Cognitive dysfunction is associated with poor diabetes control in older adults

Utilization of Frontal Assessment Battery and Executive Interview 25 in assessing for dysexecutive syndrome and its association with diabetes self-care in elderly patients with type 2 diabetes mellitus

AIMS

Executive function (EF) comprises a set of cognitive skills that controls the execution of complex activities. In the context of diabetes, this may include patients' self-monitoring and daily management of their condition. We compared two different measures of EF in a population of elderly patients with type 2 diabetes mellitus (T2DM) and studied its relationship with diabetes self-care.

METHODS

Fifty patients (34 males) had EF assessed using Frontal Assessment Battery (FAB) and Executive Interview 25 (EXIT25). Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities (SDSCA) scale. Haemoglobin A1c (HbA1c), lipid levels, blood pressure and diabetes duration were recorded.

RESULTS

The mean age of the patients was 67.0+/-7.5 years and mean duration of diabetes was 8.1+/-6.4 years. Mean HbA1c was 7.0+/-1.2%, and mean fasting plasma glucose, cholesterol and LDL-C were 7.0+/-1.7mM, 4.0+/-0.9mM and 2.1+/-0.7mM respectively. Mean EXIT25 score was 9.5+/-4.6 in the range of normal EF (14% had EXIT25 score>15, indicating impaired EF). Mean FAB score was 13.7+/-3.3 (48% having scores<15, indicating impaired EF), suggesting a degree of dysexecutive syndrome involving frontal lobe functions. EXIT25 score was inversely correlated with SDSCA (r=-0.3, p<0.05) but no significant correlation between FAB and SDSCA or HbA1c, diabetes duration, lipid levels and blood pressure with EXIT25, FAB or SDCSA was found.

CONCLUSION

A substantial proportion of elderly patients with T2DM may have dysexecutive syndrome and impairment in EF may impact on self-care in this group.

Blood pressure levels in pre-diabetic stages are associated with worse cognitive functioning in patients with type 2 diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) is associated with mild decrements in cognitive functioning, but the relation of these decrements to metabolic and vascular risk factors is unclear. The present study compared the vascular risk factor profile over the preceding 16 years between T2DM patients with good cognitive functioning and those with poor cognitive functioning.

METHODS

The Hoorn study is a population-based cohort study on glucose metabolism and vascular disease initiated in 1989, with follow-up examinations in 1996-1998, 2000-2001 and 2005-2007. Cognitive functioning was assessed in 2005-2007. Patients who developed T2DM between 1989 and 2000-2001 (n = 64) were divided in tertiles (lowest tertile = 'poor cognition', highest tertile = 'good cognition') according to a sum score for performance across cognitive domains (SUM) and the domain score for information-processing speed (IPS). The time course of vascular risk factors from 1989 to 2005-2007 was compared between these tertiles with linear mixed models adjusted for age, sex and estimated IQ.

RESULTS

Present levels (2005-2007) of vascular risk factors did not differ between patients with relatively poor or good cognition. However, patients with poor cognition had a 14-18 mmHg higher systolic blood pressure in 1989 than patients with good cognition. There were no differences in lipid profile and body weight at any time during the study between the groups. For IPS the T2DM patients with poor cognition even had a lower baseline HbA(1c) level than patients with good cognition.

CONCLUSIONS

Cognitive dysfunction in T2DM is related to the cumulative effects of long-term exposure to hypertension, even in pre-DM stages.

Epidemiological studies of smell: discussion and perspectives

The critical epidemiological data for estimating the prevalence of chemosensory disorders in the United States are lacking. Several reasons for this will be discussed, including the time-consuming nature of many existing tests, stimulus delivery in a large-scale study, and the rationale for inclusion in a large-scale epidemiological study. The opportunity to include measures of chemosensory function in ongoing population-based studies has greatly facilitated the collection of recent data that establish the high prevalence of olfactory impairment in older adults in the U.S. population and the inability of self-report measures to capture this impairment. Epidemiological studies of the complete range of the population that involve chemosensory testing pose considerable challenges, but are critical to establishing prevalence rates. These studies have the potential to suggest prevention or intervention strategies for chemosensory impairment. Key issues, including cross-cultural issues in stimulus design, testing of special populations, cohort effects, and optimal analyses of population-based chemosensory data, are considered.

Association between cognitive function and social support with glycemic control in adults with diabetes mellitus

OBJECTIVES

To examine whether cognitive impairment in adults with diabetes mellitus is associated with worse glycemic control and to assess whether level of social support for diabetes mellitus care modifies this relationship.

