Severely obese people with diabetes experience impaired emotional well-being associated with socioeconomic disadvantage: results from diabetes MILES – Australia

Aim
To examine the emotional well-being of severely obese Australians with type 2 diabetes, along with markers of social and economic disadvantage, using the Diabetes MILES – Australia dataset.
Methods
Diabetes MILES – Australia was a national survey of 3338 adults with diabetes that focused on psychosocial issues; 1795 had type 2 diabetes and reported BMI. We extracted data regarding depression (PHQ-9), anxiety (GAD-7), obesity- and diabetes- related comorbidities, and demographics. The severely obese group (SOG) (BMI ≥ 35; median BMI = 41.6) constituted 530 (30%) of the type 2 diabetes respondents and was matched with 530 controls (CG) (BMI < 35; median BMI = 28.2). Within- and between- group trends were examined.
Results
The SOG had higher depression scores (median (IQR) 6.0 (3–12)) than CG (5.0 (2–10)); p < 0.001, and were more likely to report moderate-severe depressive symptoms (37% versus 27%; p < 0.001). The groups did not differ on anxiety. The SOG, compared with the CG, were more likely to live alone (21% versus 17%), receive a disability pension (21% versus 15%), earn ≤$40.000/year (51% versus 41%; all p < 0.05), and were less likely to be employed (46% versus 53%), university or higher educated (17% versus 26%), or have health insurance (50% versus 60%; all p ≤ 0.01). Moderate-severe depression was positively associated with cumulative stressors of severe obesity, socioeconomic disadvantage, and obesity- and diabetes- related comorbidity.
Conclusions
Severely obese people living with type 2 diabetes have cumulative stressors related to health, disability, demographic and socioeconomic factors, and impaired emotional well-being.

Self-regulation of older drivers with cognitive impairment : a systematic review

Background
Cognitive decline contributes significantly to the safety risk of older drivers. Some drivers may be able to compensate for the increased crash risk by avoiding complex driving situations or restricting their driving.

Objective and Method
A comprehensive English-language systematic review was conducted to determine the level of evidence for older adult drivers with cognitive impairment engaging in self-regulation.

Results
Twelve studies were included in the review. The majority of studies investigated driver avoidance, followed by driver restriction. Few studies ascertained the reasons for changing driving behaviour.

Conclusions
The evidence supports the view that drivers with cognitive impairment do restrict their driving and avoid complex driving situations. However, it remains to be determined whether the drivers who do engage in self-regulation require insight into their own driving abilities or whether external factors result in self-regulation of driving behaviour.

Do we need both cognitive and behavioural components in interventions for depressed mood in people with mild intellectual disability?

 Background: A growing literature suggests that people with mild intellectual disability (ID) who have depressed mood may benefit from cognitive-behavioural interventions. There has been some speculation regarding the relative merit of the components of this approach. The aim of this study was to compare (i) cognitive strategies; (ii) behavioural strategies; and (iii) combined cognitive-behavioural (CB) strategies on depressed mood among a sample of 70 individuals with mild ID. Methods: Staff from three participating agencies received training in how to screen individuals with mild ID for depressive symptoms and risk factors for depression. Depressive symptoms and negative automatic thoughts were assessed prior to and at the conclusion of the intervention, and at 6-month follow-up. The interventions were run in groups by the same therapist. Results: A post-intervention reduction in depression scores was evident in participants of all three interventions, with no significant difference between groups. A significant reduction in negative automatic thoughts post-intervention was evident in the CB combination group and was maintained at follow-up. Examination of clinical effectiveness suggests some advantage of the CB combination in terms of improvement and highlights the possible short term impact of behavioural strategies in comparison with the longer-term potential of cognitive strategies. Conclusions: The findings support the use of group cognitive-behavioural interventions for addressing symptoms of depression among people with ID. Further research is necessary to determine the effectiveness of components. © 2013 John Wiley & Sons Ltd.

