Association of depression with increased risk of dementia in patients with type 2 diabetes: the Diabetes and Aging Study

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Depression as a Risk Factor for Dementia: A Meta-Analysis

Dementia is a syndrome characterized by the deterioration of cognitive function beyond what is expected. The increased risk of developing this syndrome resulting from established modifiable risk factors, such as depressive episodes, is currently a subject of interest. The aim of this study was to review the scientific evidence that addresses the relationship between depression and dementia. A bibliographic search of the PubMed and PsycInfo databases for articles published over the past 20 years was conducted with the following medical subject heading terms: depression or depressive, dementia, and incidence or cohort studies. After articles meeting the inclusion criteria were selected, relevant moderating variables were grouped as sample characteristics, methodological characteristics, extrinsic characteristics, and outcome variables. The 26 selected studies resulted in a sample comprising 1,760,262 individuals. Statistical analysis revealed a pooled relative risk for the development of dementia of 1.82 (95% CI=1.62-2.06). The primary variables evaluated were the diagnostic methods for depression and dementia and the presence of depression. Other variables, such as mean age, methodological quality of each study, follow-up time, and publication year, were also evaluated. Age was statistically but not clinically significant. No relevant publication bias or alterations in the results were found when accounting for the quality of the studies. It is recommended that new moderating variables be evaluated or that existing variables be reformulated in future studies.

Depressive Symptoms Longitudinally Mediate the Effect of Hyperglycemia on Memory Decline in Type 2 Diabetes

OBJECTIVE

We sought to examine the mediating role of changes in depressive symptoms in the association between chronic hyperglycemia and longitudinal cognition in a sample of older adults with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

We conducted a longitudinal mediation analysis using structural equation modeling of observational data collected over 6 years from 2,155 participants with T2D (aged ≥51 years) in the U.S.-wide Health and Retirement Study. T2D was defined using self-reported diagnosis, and HbA1c was assessed at study baseline. Self-reported depressive symptoms were assessed at two time points 4 years apart. Episodic memory was measured using a list-learning test administered at three time points over 6 years. We adjusted for sociodemographics, chronic health comorbidities, medication adherence, study enrollment year, and prior years' depressive symptoms and memory scores.

RESULTS

At baseline, participants' mean age was 69.4 (SD = 9.1), mean HbA1c was 7.2% (SD = 1.4%), 55.0% were women, 19.3% were non-Latinx Black, and 14.0% were Latinx. Higher baseline levels of HbA1c were associated with increases in depressive symptoms over 4 years, which, in turn, were associated with poorer memory 2 years later. Depressive symptoms accounted for 19% of the longitudinal effect of HbA1c on memory over the 6-year period. Sensitivity analyses ruled out alternative directions of associations.

CONCLUSIONS

Incident elevations in depressive symptoms mediated the longitudinal association between hyperglycemia and 6-year episodic memory scores. For older adults with T2D, interventions to prevent HbA1c-related incident depressive symptoms may be beneficial in reducing the neurotoxic effects of chronic hyperglycemia on cognition.

Baseline Profiles of Drug Prescriptions Prior to Diagnosis of Mild Cognitive Impairment (MCI) Obtained by Latent Class Analysis (LCA), and Assessment of Their Association with Conversion to Dementia

Polypharmacy has been linked to cognitive decline. However, interventions targeting modifiable risk factors, some of which are targets of the most commonly used drugs, could reduce the prevalence of dementia. Our aim was to determine the drug prescription regimen at baseline, prior to the diagnosis of mild cognitive impairment (MCI), and its possible association with progression to dementia. Data were collected from the electronic medical records of 342 MCI outpatients diagnosed during 2006-2017 at their first neurology consultation. We followed the classical three-step method of statistical analysis, starting with a Latent Class Analysis (LCA) to discover subgroups of drug prescription probability. Half of the patients were under polypharmacy (≥5 drugs), 17.5% had no recorded medication, 33.3% progressed to dementia (94.7% in ≤5 years), and 84.1% of them to Alzheimer's disease (AD). According to the LCA and based on 20 therapeutic indicators obtained from 240 substances and regrouped according the Anatomical Therapeutic Chemical Classification, we identified a four-profile model: (1) low (35.7% of patients); (2) mixed (28.7%); (3) cardio-metabolic (19.3%); and (4) psychotropic (16.4%). The binomial regression logistic model showed that profiles 2 and 3 (and 4 for AD), with a higher drug prescription conditioned probability against classic risk factors, were protective than profile 1 (OR = 0.421, p = 0.004; OR = 0.278, p = 0.000; OR = 0.457, p = 0.040, respectively), despite polypharmacy being significant in profiles 2 and 3 (mean > 7 drugs) vs. profile 1 (1.4 ± 1.6) (p = 0.000). Patients in the latter group were not significantly older, although being aged 65-79 years old quadrupled (OR = 4.217, p = 000) and being >79 tripled (OR = 2.945, p = 0.010) the conversion risk compared to patients <65 years old. According to the proposed analytical model, profiling the heterogeneous association of risk factors, which were taken prior to diagnosis, could be explored as an indicator of prior care and a predictor of conversion to dementia.

Decoding the genetic relationship between Alzheimer's disease and type 2 diabetes: potential risk variants and future direction for North Africa

Introduction

Alzheimer's disease (AD) and Type 2 diabetes (T2D) are both age-associated diseases. Identification of shared genes could help develop early diagnosis and preventive strategies. Although genetic background plays a crucial role in these diseases, we noticed an underrepresentation tendency of North African populations in omics studies.

Materials and methods

First, we conducted a comprehensive review of genes and pathways shared between T2D and AD through PubMed. Then, the function of the identified genes and variants was investigated using annotation tools including PolyPhen2, RegulomeDB, and miRdSNP. Pathways enrichment analyses were performed with g:Profiler and EnrichmentMap. Next, we analyzed variant distributions in 16 worldwide populations using PLINK2, R, and STRUCTURE software. Finally, we performed an inter-ethnic comparison based on the minor allele frequency of T2D-AD common variants.

Results

A total of 59 eligible papers were included in our study. We found 231 variants and 363 genes shared between T2D and AD. Variant annotation revealed six single nucleotide polymorphisms (SNP) with a high pathogenic score, three SNPs with regulatory effects on the brain, and six SNPs with potential effects on miRNA-binding sites. The miRNAs affected were implicated in T2D, insulin signaling pathways, and AD. Moreover, replicated genes were significantly enriched in pathways related to plasma protein binding, positive regulation of amyloid fibril deposition, microglia activation, and cholesterol metabolism. Multidimensional screening performed based on the 363 shared genes showed that main North African populations are clustered together and are divergent from other worldwide populations. Interestingly, our results showed that 49 SNP associated with T2D and AD were present in North African populations. Among them, 11 variants located in DNM3, CFH, PPARG, ROHA, AGER, CLU, BDNF1, CST9, and PLCG1 genes display significant differences in risk allele frequencies between North African and other populations.

Conclusion

Our study highlighted the complexity and the unique molecular architecture of North African populations regarding T2D-AD shared genes. In conclusion, we emphasize the importance of T2D-AD shared genes and ethnicity-specific investigation studies for a better understanding of the link behind these diseases and to develop accurate diagnoses using personalized genetic biomarkers.

Why do we not reverse the path? Stress can cause depression, reduction of brain-derived neurotrophic factor and increased inflammation

The aim of this paper is to describe the direction of the link between stress, depression, increased inflammation and brain-derived neurotrophic factor (BDNF) reduction. We hypothesize that severe stress or prolonged stress can be the driving factor that promote the onset of depression. Both stress and depression, if not resolved over time, activate the production of transcription factors that will switch on pro-inflammatory genes and translate them into cytokines. This cascade fosters systemic chronic inflammation and reduced plasma BDNF levels. Since people with depression have a 60% increased risk of developing type 2 diabetes (T2D) and show high levels of inflammation and low levels of BDNF, we hypothesize possible reasons that might explain why T2D, depression and dementia are often associated in the same patient.

Depressive symptoms mediate the relationship between diabetes and cognitive performance in a community-based sample of older adults

AIMS

To evaluate whether diabetes and prediabetes are associated with impaired cognitive performance among older adults and examine depressive symptoms as a mediator.

METHODS

We used cross-sectional data from the Einstein Aging Study, a systematically recruited, community-based cohort study of diverse older adults (N = 794; Age Mean (SD) = 78.9 (5.3); 64.4% Non-Hispanic White, 28.7% Non-Hispanic Black, 5.7% Hispanic). Diabetes status was established via self-reported diagnosis, prescribed medications, and fasting blood glucose. Depressive symptoms were assessed using the Geriatric Depression Scale. Cognitive tests included Digit Symbol, Trails-B, Free Recall, Category Fluency, Boston Naming, and Block Design. Linear regression and mediation analyses were applied.