DESIGN

Cross-sectional analysis.

SETTING

The 2003 Health and Retirement Study (HRS) Mail Survey on Diabetes and the 2004 wave of the HRS.

PARTICIPANTS

Adults aged 50 and older with diabetes mellitus in the United States (N=1,097, mean age 69.2).

MEASUREMENTS

Glycosylated hemoglobin (HbA1c) level; cognitive function, measured with the 35-point HRS cognitive scale (HRS-cog); sociodemographic variables; duration of diabetes mellitus; depressed mood; social support for diabetes mellitus care; self-reported knowledge of diabetes mellitus; treatments for diabetes mellitus; components of the Total Illness Burden Index related to diabetes mellitus; and functional limitations.

RESULTS

In an ordered logistic regression model for the three ordinal levels of HbA1c (<7.0, 7.0-7.9, >or=8.0 mg/dL), respondents with HRS-cog scores in the lowest quartile had significantly higher HbA1c levels than those in the highest cognitive quartile (adjusted odds ratio=1.80, 95% confidence interval=1.11-2.92). A high level of social support for diabetes mellitus care modified this association; for respondents in the lowest cognitive quartile, those with high levels of support had significantly lower odds of having higher HbA1c than those with low levels of support (1.11 vs 2.87, P=.02).

CONCLUSION

Although cognitive impairment was associated with worse glycemic control, higher levels of social support for diabetes mellitus care ameliorated this negative relationship. Identifying the level of social support available to cognitively impaired adults with diabetes mellitus may help to target interventions for better glycemic control.

Role of the JNK-interacting protein 1/islet brain 1 in cell degeneration in Alzheimer disease and diabetes

Numerous epidemiological studies and some pharmacological clinical trials show the close connection between Alzheimer disease (AD) and type 2 diabetes (T2D) and thereby, shed more light into the existence of possible similar pathogenic mechanisms between these two diseases. Diabetes increases the risk of developing AD and sensitizers of insulin currently used as diabetes drugs can efficiently slow cognitive decline of the neurological disorder. Deposits of amyloid aggregate and hyperphosphorylation of tau, which are hallmarks of AD, have been also found in degenerating pancreatic islets beta-cells of patients with T2D. These events may have a causal role in the pathogenesis of the two diseases. Increased c-Jun NH(2)-terminal kinase (JNK) activity is found in neurofibrillary tangles (NFT) of AD and promotes programmed cell death of beta-cells exposed to a diabetic environment. The JNK-interacting protein 1 (JIP-1), also called islet brain 1 (IB1) because it is mostly expressed in the brain and islets, is a key regulator of the JNK pathway in neuronal and beta-cells. JNK, hyperphosphorylated tau and IB1/JIP-1 all co-localize with amyloids deposits in NFT and islets of AD and patients with T2D. This review discusses the role of the IB1/JIP-1 and the JNK pathway in the molecular pathogenesis of AD and T2D.

Cognition in the early stage of type 2 diabetes

OBJECTIVE

Type 2 diabetes is known to be associated with decrements in memory and executive functions and information-processing speed. It is less clear, however, at which stage of diabetes these cognitive decrements develop and how they progress over time. In this study, we investigated cognitive functioning of patients with recent screen-detected type 2 diabetes, thus providing insight into the nature and severity of cognitive decrements in the early stage of the disease. Possible risk factors were also addressed.

RESEARCH DESIGN AND METHODS

Included in this study were 183 diabetic patients from a previously established study cohort and 69 control subjects. A full neuropsychological assessment, addressing six cognitive domains, was made for each participant. Raw test scores were standardized into z scores per domain and compared between the groups. Possible risk factors for cognitive decrements were examined with multivariate linear regression.

RESULTS

Relative to scores for the control group, mean z scores were between 0.01 and 0.2 lower in the diabetic group across all domains, but after adjustment for differences in IQ between patients and control subjects, only memory performance was significantly reduced (mean difference -0.15 [95% CI -0.28 to -0.03]). A history of macrovascular disease and current smoking were significant determinants of slower information-processing speed in patients with diabetes.

CONCLUSIONS

This study shows that modest cognitive decrements are already present at the early stage of type 2 diabetes. A history of macrovascular disease and smoking are significant risk factors for some early decrements.

