Diabetes mellitus and cerebrovascular disease: which are the actual data?

Metformin monotherapy versus predominantly older non-metformin antidiabetic medications for cerebrovascular risk in early type 2 diabetes management

AIM

Choosing the initial treatment for type 2 diabetes (T2D) is pivotal, requiring consideration of solid clinical evidence and patient characteristics. Despite metformin's historical preference, its efficacy in preventing cerebrovascular events lacked empirical validation. This study aimed to evaluate the associations between first-line monotherapy (metformin or non-metformin antidiabetic medications) and cerebrovascular complications in patients with T2D without diabetic complications.

METHODS

We analysed 9090 patients with T2D without complications who were prescribed either metformin or non-metformin medications as initial therapy. Propensity score matching ensured group comparability. Cox regression analyses, stratified by initial metformin use, assessed cerebrovascular disease risk, adjusting for multiple covariates and using competing risk analysis. Metformin exposure was measured using cumulative defined daily doses.

RESULTS

Metformin users had a significantly lower crude incidence of cerebrovascular diseases compared with non-users (p < .0001). Adjusted hazard ratios (aHRs) consistently showed an association between metformin use and a lower risk of overall cerebrovascular diseases (aHRs: 0.67-0.69) and severe events (aHRs: 0.67-0.69). The association with reduced risk of mild cerebrovascular diseases was significant across all models (aHRs: 0.73-0.74). Higher cumulative defined daily doses of metformin correlated with reduced cerebrovascular risk (incidence rate ratio: 0.62-0.94, p < .0001), indicating a dose-dependent effect.

CONCLUSION

Metformin monotherapy is associated with a reduced risk of cerebrovascular diseases in early-stage T2D, highlighting its dose-dependent efficacy. However, the observed benefits might also be influenced by baseline differences and the increased risks associated with other medications, such as sulphonylureas. These findings emphasize the need for personalized diabetes management, particularly in mitigating cerebrovascular risk in early T2D stages.

Brain functional and structural changes in diabetic children. How can intellectual development be optimized in type 1 diabetes?

The neuropsychological functioning of people with type 1 diabetes (T1D) is of key importance to the effectiveness of the therapy, which, in its complexity, requires a great deal of knowledge, attention, and commitment. Intellectual limitations make it difficult to achieve the optimal metabolic balance, and a lack of this alignment can contribute to the further deterioration of cognitive functions. The aim of this study was to provide a narrative review of the current state of knowledge regarding the influence of diabetes on brain structure and functions during childhood and also to present possible actions to optimize intellectual development in children with T1D. Scopus, PubMed, and Web of Science databases were searched for relevant literature using selected keywords. The results were summarized using a narrative synthesis. Disturbances in glucose metabolism during childhood may have a lasting negative effect on the development of the brain and related cognitive functions. To optimize intellectual development in children with diabetes, it is essential to prevent disorders of the central nervous system by maintaining peri-normal glycemic levels. Based on the performed literature review, it seems necessary to take additional actions, including repeated neuropsychological evaluation with early detection of any cognitive dysfunctions, followed by the development of individual management strategies and the training of appropriate skills, together with complex, multidirectional environmental support.

Changes in Health Status in the Ft. Devens Gulf War Veterans Cohort: 1997-2017

Gulf War veterans (GWVs) were exposed to numerous neurotoxicants during deployment. Upon returning home, many reported a multitude of symptoms including fatigue, pain, gastrointestinal and respiratory issues, and neurological, cognitive, and mood complaints, collectively termed "Gulf War Illness (GWI)." Now, nearly 30 years post-war, many GWVs continue to suffer from these symptoms, in addition to health concerns associated with normal aging. While most research on GWVs has been cross-sectional, it is important to evaluate the progression and onset of new GWI symptoms longitudinally. The current study investigated the health of GWVs 25+ years after the war by resurveying the Ft. Devens Cohort and comparing their current health to their health reported 15 to 20 years earlier. The sample consists of 317 GWVs (~54 years old at the latest survey, 38 women) who responded to both surveys (1997-1998 and 2013-2017). Multivariable regression analyses were used to assess changes in GWI symptomatology and prevalence of medical conditions. The rates of 12 of 25 health symptoms increased significantly from the prior 1997-1998 survey. Anxiety, numbness in extremities, depressed mood, and joint pain had the greatest increase in endorsement. The rates of 7 of 16 medical conditions increased significantly from the prior 1997-1998 survey. High blood pressure, diabetes, and cancer had the greatest increase in prevalence. In summary, this study demonstrates that both symptoms and physician-diagnosed medical conditions associated with GW deployment/exposure increased in prevalence. For GWVs, focus by providers on the treatment of cognitive and mental health issues as well as cardiovascular and cerebrovascular risk factors is warranted. Targeting symptom alleviation would help improve the quality of life in these veterans until treatments addressing the entire illness become available.