RESULTS

Compared to those without diabetes, diabetes was associated with worse performance on all cognitive tests (ps < 0.05), except Trails-B (p = 0.53), and increased depressive symptoms (p < 0.01). For diabetes, mediation via increased depressive symptoms was observed for Free Recall (p = 0.044), Category Fluency (p = 0.033), and Boston Naming (p = 0.048).

CONCLUSIONS

Diabetes was consistently associated with worse cognitive performance and increased depressive symptoms among this older cohort, while prediabetes was not. Mediation findings suggest depressive symptoms may be a biobehavioral pathway linking diabetes and cognition, though the temporal sequence is unclear. If causal, addressing both diabetes and depressive symptoms among older adults may protect cognitive function.

Diagnostic, Prognostic, and Mechanistic Biomarkers of Diabetes Mellitus-Associated Cognitive Decline

Cognitive dysfunctions such as mild cognitive impairment (MCI), Alzheimer's disease (AD), and other forms of dementia are recognized as common comorbidities of type 2 diabetes mellitus (T2DM). Currently, there are no disease-modifying therapies or definitive clinical diagnostic and prognostic tools for dementia, and the mechanisms underpinning the link between T2DM and cognitive dysfunction remain equivocal. Some of the suggested pathophysiological mechanisms underlying cognitive decline in diabetes patients include hyperglycemia, insulin resistance and altered insulin signaling, neuroinflammation, cerebral microvascular injury, and buildup of cerebral amyloid and tau proteins. Given the skyrocketing global rates of diabetes and neurodegenerative disorders, there is an urgent need to discover novel biomarkers relevant to the co-morbidity of both conditions to guide future diagnostic approaches. This review aims to provide a comprehensive background of the potential risk factors, the identified biomarkers of diabetes-related cognitive decrements, and the underlying processes of diabetes-associated cognitive dysfunction. Aging, poor glycemic control, hypoglycemia and hyperglycemic episodes, depression, and vascular complications are associated with increased risk of dementia. Conclusive research studies that have attempted to find specific biomarkers are limited. However, the most frequent considerations in such investigations are related to C reactive protein, tau protein, brain-derived neurotrophic factor, advanced glycation end products, glycosylated hemoglobin, and adipokines.

Synergistic Associations of Depressive Symptoms and Executive Functions With Longitudinal Trajectories of Diabetes Biomarkers Among Urban-Dwelling Adults Without Diabetes

OBJECTIVE

Depressive symptoms and executive functions (EFs) have recently emerged as novel risk factors for type 2 diabetes, but it is unknown if these factors interact to influence diabetes pathophysiology across the life span. We examined the synergistic associations of depressive symptoms and EFs with longitudinal trajectories of diabetes diagnostic criteria among middle-aged and older adults without diabetes.

METHODS

Participants were 1257 African American and White, urban-dwelling adults from the Healthy Aging in Neighborhoods of Diversity across the Life Span study who were assessed up to three times over a 13-year period (2004-2017). At baseline, participants completed the Center for Epidemiological Studies-Depression scale and measures of EFs-Trail Making Test Part B, verbal fluency, and Digit Span Backward-for a composite EFs score, and provided blood samples at each follow-up for glycated hemoglobin and fasting serum glucose.

RESULTS

A total of 155 and 220 individuals developed diabetes or prediabetes at wave 3 and wave 4, respectively. Linear mixed-effects regression models adjusting for sociodemographic factors, diabetes risk factors, and antidepressant medications revealed significant three-way interactions of Center for Epidemiological Studies-Depression, EFs, and age on change in glycated hemoglobin (b = -0.0001, p = .005) and in fasting serum glucose (b = -0.0004, p < .001), such that among individuals with lower but not higher EFs, elevated depressive symptoms were associated with steeper age-related increases in diabetes biomarkers over time.

CONCLUSIONS

Depressive symptoms and lower EFs may interactively accelerate trajectories of key diagnostic criteria, thereby increasing the risk for earlier diabetes incidence. Identifying individuals in this high-risk group may be an important clinical priority for earlier intervention, which has the promise of preventing or delaying this debilitating disease.

Effects of Leisure-Time Physical Activity on Cognitive Reserve Biomarkers and Leisure Motivation in the Pre-Diabetes Elderly

The purpose of this study was to investigate the change in cognitive reserve biomarkers of the pre-diabetic individual according to the types of leisure-time physical activity (aerobic or resistance physical activity). The research subjects (n = 184) who participated in the survey were pre-diabetic and diabetic patients who were visiting university hospitals and welfare centers. The intervention subjects (n = 36) who were elderly females with pre-diabetes volunteered to participate in the study by performing regular physical exercise (aerobic or resistance exercise). The study participants were 65 years of age or older with pre-diabetes defined by a glycated hemoglobin (HbA1c) level of (5.7−6.4)%. All research subjects performed motivation and stress questionnaire survey. All intervention subjects participated in leisure-time physical activity (LTPA) for 12 weeks. Body composition, HbA1c, and cognitive reserve biomarkers were measured at baseline, and at 6 and 12 weeks. LTPA motivation confirmed that the LTPA participants had a high level of motivation. Stress confirmed that the stress level of LTPA participants was low. Two-way within-factor ANOVA revealed significant group × time interaction for weight (p < 0.05), BMI (p < 0.01), % fat (p < 0.001), SBP (p < 0.05), HbA1c (p < 0.001), BDNF (p < 0.001), and Beta-Amyloid 1−42 (p < 0.001). In both physical activity groups, HbA1c (p < 0.001), NGF (p < 0.05), BDNF (p < 0.05), and Cathepsin B (p < 0.05) improved significantly at 12 weeks, compared to baseline and 6 weeks. In the resistance physical activity group, Beta-Amyloid 1−42 (p < 0.01) and Homocysteine (p < 0.05) significantly decreased at 12 weeks, compared to baseline and at 6 weeks. The LTPA showed high levels of integrated and identified regulation among leisure motive types, and the level of stress was found to be low. The LTPA is effective in reducing the HbA1c levels of the pre-diabetes elderly. In addition, the pre-diabetes elderly were found to have increased NGF, BDNF, and cathepsin B, and decreased Beta-Amyloid 1−42 and homocysteine. Regular leisure-time physical activity has a positive effect on cognitive reserve biomarkers through improving glycemic control by reducing weight and % fat in the pre-diabetes elderly.

Associations between depression and cognition, mild cognitive impairment and dementia in persons with diabetes mellitus: A systematic review and meta-analysis

AIMS

This systematic review aimed to examine whether persons with diabetes and depression had poorer cognition and higher dementia risk than persons with diabetes only. Moreover, the impact of timing, frequency of depressive episodes throughout life, and antidepressant treatment were examined.

METHODS

PubMed, Embase and PsycINFO were searched to obtain observational studies between August 2015 and June 2021 that examined the association between depression and cognition, mild cognitive impairment or dementia in people with diabetes. Studies published before August 2015 were retrieved from a previous systematic review. Findings were pooled using meta-analyses.

RESULTS

10 out of 19 included articles were appropriate for the meta-analyses. Persons with diabetes and depression experienced greater declines in executive function (SMD = -0.39 (-0.69, -0.08)), language (SMD = -0.80 (-1.52, -0.09)), memory (SMD = -0.63 (-1.12, -0.14)) and overall cognition (SMD = -0.77 (-1.33, -0.20)), and greater dementia risk (HR = 1.82 (1.79, 1.85)) than persons with diabetes only. No significant differences were observed for complex attention. No studies examined the role of timing and frequency of depressive episodes and antidepressant treatment.

CONCLUSION

In persons with diabetes, depression is associated with worse cognition and higher dementia risk. The potential mitigating effect of antidepressant treatment remains unclear.

Association between depression and the risk of Alzheimer's disease using the Korean National Health Insurance Service-Elderly Cohort

In this cohort study, we assessed the association between depression and the risk of Alzheimer’s disease from data obtained from the 2002 to 2013 Korean National Health Insurance Service-Elderly Cohort Database, which accounts for 10% of the South Korean population aged > 60 years. A total 518,466 patients were included in the analysis and followed up, unless they were excluded due to death or migration. Patients who sought treatment for depression or dementia within 1 year of the washout period and who were diagnosed with dementia within the 1-year period of the diagnosis of depression were excluded from the study. The risk of dementia was analysed using Cox proportional hazards models. Patients with a history of depression during the follow-up period were at a higher risk of Alzheimer’s disease than those without a history of depression (HR 3.35, CI 3.27–3.42). The severe-depression group exhibited the highest risk of Alzheimer’s disease (HR 4.41, CI 4.04–4.81), while the mild-depression group exhibited a relatively lower risk of Alzheimer’s disease (HR 3.31, CI 3.16–3.47). The risk of Alzheimer’s disease was associated with depression history and an increased severity of depression increased the risk of Alzheimer’s disease.

