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Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

Aims

To analyse the relationships between retinopathy, nephropathy, peripheral neuropathy and geriatric scale scores in elderly people with Type 2 diabetes.

Methods

GERODIAB is the first French multi-centre, prospective, observational study designed to assess the influence of glycaemic control on mortality and morbidity through a 5-year follow-up study in people with Type 2 diabetes aged 70 years and older. In this report the relationships at baseline between retinopathy, nephropathy and peripheral neuropathy, and five geriatric scale scores in 987 people, using bivariate and multivariate analyses are analysed.

Results

Retinopathy (26%) was significantly associated with impaired scores on the Mini Geriatric Depression Scale, the Mini Nutritional Assessment and the Instrumental Activities of Daily Living scale. Logistic regression showed that the duration of diabetes, BMI, Mini Geriatric Depression Scale, hypoglycaemia and HbA1c were associated with retinopathy (concordance 69.1%; P < 0.001). Nephropathy (47.4%, including 34.8% with Modification of Diet in Renal Disease < 60 ml/min) was significantly associated with impaired Activities of Daily Living and Instrumental Activities of Daily Living scale scores. Using the logistic model, the most significant factors were age, duration of diabetes, triglycerides, HDL cholesterol, hypoglycaemia, hypertension and BMI (concordance 66.3%; P < 0.001). Peripheral neuropathy (28.2%) was associated with impaired scores on the Mini Mental State Examination, Activities of Daily Living, Instrumental Activities of Daily Living and Mini Geriatric Depression Scales. In the logistic model, diastolic blood pressure, duration of diabetes and the Instrumental Activities of Daily Living, Mini Geriatric Depression Scale and Mini Mental State Examination scales were included (concordance 69.8%; P < 0.001).

Conclusion

In this specific sample, classical microvascular complications of diabetes were found to be associated with impaired geriatric scale scores. This highlights the benefits of systematic assessment in elderly people with Type 2 diabetes.

What's new?

  • In a sample of 987 people with Type 2 diabetes aged 70 years and older, retinopathy, nephropathy and peripheral neuropathy were found to be associated with impaired geriatric scale scores.
  • This study highlights the benefits of systematic assessment of cognition, autonomy, nutritional status and mood using geriatric scales in elderly people with diabetes.

Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

The prevalence of diabetes in the elderly is growing as a result of both the increase of life expectancy and incidence of diabetes in the general population [1-3]. Compared with younger people, the consequences of diabetes and ageing accumulate in the elderly and exacerbate degenerative complications and the effects of co-morbidities [4]. Elderly people with diabetes make up a heterogeneous population, which requires a patient-centred approach [5-7].

Numerous studies have analysed the factors associated with microvascular complications in people with Type 2 diabetes under 70 years of age. Associated, potentially explanatory factors are thus well known, particularly the duration of diabetes and glycaemic control [8, 9]. Other factors, including geriatric decline and functional disabilities, could be involved in older people [10-12].

The GERODIAB study is a French multi-centre prospective observational 5-year follow-up study designed to analyse the relationship between glycaemic control, morbidity and mortality in people with Type 2 diabetes aged 70 years and older who have relatively preserved autonomy (Activities of Daily Living score > 3/6). Protocol details and a description of the sample of people at inclusion were published previously [13]. This study, using information derived from elderly people with diabetes from the GERODIAB cohort at inclusion, aimed to investigate the association between retinopathy, nephropathy and peripheral neuropathy, and geriatric scale scores related to autonomy, cognition, nutrition and mood.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

The data collection was primarily based on the patient history and physical examination. Retinopathy was explored systematically with an ophthalmological examination and possible angiography. Nephropathy was studied through the glomerular filtration rate as estimated by the Modification of Diet in Renal Disease and measurement of urinary albumin excretion. Neuropathy was systematically investigated clinically (symptoms, muscular strength, 10-g monofilament testing, deep tendon reflexes). Because of the observational nature of the study, additional testing was left to the discretion of the investigators according to the French guidelines for diabetes management [14].

