Cardio-ankle vascular index for predicting cardiovascular morbimortality and determinants for its progression in the prospective advanced approach to arterial stiffness (TRIPLE-A-Stiffness) study.

BACKGROUND: The cardio-ankle vascular index (CAVI) measure of arterial stiffness is associated with prevalent cardiovascular risk factors, while its predictive value for cardiovascular events remains to be established. The aim was to determine associations of CAVI with cardiovascular morbimortality (primary outcome) and all-cause mortality (secondary outcome), and to establish the determinants of CAVI progression. METHODS: TRIPLE-A-Stiffness, an international multicentre prospective longitudinal study, enrolled >2000 subjects ≥40 years old at 32 centres from 18 European countries. Of these, 1250 subjects (55% women) were followed for a median of 3.82 (2.81-4.69) years. FINDINGS: Unadjusted cumulative incidence rates of outcomes according to CAVI stratification were higher in highest stratum (CAVI > 9). Cox regression with adjustment for age, sex, and cardiovascular risk factors revealed that CAVI was associated with increased cardiovascular morbimortality (HR 1.25 per 1 increase; 95% confidence interval, CI: 1.03-1.51) and all-cause mortality (HR 1.37 per 1 increase; 95% CI: 1.10-1.70) risk in subjects ≥60 years. In ROC analyses, CAVI optimal threshold was 9.25 (c-index 0.598; 0.542-0.654) and 8.30 (c-index 0.565; 0.512-0.618) in subjects ≥ or <60 years, respectively, to predict increased CV morbimortality. Finally, age, mean arterial blood pressure, anti-diabetic and lipid-lowering treatment were independent predictors of yearly CAVI progression adjusted for baseline CAVI. INTERPRETATION: The present study identified additional value for CAVI to predict outcomes after adjustment for CV risk factors, in particular for subjects ≥60 years. CAVI progression may represent a modifiable risk factor by treatments. FUNDING: International Society of Vascular Health (ISVH) and Fukuda Denshi, Japan.

Inappropriate prescribing in geriatric rural primary care: impact on adverse outcomes and relevant risk factors in a prospective observational cohort study.

BACKGROUND: Several tools have revealed an association between potentially inappropriate medications (PIM) and adverse outcomes, but the one most fitted for the rural population has not been determined. AIMS: We investigated the performance of the Screening Tool of Older Persons' Prescriptions (STOPP) and Screening Tool to Alert doctors to the Right Treatment (START) in identifying inappropriate prescribing and its association with adverse outcomes among older rural primary health care users. METHODS: A cohort of consenting outpatients aged ≥ 65 years in a rural Greek primary care center was assessed for PIM and potential prescribing omissions (PPO) using the START/STOPP version 2 criteria. Medications, comorbidities, functional status, and laboratory data were recorded along with 6-month incidence of emergency department visits, hospitalization, and death prospectively. RESULTS: Among 104 participants (median age 78 years, 49.1% women, receiving a median of 6 drugs), PPO was found in 78% and PIMs in 61%. PIM was multivariately correlated with multimorbidity (p = 0.029) and polypharmacy (p < 0,001), while drug-PPO was only associated with multimorbidity (p = 0.039). The number of PIM predicted emergency department visits and hospitalizations at 6-month follow-up (p value 0.011), independent of age, sex, frailty, comorbidities, and total medication number. DISCUSSION: The START/STOPP tool is useful in identifying inappropriate prescribing patterns leading to increased utilization of acute care services in older adults followed at a rural primary care setting. CONCLUSION: Inappropriate prescribing as identified by the START/STOPP criteria is prevalent among older adults with multimorbidity in rural primary care, and independently associated with future acute care visits.

Deprescribing practices, habits and attitudes of geriatricians and geriatricians-in-training across Europe: a large web-based survey.

