both in terms of clinical management and of public health. Evidence about prescribing patterns in the elderly diabetic population is limited. The aim was to describe trends in antidiabetic drug (AD) utilization patterns in the elderly in Southern Italy with a focus on drugs for cardiovascular prevention and pharmaceutical costs. The data used for this study were obtained from pharmacy records of Caserta Local Health Authority, a province in Southern Italy with 1 million of inhabitants, comprising urban and rural areas. Subjects above 65 years who received at least one dispensing of antidiabetic between January 2010 and December 2014 were selected. Prevalence and incidence rates (%) of AD use were calculated for each calendar year and stratified by class therapy and age group. Sub-analyses by cardiovascular co-medication therapy and pharmaceutical cost analysis were performed. The prevalence rate decreases from 22.0% in 2010 to 17.5% in 2014 (p<0.001). Proportion of subjects treated with monotherapy increases over the study period (33.9% in 2010; 38.6% in 2014; p<0.001). In particular, increases the proportion of users of metformin (18.2% in 2010; 23.7% in 2014; p<0.001), while the proportion of users of sulfonylureas dropped (11.0% in 2010; 7.2% in 2014; p< 0.001). About 90% of elderly diabetic patients are treated with drugs for cardiovascular prevention. The per/patient/yearly drug costs were 2,349 ∈: 28.5% for AD therapy and 71.5% for other treatments. Trend in drug utilization patterns showed a tendency towards treatment recommendations in older adults.

The prevalence of diabetes increases with age, which is also a determinant of nutrition therapy adherence. This descriptive study was conducted in a non-random sample of 66 patients aged between 47 and 75 years (M=61.5; SD=8.0) receiving health care in a Diabetes Clinic in the municipality of Faro, in the Portuguese region of the Algarve. We aimed to assess the association between age and the clinical characteristics of type 2 diabetes and to analyze the perceptions regarding the barriers to an adequate diet. Glycated hemoglobin (HbA1c) (r=-0.372, P<0.001) showed a negative correlation with age, suggesting that older patients have a better glucose control. Older age is also correlated with a higher number of daily meals (r=0.263) and lower intake of energy (r=-0.334), protein (r=-0.249), sugars (r=-0.301), and water (r=-0.223). Forty-six patients (69.7%) had a mean excess energy intake of 384 kcal (SD=630.2), when compared with individual nutritional energy estimated requirements. Excess energy intake was uncorrelated with age (r=-0.138, P=0.269). Older patients also seem more confused with the nutrition information they received (r=0.248) and feel that they need more advice on what is a proper diet (r=0.242). Nutrition education interventions in this population must be tailored in order to address these factors.

Diabetic Peripheral Neuropathy (DPN) is highly prevalent among diabetic ageing adults. The sensory and motor impairments caused by this long-term complication lead to poorer physical functioning, postural control and balance. These changes affect the activities of daily living and increase the risk of falling, subsequently leading to increased morbidity and decreased quality of life. Early detection of such functional limitations is important, as it may influence the effectiveness of rehabilitation programs and prevent further functional dependence. This review focuses on functional aspects related to balance, postural control and mobility in ageing adults suffering from DPN, as well as their assessment by valid, reliable and low-cost performance-based measurements. PUBMED was searched for articles in English published between 2004 and 2014. Search terms included diabetic neuropathy, balance, postural control, functional mobility, and functional outcomes. Reviewed literature indicates that simple and low-cost measurements, easy to include in clinical routines, can be used for screening impairments in complex functions, such as balance and mobility. Some studies have also been able to correlate results from DPN severity scales with those of functional tests, showing that applying such tests may improve the early diagnosis of this neurological disorder. Berg Balance Scale, Dynamic Gait Index, Functional Reach Test, and Time Up and Go already have modified cut-off points for the Diabetes Mellitus older population, but need validation for ageing adults with DPN. Further research on this subject should be addressed, in order to improve assessment outcomes.