Patients were systematically studied using five geriatric scales: the Mini Mental State Examination, which studies cognition (range: 0–30; impairment: ≤ 24); the screening part of the Mini Nutritional Assessment (range: 0–14; impairment: < 14); the Activities of Daily Living scale (range: 0–6; impairment: < 6) and the Instrumental Activities of Daily Living scale (range: 0–14; impairment: < 14), both of which study autonomy; and the Mini Geriatric Depression Scale, which studies mood (range: 0–4; impairment: > 0). The French versions of these scales were validated previously [15].

Results are mean ± sd or percentage. Bivariate analyses were performed using the χ2-test or the one-way analysis of variance (ANOVA). Multivariate analyses were carried out using forward and backward stepwise logistic regressions (maximum likelihood ratio). The variables tested in the multivariate model were those significantly associated with the complication under study using bivariate analyses, including demographics, history of diabetes and laboratory assays (data not shown) [13].

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

This analysis concerns the baseline data of 987 people, 473 men (48%) and 514 women (52%), aged 77 ± 5 years (median: 77; range: 70–101 years), with a mean BMI 30 ± 5 kg/m², duration of diabetes 18 ± 11 years and HbA1c 60 ± 14 mmol/l (7.6 ± 1.3%).

Retinopathy

Retinopathy had already been documented or was observed at the inclusion examination in 257 patients (26%), 90 (35%) of whom had proliferative retinopathy or had undergone laser treatment.

Retinopathy was more frequent and more severe in people with cognitive decline (Mini Mental State Examination ≤ 24) (Table 1); Mini Nutritional Assessment, Instrumental Activities of Daily Living and Mini Geriatric Depression Scale scores were impaired more often in people with retinopathy (Table 1).

Table 1. Associations between retinopathy, nephropathy peripheral neuropathy and geriatric scale scores
 RetinopathyP-value
 No retinopathy (n = 730)Non-proliferative retinopathy (n = 167)Proliferative retinopathy (n = 90)
Mini Mental State Examination ≤ 24 N (column%)166 (22.8)43 (25.9)27 (29.9)NS
Mini Nutritional Assessment (screening) < 14 N (column%)361 (49.5)76 (45.6)56 (61.8)< 0.05
Activities of Daily Living < 6 N (column%)180 (24.6)51 (30.3)30 (33.7)NS
Instrumental Activities of Daily Living < 14 N (column%)377 (51.7)99 (59.3)62 (68.6)< 0.01
Mini Geriatric Depression Scale > 0 N (column%)233 (31.9)65 (39.2)44 (49.1)< 0.05
 Nephropathy: Modification of Diet in Renal Disease (ml/min) and microalbuminuria (μA) aP-value
 

≥ 60 without μA

(n = 519)

≥ 60 with μA

(n = 125)

30–60

(n = 311)

< 30

(n = 32)

Mini Mental State Examination ≤ 24 N (column%)116 (22.4)31 (24.4)80 (25.6)10 (31.3)NS
Mini Nutritional Assessment (screening) < 14 N (column%)250 (48.2)60 (47.6)170 (54.6)14 (43.8)NS
Activities of Daily Living < 6 N (column%)112 (21.6)29 (23.4)110 (35.3) 9 (29.0)< 0.001
Instrumental Activities of Daily Living < 14 N (column%)263 (50.6)77 (61.7)176 (56.7)23 (72.4)< 0.05
Mini Geriatric Depression Scale > 0 N (column%)168 (32.3)42 (33.3)119 (38.3)11 (35.3)NS
 Peripheral neuropathyP-value
 

No peripheral neuropathy

(n = 709)

Peripheral neuropathy

(n = 278)

 
  1. a

    μA: microalbuminuria > 30 mg/day or > 20 mg/l.