PURPOSE: To provide an overview of the current deprescribing attitudes, practices, and approaches of geriatricians and geriatricians-in-training across Europe. METHODS: An online survey was disseminated among European geriatricians and geriatricians-in-training. The survey comprised Likert scale and multiple-choice questions on deprescribing approaches and practices, deprescribing education and knowledge, and facilitators/barriers of deprescribing. Responses to the survey questions and participant characteristics were quantified and differences evaluated between geriatricians and geriatricians-in-training and between European regions. RESULTS: The 964 respondents (median age 42 years old; 64% female; 21% geriatricians-in-training) were generally willing to deprescribe (98%) and felt confident about deprescribing (85%). Despite differences across European regions, the most commonly reported reasons for deprescribing were functional impairment and occurrence of adverse drug reactions. The most important barriers for deprescribing were patients' unwillingness, fear of negative consequences, lack of time, and poor communication between multiple prescribers. Perceived risk of adverse drug reactions was highest for psychotropic drugs, nonsteroidal anti-inflammatory drugs, cardiovascular drugs, and opioid analgesics. Only one in four respondents (23% of geriatricians and 37% of geriatricians-in-training) think education in medical school had sufficiently prepared them for deprescribing in clinical practice. They reported that their future deprescribing activities would probably increase with improved information sharing between various prescribers, deprescribing recommendations in guidelines, and increased education and training. Approximately 90% think that a paradigm shift is required for prescribers and patients, increasing focus on the possible benefits of deprescribing (potentially) inappropriate medications. CONCLUSIONS: Based on the outcomes of this survey, we recommend investing in improved inter-professional communication, better education and evidence-based recommendations to improve future patient-centered deprescribing practices.

Can sitting and lying blood pressure measurements be considered interchangeable in older frail adults?

BACKGROUND: To compare blood pressure (BP) values in the lying and sitting positions, and the effect of orthostatism when moving from each of these positions to the upright position in a geriatric population with various frailty levels. METHODS: In two sub-studies, we included a total of 157 consecutive patients, aged 75+ admitted to the Geriatric Department of Nancy University Hospital. BP and heart rate were sequentially measured three times in 1-min intervals each in lying, sitting and upright positions (Protocol#1, n = 107) or lying and upright positions (Protocol#2, n = 50) with an automatic validated Blood Pressure device. Patients were classified into two increasing frailty status (FS) categories: Low/Moderate (L/M-FS, n = 98) and High (H-FS, n = 59). RESULTS: BP levels were similar in the lying and sitting positions (Protocol#1, SBP 141 ± 22 mmHg vs. 142 ± 21 mmHg, respectively, and DBP 72 ± 12 mmHg vs. 72 ± 12 mmHg, respectively) in both frailty groups. In the H-FS, orthostatic drop of SBP was more pronounced from the lying (22.1 ± 5.8 mmHg, Protocol#2) as compared to the sitting to upright position (9.4 ± 1.9 mmHg, Protocol#1) (p < 0.008), and the same trend was observed for DBP. No such differences were observed in the L-M/FS frailty individuals. CONCLUSIONS: Orthostatic BP changes are more pronounced in the frailest patients when going from lying to the upright position than from the sitting to the upright position. Consequently, in these individuals, lying and sitting BP measurements cannot be interchangeable baseline positions to investigate orthostatic BP effects, and therefore, precise patient positioning should be specified when referring to "baseline BP measurements".

Simpler modified fried frailty scale as a practical tool to evaluate physical frailty: Methodological report for its cross-cultural adaptation and validation.

Frailty is a common geriatric syndrome that indicates homeostenosis and increased risk of disability and mortality. It is amenable to intervention when detected. Hence, screening frailty is of utmost importance to preserve quality-of-life and function in older age. Simpler Modified Fried Frailty Scale is a very practical frailty screening tool that has recently been introduced and has rooted from the original Fried Scale. It is developed in Turkish and has been shown to predict mortality in nursing home residents. Considering the variety of languages in Europe, it seems valid to adapt and validate this tool in different European languages. Thereby, it is expected that clinicians will have the possibility to screen for frailty more quickly and easily in their practice across many countries. This report is written to explain the details of the final consensus methodology suggested for Simpler Modified Fried Frailty Scale validation in order to guide and help the research teams in their studies.

A scoping review of the changing landscape of geriatric medicine in undergraduate medical education: curricula, topics and teaching methods.