Factors Associated with Mortality Including Nursing Home Transitions: A Retrospective Analysis of 25,418 People Prescribed Anti-Dementia Drugs in Northern Ireland

BACKGROUND

Understanding factors associated with mortality after a dementia diagnosis can provide essential information to the person with dementia, their family, and caregivers. To date very little is known about the factors associated with mortality after a dementia diagnosis in Northern Ireland.

OBJECTIVE

To determine how demographic and other factors such as deprivation and comorbidity medications influence mortality rates after a dementia diagnosis in Northern Ireland and whether these factors are influenced through nursing home transitions.

METHODS

25,418 people prescribed anti-dementia medication were identified through the enhanced prescribing database between 2010 and 2016. The impact of covariates including age, gender, marital status, deprivation measure, urban/rural classification, and comorbidity medications were examined using cox proportional hazard models with hazard ratios (HR) and 95% confidence intervals.

RESULTS

Between 2010 and 2016, 12,129 deaths occurred, with 114 deaths/1,000 person years. Males had significantly higher mortality rates in comparison to females (HR = 1.28; 95% CI = 1.23-1.33); this was true regardless of whether the person with dementia transitioned to a nursing home. People prescribed anti-dementia drugs living with lower levels of deprivation had significantly lower mortality rates in comparison to people living with the highest levels of deprivation (HR = 0.93; 95% CI = 0.89-0.97). Diabetic (HR = 1.18; 95% CI = 1.07-1.29) and anti-arrhythmic (HR = 2.44; 95% CI = 1.01-5.91) medication in particular significantly influenced mortality.

CONCLUSION

Male gender, higher comorbidity medications, and living in areas of higher deprivation significantly increased mortality rates for people prescribed anti-dementia drugs in our study population. When comorbidity medications were classified, only anti-arrhythmia and diabetic medications significantly increased mortality. Future research should continue to investigate factors which influence mortality after a dementia diagnosis.

Deciphering the links between psychological stress, depression, and neurocognitive decline in patients with Down syndrome

The relationships between psychological stress and cognitive functions are still to be defined despite some recent progress. Clinically, we noticed that patients with Down syndrome (DS) may develop rapid neurocognitive decline and Alzheimer's disease (AD) earlier than expected, often shortly after a traumatic life event (bereavement over the leave of a primary caregiver, an assault, modification of lifestyle, or the loss of parents). Of course, individuals with DS are naturally prone to develop AD, given the triplication of chromosome 21. However, the relatively weak intensity of the stressful event and the rapid pace of cognitive decline after stress in these patients have to be noticed. It seems DS patients react to stress in a similar manner normal persons react to a very intense stress, and thereafter develop a state very much alike post-traumatic stress disorders. Unfortunately, only a few studies have studied stress-induced regression in patients with DS. Thus, we reviewed the biochemical events involved in psychological stress and found some possible links with cognitive impairment and AD. Interestingly, these links could probably be also applied to non-DS persons submitted to an intense stress. We believe these links should be further explored as a better understanding of the relationships between stress and cognition could help in many situations including individuals of the general population.

African American Ethnicity, Hypertension, Diabetes, and Arthritis Independently Predict Co-occurring Depression and Obesity among Community-dwelling Older Adult Alabamians

Although obesity and depression are quite common among older adults, surprisingly published literature has not examined factors associated with co-occurring depression and obesity among older adults. The knowledge that fills this gap would be advantageous for public health social workers and other health professionals who provide health care and public health services to older adults. The objectives of this study were to access the prevalence of and independent predictors of co-occurring depression and obesity among older adults in the state of Alabama. A retrospective analysis was conducted using a statewide survey of Alabamian community-dwelling older adults (n = 1,166). Binomial logistic regression was used to examine predictors of co-occurring depression and obesity. The prevalence of co-occurring depression and obesity among older adults was 16%. In the multivariate analysis, African American ethnicity (OR = 1.505, CI: 1.019-2.223), hypertension (OR = 1.593, CI: 1.050-2.416), diabetes (OR = 1.768, CI: 1.188-2.632), and arthritis (OR = 1.640, CI: 1.096-2.454) were positively associated with co-occurring depression and obesity). Older age (OR = 0.963, CI: 0.942-0.985) and higher levels of physical activity (OR = 1.640, CI: 1.096-2.454) were negatively associated with co-occurring depression and obesity. There is a need for the development and implementation of suitable interventions to prevent and manage co-occurring depression and obesity among older adults, particularly older adults with arthritis, hypertension, diabetes, or of African American ethnicity.

Depression as a risk factor for dementia in older people with type 2 diabetes and the mediating effect of inflammation

AIMS/HYPOTHESIS

We aimed to determine the association of depression with dementia risk in people with type 2 diabetes, and to explore the possible mediating role of inflammation in this relationship.

METHODS

The Edinburgh Type 2 Diabetes Study is a prospective cohort of 1066 men and women with type 2 diabetes aged 60-75 years. Cox proportional hazards regression analysis was used to investigate the association between depression, assessed at baseline, and subsequent risk of dementia over 10 years. Depression was defined using the Hospital Anxiety and Depression Scale, while incident dementia was defined using medical records, prescription data and death certificates. The potential mediating effect of systemic inflammation was assessed by adjusting models for a generalised inflammation factor, derived from four inflammatory markers measured at baseline (C-reactive protein, IL-6, TNF-α and fibrinogen), and carrying out an exploratory mediation analysis.

RESULTS

Dementia developed in 105 participants over a median follow-up of 10.6 years. After adjusting for age and sex, depression was associated with over a 2.5-fold increase in risk of dementia (HR 2.59 [95% CI 1.62, 4.15]). Additional adjustment for the generalised inflammation factor and other covariates did not attenuate the size of association between depression and incident dementia and mediation analysis showed that it was not a mediator. Adjusted logistic regression models showed cross-sectional associations of C-reactive protein and IL-6 with depression.

CONCLUSIONS/INTERPRETATION

Depression is an important risk factor for dementia in people with type 2 diabetes. Some inflammatory markers were associated with depression, but systemic inflammation does not appear to mediate the relationship between depression and dementia. Graphical abstract.

Investigating spatial convergence of diagnosed dementia, depression and type 2 diabetes prevalence in West Adelaide, Australia

BACKGROUND

Comorbid depression and type 2 diabetes (T2D) is an important risk factor for dementia. This study investigates the factors associated with, the spatial variation and spatial convergence of diagnosed cases of these conditions. This approach may identify areas with unmet needs.

METHODS

We used cross-sectional data (2010 to 2014) from 16 general practices in west Adelaide, Australia. Multi-level modelling accounting for individual-level characteristics nested within statistical area level 1 (SA1) determined covariate associations with these three diseases. Getis-Ord Gi method was used to investigate spatial variation, hot spots and cold spots of these conditions.

RESULTS

1.4% of active patients in west Adelaide aged 45 and above were diagnosed with dementia, 9.6% with depression and 13.3% with T2D. Comorbidity was significant across all three diseases. Elderly age (65+ years) was significantly associated with diagnosed dementia and T2D. Hyperlipidemia or hypertension diagnosis and belonging to lower socioeconomic status were significantly associated with diagnosed T2D and depression. The spatial distribution of each disease varied across west Adelaide. Spatial convergence of the three diseases was observed in two large hot spot clusters and one main cluster of cold spots.

LIMITATIONS

Due to underreporting, potentially significant covariates like alcohol intake were unable to be assessed. There may be a bias towards health-conscious individuals or patients managing diagnosed diseases that actively visit their general practice.

CONCLUSIONS

Patterns of spatial convergence and the shared associations in dementia, depression and diabetes enable policymakers to tailor interventions to the areas where risk of these conditions are greater.

The association of hyperglycaemia and insulin resistance with incident depressive symptoms over 4 years of follow-up: The Maastricht Study

AIMS/HYPOTHESIS

Depression is twice as common in individuals with type 2 diabetes as in the general population. However, it remains unclear whether hyperglycaemia and insulin resistance are directly involved in the aetiology of depression. Therefore, we investigated the association of markers of hyperglycaemia and insulin resistance, measured as continuous variables, with incident depressive symptoms over 4 years of follow-up.