Challenges in managing elderly people with diabetes in primary care settings in Norway

Objective
To explore the experiences and clinical challenges that nurses and nursing assistants face when providing high-quality diabetes-specific management and care for elderly people with diabetes in primary care settings.

Design
Focus-group interviews.

Subjects and setting
Sixteen health care professionals: 12 registered nurses and four nursing assistants from nursing homes (10), district nursing service (5), and a service unit (1) were recruited by municipal managers who had local knowledge and knew the workforce. All the participants were women aged 32–59 years with clinical experience ranging from 1.5 to 38 years.

Results
Content analysis revealed a discrepancy between the level of expertise which the participants described as important to delivering high-quality care and their capacity to deliver such care. The discrepancy was due to lack of availability and access to current information, limited ongoing support, lack of cohesion among health care professionals, and limited confidence and autonomy. Challenges to delivering high-quality care included complex, difficult patient situations and lack of confidence to make decisions founded on evidence-based guidelines.

Conclusion
Participants lacked confidence and autonomy to manage elderly people with diabetes in municipal care settings. Lack of information, support, and professional cohesion made the role challenging.

Managing older people with type 2 diabetes

The Guideline for Managing Older People with Type 2 Diabetes was considered a necessary development following the launch of the IDF 2012 Global Guideline for Type 2 Diabetes. In the latter, recommendations for managing diabetes in older people were included for the first time by the IDF but the review group felt that there were many areas where specific advice was still needed and indeed would offer the clinician extra value in decision making. It was also felt that the format of recommendation in the 2012 Guideline did not offer the flexibility required to address the special issues of older people and their varied physical, cognitive, and social needs.

An international group of diabetes experts was assembled to consider the key issues that require attention in supporting the highest quality of diabetes care for older people on a global scale. This Guideline is unique as it has been developed to provide the clinician with recommendation that assist in clinical management of a wide range of older adults such as those who are not only relatively well and active but those who are functionally dependent. This latter group has been categorised as those with frailty, or dementia, or those at the end of life. We have included practical advice on assessment measures that enable the clinician to categorise all older adults with diabetes and allow the appropriate and relevant recommendations to be applied.

The Guideline has been structured into main chapter headings dealing with expected areas such as cardiovascular risk, education, renal impairment, diabetic foot disease and so on, but also includes commonly addressed areas such as seen such as sexual health. Also included is a section of 'special consideration' where areas such as pain and end of life care are addressed.

Performance of the assessment of quality of life measure in people with hip and knee joint disease and implications for research and clinical use

Objective
To comprehensively evaluate the performance of the Assessment of Quality of Life (AQoL) instrument for measuring health-related quality of life (HRQOL) in people with hip and knee joint disease (arthritis or osteoarthritis).

Methods
Data from 237 individuals were available for analysis from a national cross-sectional, population-based study of hip and knee joint disease in Australia. AQoL-4D data were evaluated using Rasch analysis. A range of measurement properties was explored, including model and item fit, threshold ordering, differential item functioning, and targeting.

Results
Good overall fit of the AQoL with the Rasch model was demonstrated across a range of tests, supporting internal validity. Only 1 item (relating to hearing) showed evidence of misfit. Most AQoL items showed logical sequencing of response option categories, with threshold disordering evident for only 2 of the 12 items (items 4 and 9). Minor issues with potential clinical and research implications include limited options for reporting pain and some evidence of measurement bias between demographic subgroups (including age and sex). Participants' HRQOL was generally better than that represented by the AQoL items (mean ± SD for person abilities −2.15 ± 1.39, mean ± SD for item difficulties 0.00 ± 0.67), indicating ceiling effects that could impact the instrument's ability to detect HRQOL improvement in population-based studies.

Conclusion
The AQoL is a competent tool for assessing HRQOL in people with hip and knee joint disease, although researchers and clinicians should consider the caveats identified when selecting appropriate HRQOL measures for future outcome assessment involving this patient group.