Malaysian Healthy Ageing Society Chew Boon How 1* MMed (FamMed) , - PowerPoint PPT Presentation

Organised by: Co-Sponsored: Malaysian Healthy Ageing Society

Chew Boon How 1* MMed (FamMed) , Sazlina Shariff-Ghazali 1 MMed (FamMed) , Zaiton Ahmad 1 MMed (FamMed) , Mastura Ismail 2 MMed (FamMed) , Jamaiyah Haniff 3 (MPH) , Mustapha Feisul Idzwan 4 (MPH) , Mohd Adam Bujang 3 (Bsc Statistic) 1 Department of Family Medicine, Universiti Putra Malaysia, 2 Klinik Kesihatan Seremban 2, Negeri Sembilan, 3 Clinical Research Centre, Hospital Kuala Lumpur, 4 Disease Control Division, Ministry of Health Malaysia, Putrajaya.

 Age has long been recognised as a significant factor for health. 1 2  Many cardiovascular disease risk scoring systems give larger weightage or marks for the older age groups. 1. de Craen AJ et al. Tijdschr Gerontol Geriatr 2009;40(6):237-43. 2. Jaakko T. Cardiovascular Risk Through The Ages, Proceedings of the Future Forum Conference held in Noordwijk, The Netherlands, October 2003 2004;5(2):9-17.

 Children of long-living parents, suggesting that they had advantageous cardiovascular risk profiles  (the Leiden research program on ageing and Framingham offspring study.) 1 6  The association of ageing and many cardiometabolic diseases were degenerative processes leading to cellular apoptosis beyond regeneration or repairs. 5 1. de Craen AJ et al. Tijdschr Gerontol Geriatr 2009;40(6):237-43. 5. Navarro A et al. American Journal of Physiology - Cell Physiology 2007;292(2):C670-C86. 6. Terry DF et al. Archives of Internal Medicine 2007;167(5):438-44.

 Cardiometabolic diseases cause premature ageing and death. 7  Vascular ageing and remodelling 9  Many studies had reported positive relationship of disease control (glycaemic, blood pressure and lipid) in T2D and diabetes-related complications and death, but the evidence was inconclusive and even against intensive control in the older group of patients. 8 7. Girndt M et al. Biomarkers of Ageing: from Molecular Biology to Clinical Perspectives 2010;45(10):797-800. 8. Huang ES et al. Diabetes Care 2011;34(6):1329-36. 9. Bachschmid MM et al. Annals of Medicine 2012:1-20.

 We examined the independent effect of age ≥ 60 years on disease control and its relationship with diabetes-related complications.

 Adult Diabetes Control and Management ( ) public health centres (289 health clinics, hospitals) patients ( patients were from hospital) health clinics hospitals (8 states and 2 federal territories) of 15 states and federal territories in Malaysia. 8

 The proportion of T2D patients notified in this database as compared to the estimated total T2D patients in these states and federal territories was .  Only adult patients ( ).  All patients were of the on-going registry and given the opportunity to .  Participation in ADCM was non-mandatory for patients and health centres. 9

 Registrations at local centers were generally performed by trained physicians, assistant physicians and nurses. , developed and maintained by Clinical Research Centre (CRC), Ministry of Health, Malaysia. 10

 The was as when their case record fulfilled all these criteria:  (i) either or  (ii) those whose current . 14

 Comparisons were performed regarding mean levels by use of the Student’s t test for unpaired samples and regarding proportions by use of the Chi square test/Fisher Exact’s Test. as dependent variables and with indentified significant registered variables as mentioned above as independent variables.  A P value < 0.05 was considered to be significant 15

Result was female.  Malay consisted of , Chinese and Indian .