METHODS

We used data from the longitudinal population-based Maastricht Study (n = 2848; mean age 59.9 ± 8.1 years, 48.8% women, 265 incident depression cases, 10,932 person-years of follow-up). We assessed hyperglycaemia by fasting and 2 h post-load OGTT glucose levels, HbA_1c and skin autofluorescence (reflecting AGEs) at baseline. We used the Matsuda insulin sensitivity index and HOMA-IR to calculate insulin resistance at baseline. Depressive symptoms (nine-item Patient Health Questionnaire score ≥10) were assessed at baseline and annually over 4 years. We used Cox regression analyses, and adjusted for demographic, cardiovascular and lifestyle risk factors.

RESULTS

Fasting plasma glucose, 2 h post-load glucose and HbA_1c levels were associated with an increased risk for incident depressive symptoms after full adjustment (HR 1.20 [95% CI 1.08, 1.33]; HR 1.25 [1.08, 1.44]; and HR 1.22 [1.09, 1.37] per SD, respectively), while skin autofluorescence, insulin sensitivity index and HOMA-IR were not (HR 0.99 [0.86, 1.13]; HR 1.02 [0.85, 1.25]; and HR 0.93 [0.81, 1.08], per SD, respectively).

CONCLUSIONS/INTERPRETATION

The observed temporal association between hyperglycaemia and incident depressive symptoms in this study supports the presence of a mechanistic link between hyperglycaemia and the development of depressive symptoms. Graphical abstract.

Diabetic Cognitive Dysfunction: From Bench to Clinic

Type 2 diabetes increases the risk of developing cognitive dysfunction in the elderly in the form of short-term memory and executive function impairment. Genetic and diet-induced models of type 2 diabetes further support this link, displaying deficits in working memory, learning, and memory performance. The risk factors for diabetic cognitive dysfunction include vascular disease, hypoglycaemia, hyperlipidaemia, adiposity, insulin resistance, lifestyle factors, and genetic factors. Using neuronal imaging technologies, diabetic patients with cognitive dysfunction show atrophy of the whole brain, particularly the grey matter, hippocampus and amygdala; increased volume of the ventricular and white matter; brain infarcts; impaired network integrity; abnormal microstructure; and reduced cerebral blood flow and amplitude of low-frequency fluctuations. The pathogenesis of type 2 diabetes with cognitive dysfunction involves hyperglycaemia, macrovascular and microvascular diseases, insulin resistance, inflammation, apoptosis, and disorders of neurotransmitters. Large clinical trials may offer further proof of biomarkers and risk factors for diabetic cognitive dysfunction. Advanced neuronal imaging technologies and novel disease animal models will assist in elucidating the precise pathogenesis and to provide better therapeutic interventions and treatment.

Managing Diabetes and Dementia

Dementia and type 2 diabetes are a serious public health problem worldwide, with increasing incidence with age. Diabetes is a risk factor for the development of dementia. Having cognitive dysfunction impairs a person's ability to perform self-care tasks. Also, community dwelling adults can have varying levels of functional impairment and can also have other geriatric syndromes. This article presents a multidisciplinary approach and treatment and goals tailored individually to patients with different levels of cognitive and activities of daily living impairments. Three case studies show the management of diabetes in older adults with different levels of care needs.

The association between antidepressants use and development of cognitive impairment among older women diagnosed with breast cancer

PURPOSE

This study aimed to evaluate the association between the development of cognitive impairment and the use of antidepressants among older women with breast cancer.

METHODS

This retrospective cohort study used the United States National Cancer Institute's Surveillance, Epidemiology, and End Results-Medicare database to identify women who were 67 years old and older and had breast cancer between 2008 and 2013. Propensity scoring was used to account for confounding pre-treatment factors, and Cox proportional hazards modeling was used to examine the risk of developing cognitive impairment among patients based on whether they used antidepressants.

RESULTS

A total of 3174 women taking antidepressants (mean age 75.2 ± 6.4) were matched with 3174 women not taking antidepressants (mean age 75.4 ± 6.7). Antidepressant use was associated with a significantly increased risk of cognitive impairment (hazard ratio [HR]: 1.33, 95%; confidence interval [CI]: 1.18-1.48). Additionally, we found that older women without a history of depression or anxiety who use antidepressants have a higher risk of developing cognitive impairment than those who did not use antidepressants (HR: 1.53, 95%; CI: 1.34-1.75 and HR: 1.39, 95%; CI: 1.23-1.56, respectively). Subgroup analysis showed that the use of non-tricyclic antidepressants (TCAs) was associated with a higher risk of cognitive impairment.

CONCLUSION

We found that non-TCA antidepressant use in older women with breast cancer was associated with a higher risk of cognitive impairment. This association was also observed among older women without depression or anxiety who used antidepressants.

Psychophysiological Models to Identify and Monitor Elderly with a Cardiovascular Condition: The Added Value of Psychosocial Parameters to Routinely Applied Physiological Assessments

The steadily growing elderly population calls for efficient, reliable and preferably ambulant health supervision. Since cardiovascular risk factors interact with psychosocial strain (e.g., depression), we investigated the potential contribution of psychosocial factors in discriminating generally healthy elderly from those with a cardiovascular condition, on and above routinely applied physiological assessments. Fifteen elderly (aged 60 to 88) with a cardiovascular diagnosis were compared to fifteen age and gender matched healthy peers. Six sequential standardized lab assessments were conducted (one every two weeks), including an autonomic test battery, a 6-min step test and questionnaires covering perceived psychological state and experiences over the previous two weeks. Specific combinations of physiological and psychological factors (most prominently symptoms of depression) effectively predicted (clinical) cardiovascular markers. Additionally, a highly significant prognostic model was found, including depressive symptoms, recently experienced negative events and social isolation. It appeared slightly superior in identifying elderly with or without a cardiovascular condition compared to a model that only included physiological parameters. Adding psychosocial parameters to cardiovascular assessments in elderly may consequently provide protocols that are significantly more efficient, relatively comfortable and technologically feasible in ambulant settings, without necessarily compromising prognostic accuracy.

Aging, Diabetes, Obesity, and Cognitive Decline: A Population-Based Study

BACKGROUND/OBJECTIVES

To investigate potential mechanisms underlying the well-established relationship of diabetes and obesity with cognitive decline, among older adults participating in a population-based study.

DESIGN/SETTING

Ten-year population-based cohort study.

PARTICIPANTS

A total of 478 individuals aged 65 years and older.

MEASUREMENTS

We assayed fasting blood for markers of glycemia (glucose and hemoglobin A1c [HbA1c]), insulin resistance (IR) (insulin and homeostatic model assessment of IR), obesity (resistin, adiponectin, and glucagon-like peptide-1), and inflammation (C-reactive protein). We modeled these indices as predictors of the slope of decline in global cognition, adjusting for age, sex, education, APOE*4 genotype, depressive symptoms, waist-hip ratio (WHR), and systolic blood pressure, in multivariable regression analyses of the entire sample and stratified by sex-specific median WHR. We then conducted WHR-stratified machine-learning (Classification and Regression Tree [CART]) analyses of the same variables.

RESULTS

In multivariable regression analyses, in the entire sample, HbA1c was significantly associated with cognitive decline. After stratifying by median WHR, HbA1c remained associated with cognitive decline in those with higher WHR. No metabolic indices were associated with cognitive decline in those with lower WHR. Cross-validated WHR-stratified CART analyses selected no predictors in participants older than 87 to 88 years. Faster cognitive decline was associated, in lower WHR participants younger than 87 years, with adiponectin of 11 or greater; and in higher WHR participants younger than 88 years, with HbA1c of 6.2% or greater.

CONCLUSIONS

Our population-based data suggest that, in individuals younger than 88 years with central obesity, even modest degrees of hyperglycemia might independently predispose to faster cognitive decline. In contrast, among those younger than 87 years without central obesity, adiponectin may be a novel independent risk factor for cognitive decline. J Am Geriatr Soc 68:991-998, 2020.

Cognitive Dysfunction in Persons with Type 2 Diabetes Mellitus: A Concept Analysis

Although cognitive dysfunction is related to type 2 diabetes mellitus (T2DM), the concept has not yet been well defined. The purpose of this study was to define the concept of cognitive dysfunction in persons with T2DM and examine its defining attributes, antecedents, and consequences. Literature was retrieved from 2008 to 2018 by systematically searching the PubMed, CINAHL, and PsycINFO databases. Based on 37 included studies, three defining attributes were identified: cognitive dysfunction is a recognized or unrecognized symptom, is characterized by a subtle decline in one or more cognitive domains, and is accompanied by pronounced structural changes observed in brain imaging. One major antecedent was diabetes-related or diabetes-specific pathological changes. Consequences included interference with diabetes self-management, nonadherence to recommended self-management behaviors, and a higher risk of having hypoglycemic events. The concept analysis provides a theoretical foundation that can be used to guide evaluations and interventions related to cognitive dysfunction in individuals with T2DM.