PURPOSE: The world's population is ageing. Therefore, every doctor should receive geriatric medicine training during their undergraduate education. This review aims to summarise recent developments in geriatric medicine that will potentially inform developments and updating of undergraduate medical curricula for geriatric content. METHODS: We systematically searched the electronic databases Ovid Medline, Ovid Embase and Pubmed, from 1st January 2009 to 18th May 2021. We included studies related to (1) undergraduate medical students and (2) geriatric medicine or ageing or older adults and (3) curriculum or curriculum topics or learning objectives or competencies or teaching methods or students' attitudes and (4) published in a scientific journal. No language restrictions were applied. RESULTS: We identified 2503 records and assessed the full texts of 393 records for eligibility with 367 records included in the thematic analysis. Six major themes emerged: curriculum, topics, teaching methods, teaching settings, medical students' skills and medical students' attitudes. New curricula focussed on minimum Geriatrics Competencies, Geriatric Psychiatry and Comprehensive Geriatric Assessment; vertical integration of Geriatric Medicine into the curriculum has been advocated. Emerging or evolving topics included delirium, pharmacotherapeutics, healthy ageing and health promotion, and Telemedicine. Teaching methods emphasised interprofessional education, senior mentor programmes and intergenerational contact, student journaling and reflective writing, simulation, clinical placements and e-learning. Nursing homes featured among new teaching settings. Communication skills, empathy and professionalism were highlighted as essential skills for interacting with older adults. CONCLUSION: We recommend that future undergraduate medical curricula in Geriatric Medicine should take into account recent developments described in this paper. In addition to including newly emerged topics and advances in existing topics, different teaching settings and methods should also be considered. Employing vertical integration throughout the undergraduate course can usefully supplement learning achieved in a dedicated Geriatric Medicine undergraduate course. Interprofessional education can improve understanding of the roles of other professionals and improve team-working skills. A focus on improving communication skills and empathy should particularly enable better interaction with older patients. Embedding expected levels of Geriatric competencies should ensure that medical students have acquired the skills necessary to effectively treat older patients.

The experiences of early career geriatricians throughout Europe during the COVID-19 pandemic.

The COVID-19 pandemic has severely affected older adults and brought about unprecedented challenges to geriatricians. We aimed to evaluate the experiences of early career geriatricians (residents or consultants with up to 10 years of experience) throughout Europe using an online survey. We obtained 721 responses. Most of the respondents were females (77.8%) and residents in geriatric medicine (54.6%). The majority (91.4%) were directly involved in the care of patients with COVID-19. The respondents reported moderate levels of anxiety and feelings of being overloaded with work. The anxiety levels were higher in women than in men. Most of the respondents experienced a feeling of a strong restriction on their private lives and a change in their work routine. The residents also reported a moderate disruption in their training and research activities. In conclusion, early career geriatricians experienced a major impact of COVID-19 on their professional and private lives.

Primary care professionals' experiences during the first wave of the COVID-19 pandemic in Greece: a qualitative study.

BACKGROUND: The coronavirus outbreak (COVID-19) tested health care systems worldwide. This qualitative study aimed to explore and understand the experiences, beliefs and concerns of Primary Care Professionals (PCPs) regarding the preparedness and response of primary care to the first wave of the pandemic in Greece, a country where a public structured primary care system has been developing. METHODS: We conducted semi-structured telephone interviews with 33 PCPs (General Practitioners, community General Internal Medicine Specialists, community Paediatricians and nurses) recruited from all regions of Greece after the first wave of the pandemic (June 2020). Interviews were transcribed verbatim, data were anonymised and analysed. Thematic analysis was applied developing a conceptual framework. RESULTS: Four main themes were identified: a) Primary care unit adaptation and issues faced during the pandemic; b) Management of suspected COVID-19 cases; c) Management of non-suspected cases; d) Consequences of the pandemic. In the first phase of the pandemic, remote management of suspected cases and their referral to the hospital were preferred as a result of a shortage of personal protective equipment and inaccessibility to coronavirus testing in primary care. Due to the discontinuation of regular medical services and the limited in-person contact between doctors and patients, chronic disease management and prevention programmes were left behind. Social and emotional consequences of the pandemic, such as workplace stigma, isolation and social seclusion, deriving from fear of viral transmission, as well as burnout symptoms and exhaustion were commonly experienced among PCPs. Positive consequences of the pandemic were considered to be the recognition of the importance of an empowered public healthcare system by citizens and the valuable insight, knowledge and experience professionals gained in times of crisis. CONCLUSIONS: Primary care has a key role to play during and after the pandemic by using its information infrastructure to identify at-risk groups, detect new cases of COVID-19, provide care according to needs, and carry out vaccination programmes. Central coordination and empowerment of primary care will increase its effectiveness, via public awareness, holistic patient management, and unburdening of hospitals.