Mental ability performance among adults with type 2 diabetes in primary care

Aim and method The present university-based outpatient clinic, cross-sectional study assessed cognitive performance in a sample of 137 adults, with the primary objective of determining differences in cognitive performance as a function of gender and hypertension status in a type 2 diabetes cohort.Results Approximately 64% of the sample was 65 years old and younger, and 50 subjects had > 13 years of education. Global mental ability scores were relatively similar by age grouping, and higher-ordered cognitive functioning and reading literacy were strongly correlated, r (98) = 0.62, P < 0.01. Approximately 30% of the sample posted global mental ability scores in the slow learner range on tasks measuring attention, immediate memory and verbal reasoning. Males achieved higher cognitive functioning scores compared to females on multiple mental ability tasks. The presence of hypertension was associated with significantly worse cognitive performance compared to those subjects without hypertension, t = 2.11, P = 0.03. Approximately 57% of the hypertension group was classified as mild cognitive impaired.Conclusion While approximately half of the general population can be expected to demonstrate an average range of performance on cognitive ability measures, such an expectation could be inappropriately generalised to persons diagnosed with type 2 diabetes, even among those who were high school educated.

Distinct modulation of voltage-gated and ligand-gated Ca2+ currents by PPAR-gamma agonists in cultured hippocampal neurons

Type 2 diabetes mellitus is a metabolic disorder characterized by hyperglycemia and is especially prevalent in the elderly. Because aging is a risk factor for type 2 diabetes mellitus, and insulin resistance may contribute to the pathogenesis of Alzheimer's disease (AD), anti-diabetic agents (thiazolidinediones-TZDs) are being studied for the treatment of cognitive decline associated with AD. These agents normalize insulin sensitivity in the periphery and can improve cognition and verbal memory in AD patients. Based on evidence that Ca(2+) dysregulation is a pathogenic factor of brain aging/AD, we tested the hypothesis that TZDs could impact Ca(2+) signaling/homeostasis in neurons. We assessed the effects of pioglitazone and rosiglitazone (TZDs) on two major sources of Ca(2+) influx in primary hippocampal cultured neurons, voltage-gated Ca(2+) channel (VGCC) and the NMDA receptor (NMDAR). VGCC- and NMDAR-mediated Ca(2+) currents were recorded using patch-clamp techniques, and Ca(2+) intracellular levels were monitored with Ca(2+) imaging techniques. Rosiglitazone, but not pioglitazone reduced VGCC currents. In contrast, NMDAR-mediated currents were significantly reduced by pioglitazone but not rosiglitazone. These results show that TZDs modulate Ca(2+)-dependent pathways in the brain and have different inhibitory profiles on two major Ca(2+) sources, potentially conferring neuroprotection to an area of the brain that is particularly vulnerable to the effects of aging and/or AD.

Multidisciplinary approach for the treatment of diabetes in the elderly

Elderly patients living with diabetes are a highly heterogeneous population with unique care needs. Unlike younger patients, elderly patients may experience an atypical presentation and nontraditional complications of diabetes. Diabetes management and education require greater individualization in elderly adults because of differences in goals of care, risks and benefits of intensive treatment and abilities to practically carry out care regimens. A multidisciplinary approach to diabetes care requires an in-depth knowledge of diabetes, an awareness of geriatric issues and access to decision and educational support. This approach may be the most successful way of delivering individualized diabetes care. Future trials of diabetes care innovations in the elderly will be required to confirm the clinical benefits of this approach.

Use of serum c-peptide level to simplify diabetes treatment regimens in older adults

BACKGROUND

Diabetes management in older adults is challenging. Poor glycemic control and high risk of hypoglycemia are common in older patients on a complicated insulin regimen. Newer oral hypoglycemic agents have provided an opportunity to simplify regimens in patients with type-2 diabetes on insulin. Serum c-peptide is a test to assess endogenous production of insulin. We analyze the use of serum c-peptide level in simplifying diabetes regimen by decreasing or stopping insulin injection and adding oral hypoglycemic agents in older adults.

METHODS

One hundred patients aged over 65 years with either poor glycemic control or difficulty coping with insulin regimen seen at a geriatric diabetes clinic were analyzed for this study. The data on serum c-peptide levels and A1c, along with demographic information, were obtained from medical charts.