Depression in type 1 diabetes and risk of dementia

OBJECTIVE

Depression afflicts 14% of individuals with type 1 diabetes (T1D). Depression is a robust risk factor for dementia but it is unknown if this holds true for individuals with T1D, who recently started living to an age conferring dementia risk. We examined if depression is a dementia risk factor among elderly individuals with T1D.

METHODS

3,742 individuals with T1D age ≥50 were followed for dementia from 1/1/96-9/30/2015. Depression, dementia, and comorbidities were abstracted from electronic medical records. Cox proportional hazard models estimated the association between depression and dementia adjusting for demographics, glycosylated hemoglobin, severe dysglycemic epidsodes, stroke, heart disease, nephropathy, and end stage renal disease. The cumulative incidence of dementia by depression was estimated conditional on survival dementia-free to age 55.

RESULTS

Five percent (N = 182) were diagnosed with dementia and 20% had baseline depression. Depression was associated with a 72% increase in dementia (fully adjusted HR = 1.72; 95% CI:1.12-2.65). The 25-year cumulative incidence of dementia was more than double for those with versus without depression (27% vs. 12%).

CONCLUSIONS

For people with T1D, depression significantly increases dementia risk. Given the pervasiveness of depression in T1D, this has major implications for successful aging in this population recently living to old age.

The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies

AIMS

Depression is a common co-morbidity in patients with type 2 diabetes mellitus (T2DM). Untreated depression in these patients adversely affects self-care activities and other diabetes complications. The aim of this study is to estimate the prevalence of depression among patients with T2DM by conducting a meta-analysis of observational studies.

METHODS

MEDLINE, Web of Science, Science Direct, and Google Scholar databases were searched for all observational studies that assessed depression in T2DM. Relevant articles were searched using the combination of Medical Subject Heading (MeSH) terms of "depression", "depressive disorder", and "diabetes mellitus" published between January 2007 and July 2018. Random effects model was used to estimate the weighted prevalence rates and 95% CI using "metaprop program in STATA 11".

RESULTS

In total, the 248 included studies (with 273 reported prevalence) identified 83,020,812 participants; of them, 23,245,827 (28%; 95% CI 27, 29) suffered from different severity levels of depressive disorders. The prevalence of depression was separately reported in 137,372 males and 134,332 females. Of them, 31,396 males (23%, 95% CI: 20, 26) and 45,673 females (34%, 95% CI: 31, 38) were depressed. Compared with global estimate, depression prevalence was lower in Europe (24%) and Africa (27%), but higher in Australia (29%) and Asia (32%). The prevalence in America was equal to the estimated prevalence in the world (28%). Depression was more common in subjects younger than 65 compared with elderlies (31% vs. 21%).

CONCLUSION

Our findings demonstrated that almost one in four adults with T2DM experienced depression. Given the high prevalence of depressive disorders in diabetic patients, screening these patients for co-morbid depression and its relevant risk factors is highly recommended.

Risk factors for cognitive impairment in older people with diabetes: a community-based study

AIM

The aim of this study was to investigate the risk factors for cognitive impairment in older people with diabetes.

METHODS

This cross-sectional study included 2626 community-dwelling participants with diabetes aged ⩾55 years, living in Beijing, China. The participants were screened for risk factors, including smoking, obesity, hypertension, stroke, coronary heart disease, dyslipidemia, depression, apolipoprotein E (APOE) genotype, and low physical activity. Cognitive function was assessed with the scholarship-adjusted Mini-Mental State Examination (MMSE): MMSE ⩽17 for iliterate participants; MMSE ⩽20 for primary school graduates (⩾6 years of education); and MMSE ⩽24 for junior school graduates or above (⩾9 years of education).

RESULTS

The prevalence of cognitive impairment in older people with diabetes was 9.90%. Multiple logistic regression analysis demonstrated that stroke [odds ratio (OR) = 1.71, 95% confidence interval (CI) = 1.20-2.43], less than 0.5 h exercise per day (OR = 1.89, 95% CI = 1.37-2.61), and depression (OR = 1.64, 95% CI = 1.06-2.54), but not smoking, obesity, hypertension, dyslipidemia, and coronary heart disease, were independent risks for cognitive impairment in older people with diabetes. In addition, being married (OR = 0.66, 95% CI = 0.47-0.93) and urban living (OR = 0.33, 95% CI = 0.22-0.48) could decrease the risk of cognitive impairment.

CONCLUSIONS

Stroke, depression, and less than 0.5 h exercise per day were independent risks for cognitive impairment in older people with diabetes, whereas being married and urban living were protective.

Pathophysiological Mechanisms Linking Type 2 Diabetes and Dementia: Review of Evidence from Clinical, Translational and Epidemiological Research

BACKGROUND

Type 2 diabetes represents an increasing health burden world-wide and its prevalence in particularly higher in elderly population. Consistent epidemiological evidence suggests an increased risk of dementia associated to type 2 diabetes; the mechanisms underlying these associations, however, remain unclear.

OBJECTIVE

The study aims to review epidemiological, clinical and pre-clinical data that weigh on pathophysiological links, mechanisms of disease and associations between type 2 diabetes and dementia to identify areas of opportunity for future research.

METHODS

We searched the following electronic bibliographic databases: PUBMED, EMBASE, SCIELO, MEDLINE and OVID for clinical, translational and epidemiological research literature that summarize diabetes-related risk factors for dementia, metabolic and neurological changes associated to T2D, evidence of therapeutic approaches in type 2 diabetes and its pathophysiological implications for dementia.

RESULTS

Type 2 diabetes mellitus increases risk for all-cause dementia, vascular dementia and Alzheimer's disease. The most evaluated mechanisms linking both disorders in pre-clinical studies include an increase in neuronal insulin resistance, impaired insulin signaling, pro-inflammatory state, mitochondrial dysfunction and vascular damage which increase deposition of β-amyloid, tau proteins and GSK3β, leading to an earlier onset of dementia in individuals with impairment in the glucose metabolism. Neuroimaging and neuropathology evidence linking cerebrovascular lesions, neurodegeneration and particularly small-vessel disease in the onset of dementia is consistent with the increased risk of incident dementia in type 2 diabetes, but consistent evidence of AD-related pathology is scarce. Epidemiological data shows increased risk of dementia related to hypoglycemic episodes, glycemic control, metabolic syndrome, insulin resistance and genetic predisposition, but the evidence is not consistent and statistical analysis might be affected by inconsistent covariate controlling. Therapeutic approaches for T2D have shown inconsistent result in relation to dementia prevention and delay of cognitive decline; lifestyle intervention, particularly physical activity, is a promising alternative to ameliorate the impact of disability and frailty on T2D-related dementia.

CONCLUSION

Vascular disease, inflammation and impaired brain insulin signaling might occur in T2D and contribute to dementia risk. Evidence from epidemiological studies has not consistently reported associations that could integrate a unified mechanism of disease in humans. Evaluation of the effect of antidiabetic medications and non-pharmacological interventions in dementia prevention in type 2 diabetes is promising but has thus far offered inconsistent results.

Physical performance and cognitive functioning among individuals with diabetes: Findings from the China Health and Retirement Longitudinal Study Baseline Survey

AIMS

The purpose of this study was to examine individual associations of each physical performance measure with domains of cognitive functioning and to determine best physical performance measures strongly associated with each domain of cognitive functioning among middle-aged and older adults with diabetes.

BACKGROUND

Tests of physical performance are strongly correlated with cognitive decline in general elderly population. However, far less is known about individual associations of each individual physical performance measure with domains of cognitive functioning among individuals with diabetes.

DESIGN

The study employed a retrospective, cross-sectional design.

METHODS

Baseline data from a national baseline survey collected from May 2011-March 2012 were used. A total of 17,314 individuals aged ≥45 years completed the baseline survey. Diabetes was confirmed for 1,905 participants and these individuals were included in this study.

RESULTS

When grip strength, walking speed, repeated chair stands and standing balance test were added in the regression models, walking speed was the only variable that was significantly associated with figure drawing and grip strength was the only variable that was significantly associated with episodic memory, orientation/attention and overall cognitive score.