The Relevance and Added Value of Geriatric Medicine (GM): Introducing GM to Non-Geriatricians.

Geriatric Medicine (GM) holds a crucial role in promoting health and managing the complex medical, cognitive, social, and psychological issues of older people. However, basic principles of GM, essential for optimizing the care of older people, are commonly unknown or undermined, especially in countries where GM is still under development. This narrative review aims at providing insights into the role of GM to non-geriatrician readers and summarizing the main aspects of the added value of a geriatric approach across the spectrum of healthcare. Health practitioners of all specialties are frequently encountered with clinical conditions, common in older patients (such as cancer, hypertension, delirium, major neurocognitive and mental health disorders, malnutrition, and peri-operative complications), which could be more appropriately managed under the light of the approach of GM. The role of allied health professionals with specialized knowledge and skills in dealing with older people's issues is essential, and a multidisciplinary team is required for the delivery of optimal care in response to the needs and aspirations of older people. Thus, countries should assure the educational background of all health care providers and the specialized health and social care services required to meet the demands of a rapidly aging society.

Feasibility and impact of a short training course on frailty destined for primary health care professionals.

BACKGROUND: There is an unmet need for training primary health care professionals on frailty, especially in countries where geriatrics is still emerging. PURPOSE: We aimed to evaluate the feasibility and efficacy of a training course for primary health care professionals on the detection, assessment, and management of frailty. METHODS: A single-day training course, developed and facilitated by three physicians trained in geriatrics abroad, was organized by the Aristotle University of Thessaloniki Primary Hearth Care Research Network. Primary health care professionals' attitudes, knowledge, and everyday practices regarding frailty were assessed by self-administered anonymous questionnaires (using Likert-type scales) at three time-points (before, upon completion of the training course, and 3 months afterward). RESULTS: Out of 31 participants (17 physicians, 12 nurses, 2 health visitors; 87.1% women; mean age 46.4 years), 31(100%) filled in the first, 30(97%) the second, and 25(81%) the third questionnaire. Improvements were reported in familiarization with the frailty syndrome (p = 0.041) and in self-perception of knowledge and skills to detect (p < 0.001) and manage (p < 0.001) frailty, that were also sustained 3 months afterward (p = 0.001 and p = 0.003 respectively). Improvement was also observed in the attitude that frailty is an inevitable consequence of aging (p = 0.007) and in the frequency of application of screening (but not management) strategies, 3 months following the workshop compared to baseline (p = 0.014). Participants reported less disagreement with the statement that systematic screening for frailty was unfeasible in their daily practice at 3 months compared to baseline (p = 0.006), mainly due to time restrictions. CONCLUSION: A short skill-oriented training course can significantly and sustainably improve primary health care professionals' attitudes and practices regarding frailty.

Perceptions, attitudes and training needs of primary healthcare professionals in identifying and managing frailty: a qualitative study.

PURPOSE: Although frailty can be delayed or prevented by appropriate interventions, these are often not available in countries lacking formal education and infrastructure in geriatrics. The aim of this study was to: (a) explore ideas, perceptions and attitudes of primary health care (PHC) professionals towards frailty in a country where geriatrics is not recognised as a specialty; (b) explore PHC professionals' training needs in frailty; and (c) define components of a frailty educational programme in PHC. METHODS: Qualitative design, using two focus groups with PHC professionals conducted in Thessaloniki, Greece. Focus groups were audio recorded and transcribed. Data were analysed with thematic analysis. RESULTS: In total 31 PHC professionals (mean age: 46 years; gender distribution: 27 females, 4 males) participated in the study (physicians n = 17; nurses n = 12; health visitors n = 2). Four main themes were identified: (1) Perceptions and understanding of frailty; (2) Facilitators and barriers to frailty identification and management; (3) Motivation to participate in a frailty training programme; (4) Education and training. The main barriers for the identification and management of frailty were associated with the healthcare system, including duration of appointments, a focus on prescribing, and problems with staffing of allied health professionals, but also a lack of education. Training opportunities were scarce and entirely based on personal incentive. Professionals were receptive to training either face-to-face or online. A focus on learning practical skills was key. CONCLUSION: Education and training of professionals and interdisciplinary collaboration are essential and much needed for the delivery of person-centred care for people with frailty living in the community.