RESULTS

Sixty-five of 100 patients (aged 79+/-14 years, duration of diabetes 21+/-13 years) had detectable serum c-peptide levels. Forty-six of 65 patients were available for simplification of regimen. Eleven of 46 patients had other co-morbidities preventing use of oral hypoglycemic agents. In 35/65 patients, simplification was completed successfully. Nineteen of 35 patients were converted to all-oral regimens (off insulin), while 16/35 had simplification of regimen by addition of oral hypoglycemic agents and lowering the number of insulin injections from an average of 2.7 to 1.5 injections/day (P=.001). Glycemic control improved significantly in patients with a simplified regimen (8.0%+/-1.5% vs 7.4%+/-1.5%; P<.002), and patients reported fewer hypoglycemia episodes.

CONCLUSIONS

Serum c-peptide level can be used to simplify insulin regimen in older adults with diabetes.

Cognitive and psychosocial aspects of caring for elderly patients with diabetes

The population is aging in the United States as well as worldwide. The prevalence of diabetes increases with increasing age. To provide optimal care to older adults with diabetes, unique psychosocial barriers need to be considered by medical providers. Unlike in younger adults, cognitive dysfunction/dementia and depressive mood disorders are common coexisting conditions in older adults with diabetes. This article reviews recent literature on epidemiology and clinical implications of cognitive and psychosocial dysfunctions in older patients with diabetes. This article focuses on cognitive dysfunctions, dementia, depression, and other psychosocial stresses, and their implications in the care of older adults with diabetes.

Diabetes and the risk of multi-system aging phenotypes: a systematic review and meta-analysis

Background

Observational studies suggested an association between diabetes and the risk of various geriatric conditions (i.e., cognitive impairment, dementia, depression, mobility impairment, disability, falls, and urinary incontinence). However, the magnitude and impact of diabetes on older adults have not been reviewed.

Methodology/Principal Findings

MEDLINE and PSYCINFO databases were searched through November 2007 for published studies, supplemented by manual searches of bibliographies of key articles. Population-based, prospective cohort studies that reported risk of geriatric outcomes in relation to diabetes status at baseline were selected. Two authors independently extracted the data, including study population and follow-up duration, ascertainment of diabetes status at baseline, outcomes of interest and their ascertainment, adjusted covariates, measures of association, and brief results. Fifteen studies examined the association of DM with cognitive dysfunction. DM was associated with a faster decline in cognitive function among older adults. The pooled adjusted risk ratio (RR) for all dementia when persons with DM were compared to those without was 1.47 (95% CI, 1.25 to 1.73). Summary RRs for Alzheimer's disease and vascular dementia comparing persons with DM to those without were 1.39 (CI, 1.16 to 1.66) and 2.38 (CI, 1.79 to 3.18), respectively. Four of 5 studies found significant association of DM with faster mobility decline and incident disability. Two studies examined the association of diabetes with falls in older women. Both found statistically significant associations. Insulin users had higher RR for recurrent falls. One study for urinary incontinence in older women found statistically significant associations. Two studies for depression did not suggest that DM was an independent predictor of incident depression.

Conclusions/Significance

Current evidence supports that DM is associated with increased risk for selected geriatric conditions. Clinicians should increase their awareness and provide appropriate care. Future research is required to elucidate the underlying pathological pathway.

Type 2 diabetes mellitus, cognition and brain in aging: A brief review

Diabetes mellitus is a complex disease with many potential complications. Whilst there have been inconsistent results in regard to an association between cognition and type 2 diabetes, there is evidence that verbal memory and processing speed are the cognitive domains usually impaired. In elderly diabetic subjects, other cognitive domains may also be involved, due to ageing. Glycemic control is implicated in the development of cognitive dysfunction, although more research is needed in this area. Insulin dysregulation and hyperglycemia play an important role in neurodegeneration. Using structural neuroimaging, it has been shown that brain atrophy is an important feature in those with type 2 diabetes. Integrative research is needed using behavioral, cognitive, imaging, and genetic platforms.