CONCLUSION

Since grip strength was the most important factor associated with several domains of cognitive functioning, strategies that improve grip strength in patients with diabetes are prudent. Early interventions to increase levels of physical activity may be important to improve both grip strength and cognitive functioning in this growing population with diabetes.

Expression of inflammatory markers in women with perinatal depressive symptoms

Perinatal depression affects 10-20% of women and is associated with poor outcomes for mother and child. Inflammation is associated with depression in non-pregnant adults. Perinatal depression and inflammation in pregnancy are independently associated with morbidities including obesity, gestational diabetes, preeclampsia, and preterm birth. The role of inflammation in perinatal depression has received little attention. We hypothesized an association between self-reported perinatal depressive symptoms and serum inflammatory biomarkers TNF-α, IL-6, IL-1β, and CRP. 110 healthy gravidas were recruited in third trimester from an academic medical center, with a baseline study visit at a mean of 32.5 (SD ± 1.8) weeks gestational age. Sixty-three participants completed the Edinburgh Postnatal Depression Scale (EPDS) and provided demographic information and serum samples upon enrollment and at 3 and 6 months postpartum. Serum inflammatory markers were quantified by multiplex array. Multiple linear mixed effects models were used to evaluate trends of biomarkers with the EPDS score in the third trimester of pregnancy and the postpartum period. Elevated serum TNF-α was associated with lower EPDS total score (β = - 0.90, p = 0.046) after adjusting for demographics and medication use. In contrast, IL-6, CRP, and IL-1β did not demonstrate statistically significant associations with depressive symptoms by the EPDS in either crude or adjusted models. Study findings showed no association or an inverse (TNF-α) association between inflammatory markers and perinatal depressive symptoms. Relevant literature evaluating a role for inflammation in depression in the unique context of pregnancy is both limited and inconsistent, and further exploration is merited.

Decision Tree for Early Detection of Cognitive Impairment by Community Pharmacists

Purpose: The early detection of Mild Cognitive Impairment (MCI) is essential in aging societies where dementia is becoming a common manifestation among the elderly. Thus our aim is to develop a decision tree to discriminate individuals at risk of MCI among non-institutionalized elderly users of community pharmacy. A more clinically and patient-oriented role of the community pharmacist in primary care makes the dispensation of medication an adequate situation for an effective, rapid, easy, and reproducible screening of MCI.

Methods: A cross-sectional study was conducted with 728 non-institutionalized participants older than 65. A total of 167 variables were collected such as age, gender, educational attainment, daily sleep duration, reading frequency, subjective memory complaint, and medication. Two screening tests were used to detect possible MCI: Short Portable Mental State Questionnaire (SPMSQ) and the Mini-Mental State Examination (MMSE). Participants classified as positive were referred to clinical diagnosis. A decision tree and predictive models are presented as a result of applying techniques of machine learning for a more efficient enrollment.

Results: One hundred and twenty-eight participants (17.4%) scored positive on MCI tests. A recursive partitioning algorithm with the most significant variables determined that the most relevant for the decision tree are: female sex, sleeping more than 9 h daily, age higher than 79 years as risk factors, and reading frequency. Moreover, psychoanaleptics, nootropics, and antidepressants, and anti-inflammatory drugs achieve a high score of importance according to the predictive algorithms. Furthermore, results obtained from these algorithms agree with the current research on MCI.

Conclusion: Lifestyle-related factors such as sleep duration and the lack of reading habits are associated with the presence of positive in MCI test. Moreover, we have depicted how machine learning provides a sound methodology to produce tools for early detection of MCI in community pharmacy.

Impact of findings on practice: The community of pharmacists provided with adequate tools could develop a crucial task in the early detection of MCI to redirect them immediately to the specialists in neurology or psychiatry. Pharmacists are one of the most accessible and regularly visited health care professionals and they can play a vital role in early detection of MCI.

Potential Risk Factors of the Cognitive Dysfunction in Patients with Type 2 Diabetes Mellitus

It is known that the aged persons with type 2 diabetes mellitus present a high risk for developing neurocognitive disorders and in order to explain this phenomenon we have proposed some potential risk factors. They can be involved in the causality patterns or can act as useful markers of the cerebrovascular lesions (or both) and for which there are strong proofs, including the poor glycemic control, hypoglycemia, microvascular diseases, inflammation or depression. For the macrovascular affections, the association with the cognitive disorders seems to devolve on the examined vascular system. It is put into discussion that for the next researches it is important to analyze how exactly the interrelations between the risk factors can contribute to cognitive disorders.

Improving mental health through integration with primary care in rural Karnataka: study protocol of a cluster randomized control trial

BACKGROUND

People who are diagnosed with both mental and chronic medical illness present unique challenges for the health care system. In resource-limited settings, such as rural India, people with depression and anxiety are often under-served, due to both stigma and lack of trained providers and resources. These challenges can lead to complications in the management of chronic disease as well as increased suffering for patients, families and communities. In this study, we evaluate the effects of integrating mental health and chronic disease treatment of patients in primary health care (PHC) settings using a collaborative care model to improve the screening, diagnosis and treatment of depression in rural India.

METHODS

This study is a multi-level randomized controlled trial among patients with depression or anxiety and co-morbid diabetes, or cardiovascular disease. Aim 1 examines whether patients screened at community health-fairs are more likely to be diagnosed and treated for these co-morbid conditions than patients screened after presenting at PHCs. Aim 2 evaluates the impact of collaborative care compared to usual care in a cluster RCT, randomizing at the level of the PHCs. Intervention arm PHC staff are trained in mental health diagnoses, treatment, and the collaborative care model. The intervention also involves community-based "Healthy Living groups" co-led by Ashas, using cognitive-behavioral strategies to promote healthy behaviors. The primary outcome is severity of common mental disorders, with secondary outcomes being diabetes and cardiovascular risk, staff knowledge and patient perceptions.

DISCUSSION

If effective, our results will contribute to the field in five ways: 1) expand on implementation research in low resource settings by examining how multiple chronic diseases can be treated using integrated low-cost, evidence-based strategies, 2) build the capacity of PHC staff to diagnose and treat mental illness within their existing clinic structure and strengthen referral linkages; 3) link community members to primary care through community-based health fairs and healthy living groups; 4) increase mental health awareness in the community and reduce mental health stigma; 5) demonstrate the potential for intervention scale-up and sustainability.

TRIAL REGISTRATION

http://Clinicaltrials.gov : NCT02310932 registered December 8, 2014 URL: https://clinicaltrials.gov/ct2/show/record/NCT02310932 ; Clinical Trials Registry India: CTRI/2018/04/013001 retrospectively registered on April 4, 2018.

Ginsenoside Ameliorates Cognitive Dysfunction in Type 2 Diabetic Goto-Kakizaki Rats

Background

Ginsenoside is the major bioactive component of ginseng, which has been proven to be a neuroprotective drug. The aim of this study was to evaluate the therapeutic effect of ginsenoside in a diabetic Goto-Kakizaki (GK) rat model.

Material/Methods

Twenty GK rats were randomly divided into a diabetic model (DM) group (n=10) and a ginsenoside + DM group (n=10); Wistar rats with the same age and body weight were used as the control (CON) group (n=10). Food and water intake, body weight, and blood fasting plasma glucose were measured. The Morris water maze test was used to detect learning and memory functions of the rats. Superoxide dismutase (SOD), malondialdehyde (MDA), and inflammatory cytokines (TNF-α, IL-1β, and IL-6) in the hippocampus were analyzed after ginsenoside treatment.

Results

The blood glucose, body weight, Morris correlation index, SOD, MDA, and other test results were increased in the diabetic rats. Ginsenoside ameliorated diabetic cognitive decline.

Conclusions

The possible mechanism was related to inhibiting brain oxidative/nitrosative damage and affecting the expression of the cytokines IL-1β, IL-6, and TNF-α.

Heterogeneity in 14-year Dementia Incidence Between Asian American Subgroups

BACKGROUND

Asian Americans are a rapidly growing and diverse population. Prior research on dementia among Asian Americans focused on Japanese Americans or Asian Americans overall, although marked differences in cardiometabolic conditions between subgroups have been documented.

MATERIALS AND METHODS

We compared dementia incidence among 4 Asian American subgroups (n=8384 Chinese; n=4478 Japanese; n=6210 Filipino; n=197 South Asian) and whites (n=206,490) who were Kaiser Permanente Northern California members aged 64 years and above with no dementia diagnoses as of January 1, 2000. Dementia diagnoses were collected from medical records January 1, 2000 to December 31, 2013. Baseline medical utilization and comorbidities (diabetes, depression, hypertension, stroke, cardiovascular disease) were abstracted from medical records January 1, 1996 to December 31, 1999. We calculated age-standardized dementia incidence rates and Cox models adjusted for age, sex, medical utilization, and comorbidities.