Diabetes mellitus involves long-term complications that affect diabetic patients’ quality of life. The best way to prevent these complications is that patients achieve good metabolic control. In order to reach this goal, patients are requested to acquire daily behaviours (self-care). Such behaviours are sometimes hard to adhere, because they require changes in habits acquired over time. The aim of the present study is to evaluate the improvement on self-care after a pharmaceutical intervention on home regime patients. We performed a controlled experimental comparative study with a follow up of 6 months, on 87 patients, randomized in control group (n=43) and intervention group (n=44). We accessed sociodemographic and clinical data (glycaemic profile), as well as adherence to drug therapy and self-assessed care (beforeafter). In the intervention group, mean age was 74.2±5.4 years, and the median time of T2DM diagnosis was 14.7±8.5years. At the end of study, the decrease in fasting blood glucose was higher in the intervention group patients than that observed in the control group (50.2mg/dL), with statistically significant difference (p<0.05), as well as the decrease verified in HbA1c. In self-care adherence, alterations in the levels of adherence of the general nutrition and physical exercise dimensions became evident, with an increase in the number of days of adherence. On medication adherence statistically significant alterations (p<0.05) were also recorded. We can conclude that an individualized pharmaceutical intervention can improve self-care behaviours, as well as medication adherence, contributing to better metabolic control.

This review explores the relation between obstructive sleep apnoea syndrome (OSAS) and diabetes. It aims to address the following issues: 1. the epidemiological evidence of the association between OSAS and type 2 diabetes; 2. the independence of this association from the comorbidities shared by the two conditions; 3. the chronological and quantitative characteristics of this association (Which comes first? Is there severity interdependence? Is treatment of one condition able to modify the natural history of the other?); 4. the mechanisms that make interaction plausible; 5. the impact of the OSAS-diabetes relation on micro- and macrovascular diabetic complications. OSAS is common in type 2 diabetes. Despite the association being affected by the confounding action of type 2 diabetes comorbidities (also risk factors for OSAS), it does not seem to be fully attributable to them. There is also a relation between OSAS severity and glucose metabolism alteration. A link between OSAS and insulin resistance appears early, prior to impaired glucose tolerance and the onset of diabetes. Therefore, a debate is ongoing on the pathogenetic role of OSAS in type 2 diabetes development and any consequent relevance to diabetes treatment with no conclusive evidence to date. A multiplicity of hypothetical mechanisms may mediate this relation. Most experimental findings support sympathetic activation and changes in chemoreflex sensitivity based on the interaction between chemoreflex and baroreflex. Some studies suggest bidirectional relationship between OSAS and diabetes, additive or synergistic effects for diabetic complications and a reciprocal enhancement in their impact on hypertension and cardiovascular disease. Clarification of these items could benefit diabetes management and prevention of diabetic cardiovascular complications.

Rheumatoid arthritis (RA) is a systemic autoimmune disease of unknown etiology characterized by chronic inflammation of the synovial membranes and articular structures of the joints. The concomitant comorbidities are important in the management and treatment of patients with RA, because they decrease their life quality and expectancy – with cardiovascular diseases being the most common comorbidities and primary cause of death in RA. Traditional cardiovascular risk factors, such as diabetes mellitus (DM) and insulin resistance (IR) are prevalent in these patients. The prevalence of DM in RA patients has not been well established and the association between these diseases is controversial. On the other hand, several epidemiological studies support the association between RA and IR, with the latter being linked to systemic inflammatory markers, including C reactive protein and erythrocyte sedimentation rate. Patients with RA who underwent glucocorticoid therapy were also determined to have a defective insulin sensitivity and pancreatic β-cell dysfunction. It has been proposed that systemic inflammation due to RA may result in insulin resistance – moreover, studies have examined the effect of inflammatory cytokines such as TNF-α, IL-6 and IL-1 on insulin sensitivity and glucose metabolism. Likewise, the association between RA and IR, and its role on the different characteristics of the disease, such as duration, activity, and treatment with glucocorticoids has not been well defined. A gap in the current understanding regarding the role that the systemic inflammation and the different RA characteristics have on the insulin function and glucose metabolism of RA patients suggest that more studies are required to elucidate these mechanisms.