(Pre)diabetes, brain aging, and cognition

Cognitive dysfunction and dementia have recently been proven to be common (and underrecognized) complications of diabetes mellitus (DM). In fact, several studies have evidenced that phenotypes associated with obesity and/or alterations on insulin homeostasis are at increased risk for developing cognitive decline and dementia, including not only vascular dementia, but also Alzheimer's disease (AD). These phenotypes include prediabetes, diabetes, and the metabolic syndrome. Both types 1 and 2 diabetes are also important risk factors for decreased performance in several neuropsychological functions. Chronic hyperglycemia and hyperinsulinemia primarily stimulates the formation of Advanced Glucose Endproducts (AGEs), which leads to an overproduction of Reactive Oxygen Species (ROS). Protein glycation and increased oxidative stress are the two main mechanisms involved in biological aging, both being also probably related to the etiopathogeny of AD. AD patients were found to have lower than normal cerebrospinal fluid levels of insulin. Besides its traditional glucoregulatory importance, insulin has significant neurothrophic properties in the brain. How can clinical hyperinsulinism be a risk factor for AD whereas lab experiments evidence insulin to be an important neurothrophic factor? These two apparent paradoxal findings may be reconciliated by evoking the concept of insulin resistance. Whereas insulin is clearly neurothrophic at moderate concentrations, too much insulin in the brain may be associated with reduced amyloid-beta (Abeta) clearance due to competition for their common and main depurative mechanism - the Insulin-Degrading Enzyme (IDE). Since IDE is much more selective for insulin than for Abeta, brain hyperinsulinism may deprive Abeta of its main clearance mechanism. Hyperglycemia and hyperinsulinemia seems to accelerate brain aging also by inducing tau hyperphosphorylation and amyloid oligomerization, as well as by leading to widespread brain microangiopathy. In fact, diabetes subjects are more prone to develop extense and earlier-than-usual leukoaraiosis (White Matter High-Intensity Lesions - WMHL). WMHL are usually present at different degrees in brain scans of elderly people. People with more advanced WMHL are at increased risk for executive dysfunction, cognitive impairment and dementia. Clinical phenotypes associated with insulin resistance possibly represent true clinical models for brain and systemic aging.

Cognitive impairment: an increasingly important complication of type 2 diabetes: the age, gene/environment susceptibility--Reykjavik study

Persons with type 2 diabetes are at increased risk of cognitive dysfunction. Less is known about which cognitive abilities are affected and how undiagnosed diabetes and impaired fasting glucose relate to cognitive performance. The authors explored this question using data from 1,917 nondemented men and women (average age = 76 years) in the population-based Age, Gene/Environment Susceptibility-Reykjavik Study (2002-2006). Glycemic status groups included diagnosed diabetes (self-reported diabetes or diabetic medication use; n = 163 (8.5%)), undiagnosed diabetes (fasting blood glucose >or=7.0 mmol/L without diagnosed diabetes; n = 55 (2.9%)), and impaired fasting glucose (fasting blood glucose 5.6-6.9 mmol/L; n = 744 (38.8%)). Composites of memory, processing speed (PS), and executive function were constructed from a neuropsychological battery. Linear regression was used to investigate cross-sectional differences in cognitive performance between glycemic groups, adjusted for demographic and health factors. Persons with diagnosed diabetes had slower PS than normoglycemics (beta = -0.12; P < 0.05); diabetes duration of >or=15 years was associated with significantly poorer PS and executive function. Undiagnosed diabetics had slower PS (beta = -0.22; P < 0.01) and poorer memory performance (beta = -0.22; P < 0.05). Persons with type 2 diabetes have poorer cognitive performance than normoglycemics, particularly in PS. Those with undiagnosed diabetes have the lowest cognitive performance.

Blood glucose levels before and after cognitive testing in diabetes mellitus

The primary indices of diabetes mellitus (DM), including hemoglobin A1c (HbA1c) and fasting glucose, appear to be only moderately predictive of the cognitive impairments exhibited by patients with DM. There is evidence that in DM the ability to utilize glucose is compromised and the authors hypothesized that this difficulty might be relevant to the study of cognitive function in DM. Thus, the authors examined the relationship between cognitive performance and changes in peripheral glucose from the start to the conclusion of cognitive testing. Individuals who showed decreased glucose levels from the start to the conclusion of cognitive testing performed significantly better than those exhibiting moderate to slight increases in glucose levels from the start to the conclusion of testing. Apparently, the putative utilization of blood glucose rather than the glucose levels prior to or following a cognitive challenge is associated with better cognitive performance primarily on more complex cognitive tests. This brief and inexpensive test of changes in glucose levels has potential clinical implications for assessing cognitive status in DM.