RESULTS

Mean baseline age was 71.7 years; mean follow-up was 9.6 years. Age-standardized dementia incidence rates were higher among whites than "All Asian-Americans" or any subgroup. Compared with Chinese (13.7/1000 person-years), dementia incidence was slightly higher among Japanese [14.8/1000 person-years; covariate-adjusted hazard ratio (adjusted-HR)=1.08; 95% confidence interval (CI), 0.99-1.18] and Filipinos (17.3/1000 person-years; adjusted-HR=1.20; 95% CI, 1.11-1.31), and lower among South Asians (12.1/1000 person-years; adjusted-HR=0.81; 95% CI, 0.53-1.25).

CONCLUSIONS

Future studies are needed to understand how immigration history, social, environmental, and genetic factors contribute to dementia risk in the growing and diverse Asian American population.

A Review on the General Stability of Mood Disorder Diagnoses Along the Lifetime

PURPOSE OF REVIEW

The purpose of this review is to review the most recent literature regarding diagnostic stability of mood disorders, focusing on epidemiological, clinical-psychopathological, and neurobiological data for unipolar and bipolar affective disorders.

RECENT FINDINGS

Unipolar depression follows a chronic course in at least half of all cases and presents a considerable diagnostic stability across all age ranges. Studies using latent class analysis are allowing improved profiling of depressive subtypes and assessment of their prevalence. Advances have been made in our understanding of the neurobiological underpinnings of depression, with data highlighting the roles of amyloid deposits, the ApoE4 allele, and atrophy of the anterior hippocampus or frontal cortex. The diagnostic instability of bipolar disorder is manifest in the early years, seen in both the extent of diagnostic delay and the high rate of diagnostic conversion from unipolar depression. Regarding disruptive mood dysregulation disorder, we have little data to date, but those which exist indicate a high rate of comorbidity and minimal diagnostic stability for this disorder. Diagnostic stability varies substantially among mood disorders, which would be related to the validity of current diagnostic categories and our diagnostic accuracy.

In Silico Preliminary Association of Ammonia Metabolism Genes GLS, CPS1, and GLUL with Risk of Alzheimer's Disease, Major Depressive Disorder, and Type 2 Diabetes

Ammonia is a toxic by-product of protein catabolism and is involved in changes in glutamate metabolism. Therefore, ammonia metabolism genes may link a range of diseases involving glutamate signaling such as Alzheimer's disease (AD), major depressive disorder (MDD), and type 2 diabetes (T2D). We analyzed data from a National Institute on Aging study with a family-based design to determine if 45 single nucleotide polymorphisms (SNPs) in glutaminase (GLS), carbamoyl phosphate synthetase 1 (CPS1), or glutamate-ammonia ligase (GLUL) genes were associated with AD, MDD, or T2D using PLINK software. HAPLOVIEW software was used to calculate linkage disequilibrium measures for the SNPs. Next, we analyzed the associated variations for potential effects on transcriptional control sites to identify possible functional effects of the SNPs. Of the SNPs that passed the quality control tests, four SNPs in the GLS gene were significantly associated with AD, two SNPs in the GLS gene were associated with T2D, and one SNP in the GLUL gene and three SNPs in the CPS1 gene were associated with MDD before Bonferroni correction. The in silico bioinformatic analysis suggested probable functional roles for six associated SNPs. Glutamate signaling pathways have been implicated in all these diseases, and other studies have detected similar brain pathologies such as cortical thinning in AD, MDD, and T2D. Taken together, these data potentially link GLS with AD, GLS with T2D, and CPS1 and GLUL with MDD and stimulate the generation of testable hypotheses that may help explain the molecular basis of pathologies shared by these disorders.

Cardiometabolic dysregulation and cognitive decline: potential role of depressive symptoms

BACKGROUND

Previous studies have examined associations of cardiometabolic factors with depression and cognition separately. Aims To determine if depressive symptoms mediate the association between cardiometabolic factors and cognitive decline in two community studies.

METHOD

Data for the analyses were drawn from the Rotterdam Study, the Netherlands (n = 2940) and the Whitehall II study, UK (n = 4469).

RESULTS

Mediation analyses suggested a direct association between cardiometabolic factors and cognitive decline and an indirect association through depression: poorer cardiometabolic status at time 1 was associated with a higher level of depressive symptoms at time 2 (standardised regression coefficient 0.07 and 0.06, respectively), which, in turn, was associated with greater cognitive decline between time 2 and time 3 (standardised regression coefficient of -0.15 and -0.41, respectively).

CONCLUSIONS

Evidence from two independent cohort studies suggest an association between cardiometabolic dysregulation and cognitive decline and that depressive symptoms tend to precede this decline. Declaration of interest None.

Mild cognitive impairment and progression to dementia in people with diabetes, prediabetes and metabolic syndrome: a systematic review and meta-analysis

PURPOSE

We aimed to quantify the relative risk of progression from mild cognitive impairment (MCI) to dementia in people with and without diabetes, and with and without the MetS (MetS); and to identify potential modifiers of the risk of progression from MCI to dementia in people with diabetes or MetS.

METHODS

We searched Medline, Embase, PsycINFO, PsycArticles and Web of Science from inception through to 20th March 2018. Where possible, the results from three or more studies were pooled in a meta-analysis, while other findings have been described narratively.

RESULTS

We included 15 articles reporting 12 studies (6865 participants). The overall unadjusted pooled odds ratio for the progression of MCI to dementia in people with diabetes/MetS was 1.67 (95% CI 1.27-2.19); the pooled odds ratio for progression in diabetes + MCI was 1.53 (95% CI 1.20-1.97) and in people with MetS + MCI was 2.95 (95% CI 1.23-7.05). There was moderate heterogeneity in the included studies (I² < 60%). In diabetes, a longer duration of diabetes and the presence of retinopathy were associated with an increased risk of progression, while the use of statins and oral hypoglycaemic agents reduced the risk. Having multiple cardiovascular risk factors was a significant risk factor for progression from MCI to dementia in people with MetS.

CONCLUSIONS

Diabetes and MetS were both associated with an increased incidence of dementia when co-existing with MCI. Intensive cardiovascular risk reduction and lifestyle changes for patients presenting with MCI and diabetes, prediabetes or MetS may be important in reducing incidence of dementia in this high risk population.

Biomarkers for cognitive decline in patients with diabetes mellitus: evidence from clinical studies

Diabetes mellitus is considered as an important factor for cognitive decline and dementia in recent years. However, cognitive impairment in diabetic patients is often underestimated and kept undiagnosed, leading to thousands of diabetic patients suffering from worsening memory. Available reviews in this field were limited and not comprehensive enough. Thus, the present review aimed to summarize all available clinical studies on diabetic patients with cognitive decline, and to find valuable biomarkers that might be applied as diagnostic and therapeutic targets of cognitive impairment in diabetes. The biomarkers or risk factors of cognitive decline in diabetic patients could be classified into the following three aspects: serum molecules or relevant complications, functional or metabolic changes by neuroimaging tools, and genetic variants. Specifically, factors related to poor glucose metabolism, insulin resistance, inflammation, comorbid depression, micro-/macrovascular complications, adipokines, neurotrophic molecules and Tau protein presented significant changes in diabetic patients with cognitive decline. Besides, neuroimaging platform could provide more clues on the structural, functional and metabolic changes during the cognitive decline progression of diabetic patients. Genetic factors related to cognitive decline showed inconsistency based on the limited studies. Future studies might apply above biomarkers as diagnostic and treatment targets in a large population, and regulation of these parameters might shed light on a more valuable, sensitive and specific strategy for the diagnosis and treatment of cognitive decline in diabetic patients.

Psychosocial Interventions and Wellbeing in Individuals with Diabetes Mellitus: A Systematic Review and Meta-Analysis

Purpose: A number of studies, including systematic reviews, show beneficial effects of psychosocial interventions for people with diabetes mellitus; however, they have not been assessed using meta-analysis. The purpose of this meta-analysis of randomized controlled trials is to investigate the effects of psychosocial interventions on depressive and anxiety symptoms, quality of life and self-efficacy in individuals with diabetes mellitus.

Methods: The databases Pubmed, MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science and SocINDEX were searched with no year restriction. Eligible studies were randomized controlled trials published in English that included individuals diagnosed with diabetes mellitus, aged 18 years or above, who engaged in a psychosocial intervention, with outcome measures addressing depressive or anxiety symptomology, quality of life or self-efficacy. Eligible studies needed to compare the intervention to usual care. Study selection was completed using Covidence and meta-analysis was undertaken using Comprehensive Meta-Analysis software.