Start low, go slow, but look far: the case of geriatric medicine in Balkan countries.

PURPOSE: To present an insight of the situation of geriatric medicine in Balkan countries, as it was presented in the context of the 2nd pre-congress seminar of the 16th European Geriatric Medicine Society (EuGMS) Congress Athens 2021. METHODS: Representatives from 8 Balkan countries (Albania, Croatia, Greece, Republic of North Macedonia, Romania, Serbia, Slovenia, Turkey) answered 3 questions to reflect the state of geriatric medicine in their country: education on geriatrics; systems/methods for assessment of functional status and frailty; pre-operative risk assessment. An open discussion followed. RESULTS: Undergraduate education in geriatric medicine seems underestimated in medical faculties of Balkan countries, whereas a high heterogeneity is observed at a post-graduate level. Only a few Balkan countries have geriatric medicine as a recognized medical specialty or subspecialty. Functional status and frailty are only sporadically assessed, and pre-operative risk assessment is very rarely performed with a geriatric focus. Scarcity of expertise and structures relevant to geriatric medicine seems to be common. Developing a training curriculum and geriatrics-related structures are two interconnected aspects. Cooperation among physicians and multidisciplinary teams are essential for the practice of geriatric medicine. A functional geriatric network is eventually necessary and ambulatory geriatric expertise is probably a feasible and clinically relevant starting point. Providing pragmatic solutions to the pressing challenges in variable clinical settings, supplementing and working in harmony with existing components of each health system, is probably the most convincing strategy to gain political support in developing geriatric medicine. CONCLUSION: Balkan countries share common experiences and challenges in developing geriatrics. Whilst the principles of geriatric medicine are perhaps universal, proposed solutions should be adapted to each country's specific circumstances. Cooperation of the Balkan countries could promote in each the development of geriatric medicine. EuGMS is willing to foster relevant actions.

Using a Virtual Reality Serious Game to Assess the Performance of Older Adults with Frailty.

OBJECTIVES: The comparison of cognitive performance of older adults with frailty and non-frail ones (according to Fried's criteria) was investigated. METHODS/DESIGN: The differences in performance between people with frailty and individuals without frailty according to Fried were tested using a Virtual Reality (VR) application. The Fried criteria for frailty were used to categorize users into study groups, while standardized batteries were used for a Comprehensive Geriatric Assessment, including Activities of Daily Living (ADL), lifestyle, cognition, and depression screening. A group of 80 elders (78.08 years old in average) played the VR game entitled Virtual Supermarket (VSM). From those, 39 were healthy controls and 30 were categorized as pre-frail and 11 as frail. The VSM application presented users with a virtual shopping experience where users had to locate and purchase items displayed in a shopping list. This application was designed to test player's ability to reproduce a typical customer behavior in a simulated environment which requires spatial orientation, short-term memory, selective attention, and cognition speed. The performance, duration, and error rate were used as measurements. RESULTS: The analysis showed that there was a statistically significant difference in game performance between the different user groups with X2 (2) = 9.929, p = 0.007. Moreover, the multinomial logistic regression model generated, which based on game performance metrics, was found to be statistically significant with X2 (4) = 15.662, p = 0.004. CONCLUSIONS: Results shed more light toward the possible use of VR for distant self-administered evaluation of the frail status.

Let food and physical activity be your medicine : Lessons from EuGMS Athens 2020 pre-congress seminar.

Purpose In the context of the preparation of the 16th EuGMS Congress that will be held in Athens in 2020, EUGMS and the Hellenic Consortium for Geriatric Medicine organized a pre-congress seminar in November 2018. METHODS: The seminar focused on the role of diet and physical activity in healthy aging. RESULTS: It seems that the Mediterranean Diet (MD) remains one of the most well-studied and scientifically appreciated diets and holds much promise also in older age. It is never too late to adhere to a healthier diet and MD seems to attenuate inflammaging and reduce the risk of various chronic diseases, impaired cognition, and frailty. Food preparation also emerges as a critical issue due to its relation to Advanced Glycation End-products that are tightly related to the aging process. Physical activity is the second pillar of health-promoting lifestyle changes. It can alleviate related to age structural and physiological decline. It does not only reduce total morbidity and mortality in older adults, but also improves functionality and decreases disability in aerobic capacity, body composition, muscle mass, bone density, articulation performance. A multi-component physical activity, combining endurance, strength, balance, and flexibility training which is preferable for older adults is advisable. However, adherence to an active lifestyle meets additional challenges for older people, which could be overcome by adjusting intensity and types of exercise in individual capacities and preferences and by campaigning against stereotypes. CONCLUSIONS: Promoting healthy diet and physical activity as the new trend in healthy aging is a relevant, cost-effective, and challenging perspective, adjustable to individual needs and values. But most importantly, eating and moving are part of our living, our socializing, and our cultural routines, and by these means, could consist two particularly effective remedies.