  2. N, number; NS, not significant.

Mini Mental State Examination ≤ 24 N (column%)149 (21.0)88 (31.6)< 0.001
Mini Nutritional Assessment (screening) < 14 N (column%)346 (48.8)147 (53.0)NS
Activities of Daily Living < 6 N (column%)166 (23.4)94 (33.8)< 0.001
Instrumental Activities of Daily Living < 14 N (column%)365 (51.5)174 (62.6)< 0.01
Mini Geriatric Depression Scale > 0 N (column%)215 (30.3)127 (45.6)< 0.001

Multivariate stepwise logistic regression analysis associated retinopathy with the duration of diabetes (P < 0.001), BMI (P < 0.01), Mini Geriatric Depression Scale > 0 (P < 0.05), hypoglycaemia (P < 0.05) and HbA1c (P < 0.05), successively (concordance 69.1%; P < 0.001).

Nephropathy

At baseline, over half the patients (519; 52.6%) had no known nephropathy, 125 (12.7%) had micro- or macroalbuminuria without significant impairment in renal function, 311 (31.5%) had a Modification of Diet in Renal Disease value between 30 and 60 ml/min and 32 (3.2%) had a Modification of Diet in Renal Disease < 30 ml/min. Activities of Daily Living scores were impaired more often in people with severe renal involvement (Table 1).

Multivariate stepwise logistic regression analysis associated nephropathy with triglyceride level, duration of diabetes, patient history of hypertension, age (P < 0.001) and HDL cholesterol level (P < 0.01), successively, with a 66.3% concordance rate.

Neuropathy

Peripheral neuropathy was observed in 278 (28.2%) of patients at baseline.

Cognitive decline (Mini Mental State Examination ≤ 24) was more frequent in people with neuropathy (Table 1). All the other geriatric scale scores were impaired more often, with the exception of the Mini Nutritional Assessment score (Table 1).

Multivariate stepwise logistic regression analysis associated neuropathy with low diastolic blood pressure, duration of diabetes (P < 0.001) and the Instrumental Activities of Daily Living, the Mini Geriatric Depression (P < 0.01) and the Mini Mental State Examination (P < 0.05) scales, successively (69.8% concordance; P < 0.001).

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

This analysis concerns data at baseline of 987 outpatients with Type 2 diabetes, all aged 70 years or older and with relatively preserved autonomy, consecutively included in the prospective GERODIAB cohort. It shows the associations between the three studied complications and some geriatric scale scores, notably the autonomy and cognition scores. Similar results have been reported previously, especially regarding the impact on physical function [12]. However, studies in elderly people with Type 2 diabetes remain uncommon, whereas life expectancy and incidence of diabetes are increasing. Therefore, it is now important to analyse the relationships between diabetes complications and geriatric functions in this study.

In our observational study, some degenerative complications might have been under evaluated, as the use of additional examinations was left to the discretion of each investigator. Considering the duration of the diabetes in this sample of people, this underestimation may have only concerned clinically asymptomatic complications, which had not been screened for previously.

Retinopathy was observed in just over a quarter of patients, and close to 10% of patients had a proliferative form. These figures are relatively modest when compared with those observed with Type 1 diabetes or in younger people with Type 2 diabetes [16, 17], but one of the inclusion criteria (autonomy preserved with Activities of Daily Living ≥ 3/6) may have excluded some people with severe visual disorders. Our results highlight the association between retinopathy and impairment of the scale scores concerning autonomy, cognition, nutrition and depression, with the Mini Geriatric Depression Scale emerging here as a significant factor, even after taking other variables into consideration in multivariate analysis. On the one hand, these findings may result from common mechanisms, ageing, and/or microangiopathy of the cerebral vessels; these associations, however, mainly suggest the impact of impaired visual acuity on autonomy, nutrition, mood and cognitive functions [18, 19]. On the other hand, malnutrition can alter visual function. Similarly, associations with clinical factors, such as BMI or hypoglycaemia have sometimes been reported, but their mechanisms remain controversial [20]. Our results at baseline highlight these points, but remain hypotheses and more appropriate conclusions should be drawn from follow-up results over 5 years.