Results: Seven studies were included in the meta-analysis. Five studies investigated the effects of psychosocial interventions and showed a medium to large benefit for depressive symptoms (SMD: −0.70; CI: −1.27, −0.13) which persisted at follow up (SMD: −1.54, CI: −2.97, −0.12). Similar results were not seen immediately post-intervention in the three studies that assessed anxiety symptoms (SMD: −0.30; CI: −0.69, 0.10); however, a medium beneficial effect was seen at follow up (SMD = −0.61, CI = −0.92 to −0.31). Small benefits were seen in the three studies assessing quality of life outcomes (SMD: 0.30, CI: 0.06, 0.55). No benefit was seen in the two studies assessing self-efficacy (SMD: 0.23, CI: −0.11, 0.57).

Conclusions: The results of the current study provide preliminary evidence that psychosocial interventions, compared to usual care, reduce depressive symptoms, and may improve quality of life in individuals with diabetes. However, only a few studies were included and the clinical significance of these findings is unknown.

Insulin resistance, an unmasked culprit in depressive disorders: Promises for interventions

Depressive disorders constitute a set of debilitating diseases with psychological, societal, economic and humanitarian consequences for millions of people worldwide. Scientists are beginning to understand the reciprocal communication between the brain and the rest of the body in the etiology of these diseases. In particular, scientists have noted a connection between depressive disorders, which are primarily seen as brain-based, and, insulin resistance (IR), a modifiable metabolic inflammatory state that is typically seen as peripheral. We highlight evidence showing how treating IR, with drugs or behavioral interventions, may ameliorate or possibly prevent, depressive disorders and their long-term consequences at various stages of the life course. This article is part of the Special Issue entitled 'Metabolic Impairment as Risk Factors for Neurodegenerative Disorders.'

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Obesity and Co-morbid Conditions Are Associated with Specific Neuropsychiatric Symptoms in Mild Cognitive Impairment

Background: Neuropsychiatric symptoms (NPSs) in MCI, and midlife obesity increase the likelihood of developing Alzheimer's disease. It is unknown whether obesity or related health conditions modify the risk of NPS or severity of cognitive impairment in MCI. Methods: One hundred and thirteen subjects with MCI were assessed near the time of MCI diagnosis. The sample was divided by BMI and related disorders, type-2 diabetes (T2D) and obstructive sleep apnea (OSA) to measure the relationship of these groups with NPS and severity of MCI. NPSs scores were evaluated based on the Neuropsychiatric Inventory-Questionnaire (NPI-Q) and Geriatric Depression Scale, along with NPI-Q clusters. MCI-severity was estimated based on a composite z-score of neuropsychological tests. Results: Obese and overweight subjects represented 65% of the sample and were on average 7 years younger than normal weight subjects. The presence of obesity, T2D and OSA status modified the prevalence and severity of specific NPI-Q symptom clusters, specifically affective symptoms were more frequent across groups and severe in OB and T2D. Total NPS scores were higher for subjects with T2D and OSA although MCI-severity did not differ across groups. Conclusion: MCI subjects with obesity, T2D and OSA demonstrated a higher susceptibility to psychopathologic changes.

Effect of Out-of-Pocket Cost on Medication Initiation, Adherence, and Persistence among Patients with Type 2 Diabetes: The Diabetes Study of Northern California (DISTANCE)

OBJECTIVE

To estimate the effect of out-of-pocket (OOP) cost on nonadherence to classes of cardiometabolic medications among patients with diabetes.

DATA SOURCES/SETTING

Electronic health records from a large, health care delivery system for 223,730 patients with diabetes prescribed 842,899 new cardiometabolic medications during 2006-2012.

STUDY DESIGN

Observational, new prescription cohort study of the effect of OOP cost on medication initiation and adherence.

DATA COLLECTION

Adherence and OOP costs were based on pharmacy dispensing records and benefits.

PRINCIPAL FINDINGS

Primary nonadherence (never dispensed) increased monotonically with OOP cost after adjusting for demographics, neighborhood socioeconomic status, Medicare, medical financial assistance, OOP maximum, deductibles, mail order pharmacy incentive and use, drug type, generic or brand, day's supply, and comorbidity index; 7 percent were never dispensed the new medication when OOP cost ≥$11, 5 percent with OOP cost of $1-$10, and 3 percent when the medication was free of charge (p < .0001). Higher OOP cost was also strongly associated with inadequate secondary adherence (≥20 percent of time without adequate medication). There was no clinically significant or consistent relationship between OOP costs and early nonpersistence (dispensed once, never refilled) or later stage nonpersistence (discontinued within 24 months).

CONCLUSIONS

Cost-sharing may deter clinically vulnerable patients from initiating essential medications, undermining adherence and risk factor control.

Type 2 diabetes, depressive symptoms and trajectories of cognitive decline in a national sample of community-dwellers: A prospective cohort study

We examined the individual and synergistic effects of type 2 diabetes and elevated depressive symptoms on memory and executive function trajectories over 10 and eight years of follow-up, respectively. Our sample comprised 10,524 community-dwellers aged ≥50 years in 2002–03 from the English Longitudinal Study of Ageing. With respect to memory (word recall), participants with either diabetes or elevated depressive symptoms recalled significantly fewer words compared with those free of these conditions (reference category), but more words compared with those with both conditions. There was a significant acceleration in the rate of memory decline in participants aged 50–64 years with both conditions (-0.27, 95% CI, -0.45 to -0.08, per study wave), which was not observed in those with either condition or aged ≥65 years. With respect to executive function (animal naming), participants aged ≥65 years with diabetes or those with elevated depressive symptoms named significantly fewer animals compared with the reference category, while those with both conditions named fewer animals compared with any other category. The rate of executive function decline was significantly greater in participants with both conditions (-0.54, 95% CI, -0.99 to -0.10; and –0.71, 95% CI, -1.16 to -0.27, per study wave, for those aged 50–64 and ≥65 years, respectively), but not in participants with either condition. Diabetes and elevated depressive symptoms are inversely associated with memory and executive function, but, individually, do not accelerate cognitive decline. The co-occurrence of diabetes and elevated depressive symptoms significantly accelerates cognitive decline over time, especially among those aged 50–64 years.

Diabetes mitigates the role of memory complaint in predicting dementia risk: Results from the Prevention of Alzheimer's Disease with Vitamin E and Selenium Study

BACKGROUND

Subjective memory complaints (SMCs) are associated with increased risk of dementia in older adults, but the role of comorbidities in modifying this risk is unknown.

OBJECTIVES

To assess whether comorbidities modify estimated dementia risk based on SMCs.

DESIGN

The Prevention of Alzheimer's Disease with Vitamin E and Selenium Study (PREADVISE) was designed as an ancillary study to the Selenium and Vitamin E Cancer Prevention Trial (SELECT), a randomized, multi-center prostate cancer prevention trial with sites in the Unites States, Puerto Rico, and Canada. In 2009, PREADVISE and SELECT were changed into cohort studies.

SETTING

Secondary analysis of PREADVISE data.

PARTICIPANTS

PREADVISE recruited 7,540 non-demented male volunteers from participating SELECT sites from 2002 to 2009. SMCs, demographics, and comorbidities including hypertension, diabetes, coronary artery bypass graft (CABG), stroke, sleep apnea, and head injury were ascertained by participant interview.

MEASUREMENTS

Cox models were used to investigate whether baseline comorbidities modified hazard ratios (HR) for SMC-associated dementia risk using two methods: (1) we included one interaction term between SMC and a comorbidity in the model at a time, and (2) we included all two-way interactions between SMC and covariates of interest and reduced the model by "backward" selection. SMC was operationalized as any complaint vs. no complaint.

RESULTS

Baseline SMCs were common (23.6%). In the first analyses, with the exception of stroke, presence of self-reported comorbidities was associated with lower estimated HR for dementia based on SMC status (complaint vs. no complaint), but this difference was only significant for diabetes. In the second analysis, the two-way interactions between SMC and race as well as SMC and diabetes were significant. Here, black men without diabetes who reported SMC had the highest estimated dementia risk (HR=5.05, 95% CI 2.55-10.00), while non-black men with diabetes who reported SMC had the lowest estimated risk (HR=0.71, 95% CI 0.35-1.41).

CONCLUSIONS

SMCs were more common among men with comorbidities, but these complaints appeared to be less predictive of dementia risk than those originating from men without comorbidities, suggesting that medical conditions such as diabetes may explain SMCs that are unrelated to an underlying neurodegenerative process.