Effects of metabolic syndrome on arterial function in different age groups: the Advanced Approach to Arterial Stiffness study.

OBJECTIVE: The aim of the Advanced Approach to Arterial Stiffness study was to compare arterial stiffness measured simultaneously with two different methods in different age groups of middle-aged and older adults with or without metabolic syndrome (MetS). The specific effects of the different MetS components on arterial stiffness were also studied. METHODS: This prospective, multicentre, international study included 2224 patients aged 40 years and older, 1664 with and 560 without MetS. Patients were enrolled in 32 centres from 18 European countries affiliated to the International Society of Vascular Health & Aging. Arterial stiffness was evaluated using the cardio-ankle vascular index (CAVI) and the carotid-femoral pulse wave velocity (CF-PWV) in four prespecified age groups: 40-49, 50-59, 60-74, 75-90 years. In this report, we present the baseline data of this study. RESULTS: Both CF-PWV and CAVI increased with age, with a higher correlation coefficient for CAVI (comparison of coefficients P < 0.001). Age-adjusted and sex-adjusted values of CF-PWV and CAVI were weakly intercorrelated (r = 0.06, P < 0.001). Age-adjusted and sex-adjusted values for CF-PWV but not CAVI were higher in presence of MetS (CF-PWV: 9.57 ±â€Š0.06 vs. 8.65 ±â€Š0.10, P < 0.001; CAVI: 8.34 ±â€Š0.03 vs. 8.29 ±â€Š0.04, P = 0.40; mean ±â€ŠSEM; MetS vs. no MetS). The absence of an overall effect of MetS on CAVI was related to the heterogeneous effects of the components of MetS on this parameter: CAVI was positively associated with the high glycaemia and high blood pressure components, whereas lacked significant associations with the HDL and triglycerides components while exhibiting a negative association with the overweight component. In contrast, all five MetS components showed positive associations with CF-PWV. CONCLUSION: This large European multicentre study reveals a differential impact of MetS and age on CAVI and CF-PWV and suggests that age may have a more pronounced effect on CAVI, whereas MetS increases CF-PWV but not CAVI. This important finding may be due to heterogeneous effects of MetS components on CAVI. The clinical significance of these original results will be assessed during the longitudinal phase of the study.

Higher prevalence and earlier appearance of geriatric phenotypes in old adults with type 2 diabetes mellitus.

AIMS: To compare the prevalence of cognitive dysfunction, depression, lower mobility performance, disability and falls in older community-dwelling individuals with type 2 diabetes mellitus (T2DM) and in controls of similar age. METHODS: We conducted a cross-sectional study in primary health care settings in 3 semi-urban regions in Greece. Were assessed 403 community-dwelling older persons (age ≥65 years, median: 73), 198 with and 205 without diabetes. Common geriatric syndromes were studied using structured individual interviews and widely-used screening scales. An ensuing secondary analysis per age group was performed. RESULTS: After adjusting for several confounding factors, the diabetes group presented a 2-fold greater odds of having abnormal scores in Mini Mental State Examination (95%CI: 1.2-3.4, p = 0.006), a 1.5-fold greater odds of abnormal performance in the Clock Drawing Test (95%CI: 1.0-2.4, p = 0.05) and a 2-fold greater odds of slower performance in Timed-Up-And-Go test (95%CI: 1.1-3.4, p = 0.022). In the analysis per age group, impaired cognitive and mobility performances were observed in individuals with diabetes of the younger subgroup (65-74 years), while in the older subgroup (≥75 years), those differences disappeared. CONCLUSIONS: In a community-dwelling population aged ≥65 years, cognitive and physical fragilisation is more frequent and is observed at an earlier age in individuals with T2DM than in those without.