≥ 60 years, n (%) χ 2 or t Statistic < 60 years, n (%) p Age , mean (SD) 50.22 (7.19) 68.12 (6.54) 343.50 <0.0001 Gender Male 15150 (39.0) 13789 (43.0) Female 23584 (60.8) 18257 (56.9) 112.76 <0.0001 Missing 66 (0.2) 43(0.1) Total 38800 (100.0) (54.7)* 32089 (100.0) (45.3)* Ethnicity Malay 25942 (66.9) 17960 (56.0) Chinese 4823 (12.4) 8628 (26.9) Indian 7555 (19.5) 5184 (16.2) 2397.60 <0.0001 Other Malaysians 351 (0.9) 237 (0.7) Foreigner 65 (0.2) 23 (0.1) Missing 64 (0.2) 57 (0.2) Total 38800 (100.0) (54.7)* 32089 (100.0) (45.3)* Diabetes Duration in year, mean (SD) 4.84 (4.53) 7.12 (6.39) 49.81 <0.0001 <5 18467 (47.6) 10717 (33.4) 5-9 9618 (24.8) 8896 (27.7) 2077.02 <0.0001 >=10 3693 (9.5) 6071 (18.9) Missing 7022 (18.1) 6405 (20.0) Total 38800 (100.0) (54.7)* 32089 (100.0) (45.3)*

≥ 60 years, n (%) χ 2 or t Statistic < 60 years, n (%) p BMI , mean (SD) 28.22 (5.69) 26.10 (6.07) -41.74 <0.0001 BMI < 23 12629 (32.5) 14072 (43.9) 955.88 <0.0001 BMI ≥ 23 26171 (67.5) 18017 (56.1) Total 38800 (100.0) (54.7)* 32089 (100.0) (45.3)* Systolic BP , mean (SD) 134.21 (18.46) 139.86 (20.35) 34.57 <0.0001 Diastolic BP , mean (SD) 80.36 (10.23) 76.78 (10.81) -40.38 <0.0001 BP ≥ 130/80 mmHg 23544 (75.2) 19679 (78.2) 70.60 <0.0001 BP < 130/80 mmHg 7784 (24.8) 5496 (21.8) Total 31328 (100.0) (55.4)* 25175 (100.0) (44.6)* HbA1c , mean (SD) 8.68 (2.28) 7.94 (2.02) -32.85 <0.0001 HbA1c ≥ 6.5% 17487 (85.5) 13022 (77.4) 410.04 <0.0001 HbA1c < 6.5% 2956 (14.5) 3798 (22.6) Total 20443 (100.0) (54.9)* 16820 (100.0) (45.1)* LDL-C , mean (SD) 3.24 (1.11) 3.12 (1.08) -11.10 <0.0001 LDL-C> 2.6 15462 (71.5) 11337 (65.8) 75.54 <0.0001 LDL- C≤ 2.6 6164 (28.5) 5885 (34.2) Total 21626 (100.0) (55.7)* 17222 (100.0) (44.3)* HDL-C , mean (SD) 1.28 (0.52) 1.32 (0.52) 7.05 <0.0001 HDL-C< 1.1 7527 (34.4) 5258 (30.2) 99.98 <0.0001 HDL- C≥ 1.1 14348 (65.6) 12144 (69.8) Total 21875 (100.0) (55.7)* 17402 (100.0) (44.3)* TG , mean (SD) 2.02 (1.33) 1.83 (1.12) -15.90 <0.0001 TG> 1.7 11940 (47.0) 8380 (41.2) 151.55 <0.0001 TG≤ 1.7 13461 (53.0) 11936 (58.8) Total 25401 (100.0) (55.6)* 20316 (100.0) (44.4)*

