Managing Diabetes and Dementia

Key points

Risk factors for cognitive dysfunction in diabetes

Diabetes is an important risk factor for Alzheimer and vascular dementia. Several studies have shown increased risk of dementia in older adults with type 2 diabetes.⁷ Specific risk factors to assess include hyperglycemia, hypoglycemia, and depression.

How to identify cognitive dysfunction

It is difficult to identify subtle changes in memory. Patients with early memory loss and a simple medication regimen may function well and cognitive impairment may be difficult to identify. Current guidelines recommend testing for patients more than 65 years of age with diabetes for memory loss. Mini-Cog²¹ is a short, time-efficient screening test useful in a busy practice to identify cognitive impairment. Various other tests, such as the Montreal cognitive assessment (MoCA)²² and the Mini

Impact of cognitive dysfunction on diabetes management

Patients with cognitive impairment are at increased risk of developing both hypoglycemia and hyperglycemia. Hypoglycemia can have bidirectional impact: it increases the risk of dementia, and dementia then increases the risk of hypoglycemia.¹¹

Patients with cognitive dysfunction have poorly controlled diabetes because they are unable to perform self-care tasks. For example, they may forget to take medication or administer insulin, or may take a wrong dose and forget to eat meals. This possibility

Individualized glycemic goal setting

Most of the guidelines in management of diabetes take into account the cognitive ability, life expectancy, and the overall health of patients along with their comorbidities. Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive function and functional status should have lower glycemic goals (hemoglobin A1c [HbA1c] <7.5%).⁶

Individuals with chronic coexisting illness and cognitive impairment and/or functional dependence should have less stringent goals

Management of diabetes: clinical case Simulations

Diabetes management should include treatment with lifestyle modification, diet, and exercise. However, special consideration should be given to treatment of older adults with different levels of functional and cognitive impairment. The following 3 cases show treatment options relevant to each patient’s respective localization on the activities of daily living (ADL) and cognition spectrum. An overall framework for approaching any of these clinical case scenarios can be the 4M (what matters most,

Summary

An aging global population has heralded the ever-growing prevalence of diabetes with concurrent dementia. Annual cognitive and functional assessments engender a clinical paradigm shift toward both early intervention and developing personalized care plans, customized to individual cognitive and functional capabilities. Integral to fostering this is a multidisciplinary team approach, including recruiting patient/family support. Simplification and deintensification of medication regimens and

Disclosure

The authors have nothing to disclose.