Cognitive dysfunction and diabetes mellitus

The deleterious effects of diabetes mellitus on the retinal, renal, cardiovascular, and peripheral nervous systems are widely acknowledged. Less attention has been given to the effect of diabetes on cognitive function. Both type 1 and type 2 diabetes mellitus have been associated with reduced performance on numerous domains of cognitive function. The exact pathophysiology of cognitive dysfunction in diabetes is not completely understood, but it is likely that hyperglycemia, vascular disease, hypoglycemia, and insulin resistance play significant roles. Modalities to study the effect of diabetes on the brain have evolved over the years, including neurocognitive testing, evoked response potentials, and magnetic resonance imaging. Although much insightful research has examined cognitive dysfunction in patients with diabetes, more needs to be understood about the mechanisms and natural history of this complication in order to develop strategies for prevention and treatment.

Cognitive dysfunction and diabetes mellitus

The deleterious effects of diabetes mellitus on the retinal, renal, cardiovascular, and peripheral nervous systems are widely acknowledged. Less attention has been given to the effect of diabetes on cognitive function. Both type 1 and type 2 diabetes mellitus have been associated with reduced performance on numerous domains of cognitive function. The exact pathophysiology of cognitive dysfunction in diabetes is not completely understood, but it is likely that hyperglycemia, vascular disease, hypoglycemia, and insulin resistance play significant roles. Modalities to study the effect of diabetes on the brain have evolved over the years, including neurocognitive testing, evoked response potentials, and magnetic resonance imaging. Although much insightful research has examined cognitive dysfunction in patients with diabetes, more needs to be understood about the mechanisms and natural history of this complication in order to develop strategies for prevention and treatment.

Comorbid conditions and glycemic control in elderly patients with type 2 diabetes mellitus, 1988 to 1994 to 1999 to 2004

OBJECTIVES

To compare the prevalence of type 2 diabetes mellitus in the U.S. elderly population between 1988 to 1994 and 1999 to 2004 and to assess glycemic control and comorbid conditions in this population.

DESIGN

Serial U.S. population-based cross-sectional surveys.

SETTING

National Health and Nutrition Examination Surveys (1988-1994 and 1999-2004).

PARTICIPANTS

Survey participants aged 65 and older with type 2 diabetes mellitus.

MEASUREMENTS

Glycemic control, measured as hemoglobin A1C (hA1C) less than 7%, prevalence of comorbid conditions, pharmacologic treatment rate, blood pressure, and serum cholesterol.

RESULTS

The prevalence of diagnosed type 2 diabetes mellitus in the U.S. elderly population increased from 12.0% to 14.1% (P=.004) between 1988 and 2004. Many patients had comorbid conditions; in 1999 to 2004, 36.7% had nephropathy, 31.5% renal insufficiency, 20.2% history of myocardial infarction, and 17.9% heart failure. The proportion of patients treated with antihyperglycemic medication increased from 75.1% in 1988 to 1994 to 85.6% in 1999 to 2004 (P<.001), and glycemic control rates also improved, from 44.7% to 54.8% (P<.001). Greater improvement in glycemic control rates was evident in patients without comorbidities (P<.001). Adjusted for patient characteristics, including duration of diabetes mellitus, patients with nephropathy or renal insufficiency were 40% less likely to achieve controlled hA1C as those without.

CONCLUSION

Despite improvements in the rates of treatment and glycemic control, approximately half of elderly patients diagnosed with type 2 diabetes mellitus have hA1C levels of 7% or higher. Many patients suffer from comorbid conditions, which may present a challenge for successful diabetes mellitus management.

Executive summary. The State of the Science on Nursing Best Practices for Diabetes Self-Management

The State of the Science on Nursing Best Practices for Diabetes Self-Management.

Accountability for patient self-management of chronic conditions; ethical analysis and a proposal

Patient self-management (PSM) of varying portions of therapy for chronic illness is expanding. However, several current conditions of practice are ethically problematic. Standards remain process-oriented, and accountability for patient outcomes and quality of practice of both patient and provider is diffuse. PSM carries important benefits but largely unmonitored potential harms. Also, access to preparation for safe PSM appears to be skewed in favour of high socio-economic classes. This condition persists even though available evidence supports the conclusion that less advantaged patients with poor disease outcomes can be taught to self-manage, albeit they require more intensive and prolonged interventions. Routine clinical use of well-validated measurement instruments could serve to develop evidence-based standards of PSM, quality improvement and effective public policy. Development of a standard dataset would facilitate description of the effectiveness of existing programmes and comparison across programmes. Such reform will require investment in the development of instruments that measure patient ability to make sound clinical judgements and sustain PSM over changed disease and social conditions. It will take advantage of modem psychometric theory, which is increasingly necessary for building the empirical base for evidence-based healthcare.