95% C.I. for OR Nagelkerke B SE Wald df p value OR* R 2 Lower Upper HbA1c ≤ 6.5% (1), n= 37263 ≥ 60 years 0.58 0.03 420.97 1 <0.0001 1.79 1.70 1.90 0.04 Blood Pressure < 130/80 mmHg (1), n= 56503 -0.24 0.02 126.41 1 <0.0001 0.76 0.82 ≥ 60 years 0.80 0.02 LDL- C ≤ 2.6 mmol/L (1), n= 38848 0.14 0.02 37.74 1 <0.0001 1.15 1.10 1.21 ≥ 60 years 0.03 HDL- C ≥ 1.1 mmol/L (1), n= 39277 0.19 0.02 64.60 1 <0.0001 1.21 1.15 1.26 ≥ 60 years 0.08 TG ≤ 1.7 mmol/L (1), n= 45717 0.18 0.02 83.56 1 <0.0001 1.20 1.15 1.25 ≥ 60 years 0.02

95% C.I. for OR Nagelker B SE Wald df p value OR* ke R 2 Lower Upper Any Diabetes Complications (1), n= 53393 ≥ 60 years 0.30 0.02 162.33 1 <0.0001 1.35 1.29 1.41 0.10 Macrovascular Complications (stroke or IHD) (1), n= 53393 ≥ 60 years 0.66 0.04 233.57 1 <0.0001 1.94 1.78 2.11 0.16 Stroke (1), n= 41421 ≥ 60 0.58 0.09 39.99 1 <0.0001 1.79 1.49 2.14 0.12 years IHD (1), n= 38768 ≥ 60 0.68 0.05 197.84 1 <0.0001 1.97 1.79 2.16 0.18 years

95% C.I. for OR Nagelker B SE Wald df p value OR* ke R 2 Lower Upper Microvascular Complications (retinopathy or nephropathy or foot problem) (1), n= 53393 ≥ 60 years 0.20 0.03 62.92 1 <0.0001 1.22 1.16 1.28 0.08 Retinopathy (1), n= 32663 ≥ 60 0.32 0.04 63.20 1 <0.0001 1.38 1.27 1.49 0.09 years Nephropathy (1), n= 39161 ≥ 60 0.11 0.03 11.41 1 0.001 1.12 1.05 1.19 0.10 years Diabetes Foot Problems (1), n= 42755 ≥ 60 0.26 0.04 35.27 1 <0.0001 1.30 1.19 1.41 0.04 years

Discussion- Risk Control & Age  The proportion of our older patients achieving HbA1c and LDL-C targets were comparable to the Asian countries (Hong Kong, India, Korea, Philippines, Singapore, Taiwan, and Thailand) in the (Joint Asia Diabetes Evaluation) program (35.3% achieved HbA1c < 7% and 34% achieved LDL-C < 2.6 mmol/L). 26 26. So W-Y et al. Journal of Diabetes 2011;3(2):109-18.

Discussion- Age & Risk  The attenuated association between cardiometabolic risk markers and older people was also reported in United States and these Asian countries. 25 26  Inverse relationship of glycaemic control (HbA1c ≤ 7.5%) and age among the T2D patients was also reported in a primary care setting in UK. 27 25. Janssen I. Nutr Metab Cardiovasc Dis. 2009;19(3):163-69. 26. So W-Y et al. Journal of Diabetes 2011;3(2):109-18. 27. Nagrebetsky A et al. Diabetes Res Clin Pract . 2012 Jan 17.

Discussion-Risk & Complication  Despite good control of most cardiovascular risk factors, the elderly patients with T2D were still suffering from all types of diabetes complications.  Improving diseases control and increasing complications were observed in French elderly T2D. 30  In a 15-years follow-up Chinese Multi-provincial study, diabetes and older age (≥ 45 years) were predictors of coronary heart disease and ischaemic stroke despite well controlled LDL-C. 31 30. Pornet C et al. Diabetes Metab 2011;37(2):152-61. 31. Liu J et al. Diabetes Res Clin Pract. 2012 Jan 11. [Epub ahead of print]

Limitations  Missing data/unknown status for many complications  Representativeness  Not generalizable to east Malaysia  Could not ascertain the sequence of events between onset of the diabetes-related complications and diseases control  Unobservable confounders may still exist and bias the results as evidenced by the modest effect of the models