Nearly half of people had renal involvement, but less than 4% had severe renal failure. Nephropathy was expressed here in four classes by combining microalbuminuria and the glomerular filtration rate as estimated by the Modification of Diet in Renal Disease. The reliability of the microalbuminuria results may be questioned in this sample, particularly because of the difficulties of urine collection, and possible urinary tract infections or contamination. Similar results were found for the Modification of Diet in Renal Disease alone (data not shown). The association with the decreased Mini Mental State Examination, Activities of Daily Living and Instrumental Activities of Daily Living scores suggests that nephropathy, which is commonly associated with increased frailty, can explain cognitive decline and autonomy loss [10]. The absence of significant association between malnutrition and nephropathy is more unexpected, but could be attributable to the low frequency of severe renal involvement in our sample.

Peripheral neuropathy was only diagnosed in 28% of the people. When interpreting this, it should be kept in mind that the screening tests used in this study were only clinical [21], and it is therefore likely that the subclinical forms were not detected. This could explain the failure to find an association between neuropathy and nutrition. A very distinctive aspect of our study is the existence of strong associations between neuropathy and geriatric scale scores, particularly the Instrumental Activities of Daily Living (autonomy), Mini Geriatric Depression Scale (depression) and the MMS (cognition); these associations remain significant in the logistic model. A common mechanism, involving both brain and peripheral nerves, could be suspected. However, the influence of drugs, particularly analgesics commonly used in elderly people, cannot be ruled out.

The use of multivariate analyses is important to our results, as they take into account the relative importance of different factors associated with microangiopathic complications, including demographics, history of diabetes and laboratory data. Therefore, all factors significantly associated with complications were confronted. Geriatric scale scores remained significantly associated with retinopathy and neuropathy, suggesting the main benefits of cognition, autonomy, nutrition and mood assessment in elderly people with diabetes. Conversely, geriatric scales did not remain significantly associated with nephropathy, but this could be because of the low occurrence of severe renal involvement in our results.

Our cross-sectional study cannot clarify the causal direction of the association between microvascular complications and impaired cognition, autonomy, nutritional status and mood. The clinical impact of retinopathy, nephropathy and peripheral neuropathy on the geriatric condition could be implicated [22, 23], but common mechanisms related to diabetes may also be involved [24]. Alternatively, cognitive decline, impaired autonomy, poor nutritional status and mood disorders, leading to frailty, could alter the management of diabetes and its treatment. A bidirectional relationship, involving the influence of both diabetes complications and geriatric functional decline on each other could be involved [25]. The 5-year follow-up of people from the GERODIAB cohort may enable these associations and their causal directions to be specified and possible mechanisms identified.

In conclusion, our study shows some significant associations between microangiopathic complications and impairment of geriatric scale scores that were systematically implemented in elderly people with Type 2 diabetes. Although our results at baseline should be confirmed after follow-up and by other studies, they highlight the benefits of systematic assessment using geriatric scales in elderly people with Type 2 diabetes, as well as at early stages of the disease [24]. This approach, which is patient-centred, simple and inexpensive, could result in more appropriate care goals and treatments.

Funding sources

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

This work was supported by grants from the National PHRC (French Research Funds for Public Hospital), the Francophone Society for Diabetes (SFD), Novo-Nordisk and Merck-Serono.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information

We wish to thank the CRO Umanis (D. Dubois, C. Hilbert, A. Ourliac and D. Boichut) for data collection and management. We thank J. Klain-Ratziu for her contribution to the translation. The complete list of authors and members of the SFD-SFGG group appears in the Supporting Information (Appendix S1).

References

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  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Funding sources
  8. Competing interests
  9. Acknowledgements
  10. References
  11. Supporting Information
FilenameFormatSizeDescription
dme12327-sup-0001-appendixS1.docWord document25KAppendix S1. List of authors and members of the SFD-SFGG group.

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