Chronic Diabetes Complications: The Need to Move beyond Classical Concepts

Chronic-diabetes-related complications simultaneously compromise both the micro- and macrovascular trees, with target organs considered as the paradigm of large vessel injury also entailing microangiopathic changes. However, complications independent or partially independent from vascular damage are often overlooked. This includes neuronal dysfunction (e.g., retinal neurodegeneration), interstitial injury (e.g., tubulointerstitial disease), metabolic damage (e.g., in the heart and liver), and nonclassical conditions such as cognitive decline, impaired pulmonary function, or increased risk of cancer. In this scenario, researchers, endocrinologists and primary care physicians should have a holistic view of the disease and pay further attention to all organs and all potential clinical repercussions, which would certainly contribute to a more rational and integrated patient health care.

Derivation and external validation of risk algorithms for cerebrovascular (re)hospitalisation in patients with type 2 diabetes: Two cohorts study

AIMS

Cerebrovascular disease is one of more typical reasons for hospitalisation and re-hospitalisation in people with type 2 diabetes. We aimed to derive and externally validate two risk prediction algorithms for cerebrovascular hospitalisation and re-hospitalisation.

METHODS

Two independent cohorts were used to derive and externally validate the two risk scores. The development cohort comprises 4704 patients with type 2 diabetes registered in 18 general practices across Cambridgeshire. The validation cohort includes 1121 type 2 patients from a post-trial cohort data. Outcomes were cerebrovascular hospitalisation within two years and cerebrovascular re-hospitalisation within ninety days of the previous cerebrovascular hospitalisation. Logistic regression was applied to derive the two risk scores for cerebrovascular hospitalisation and re-hospitalisation from development cohort, which were externally validated in the validation cohort.

RESULTS

The incidence of cerebrovascular hospitalisation and re-hospitalisation was 3.76% and 1.46% in the development cohort, and 4.99% and 1.87% in the external validation cohort. Age, gender, body mass index, blood pressures, and lipid profiles were included in the final model. Model discrimination was similar in both cohorts, with all C-statistics > 0.70, and very good calibration of observed and predicted individual risks.

CONCLUSION

Two new risk scores that quantify individual risks of cerebrovascular hospitalisation and re-hospitalisation have been well derived and externally validated. Both scores are on the basis of a few of clinical measurements that are commonly available for patients with type 2 diabetes in primary care settings and could work as tools to identify individuals at high risk of cerebrovascular hospitalisation and re-hospitalisation.

Effects of glucose-lowering agents on ischemic stroke

Diabetes mellitus (DM) is a major risk factor for cardiovascular events, including ischemic stroke. Moreover, ischemic stroke appears to be more severe in these patients and to be associated with less favorable outcomes. However, strict glycemic control does not appear to reduce the risk of ischemic stroke. On the other hand, newer glucose-lowering agents (glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors) reduced the risk of cardiovascular events in recent randomized, placebo-controlled trials. Semaglutide also reduced the risk of ischemic stroke. These benefits are independent of glucose lowering and might be due to the favorable effects of these agents on body weight and blood pressure. Pioglitazone also reduced the risk of recurrent stroke in patients with insulin resistance or type 2 DM but the unfavorable safety profile limits its use. In contrast, sulfonylureas and dipeptidyl peptidase 4 inhibitors have a neutral effect on cardiovascular morbidity and might be less attractive options in this high-risk population.

Nonalcoholic fatty liver disease in patients with acute ischemic stroke is associated with more severe stroke and worse outcome

BACKGROUND

There is a paucity of data regarding the association between nonalcoholic fatty liver disease (NAFLD) and acute ischemic stroke. Stroke is largely preventable, so that knowledge of risk factors is essential to achieve reductions in the stroke rate and resulting disease burden.

OBJECTIVE

The aim of the present study was to evaluate the prognostic value of NAFLD on stroke severity and outcome.

METHODS

We prospectively studied 200 patients who were admitted with acute ischemic stroke between September 2013 and August 2015. Demographic and vascular risk factors were detailed for all subjects. The severity of stroke was assessed with National Institutes of Health Stroke Scale score at admission. NAFLD was defined as serum alanine aminotransferase and/or aspartate aminotransferase levels above the upper limit of normal in the absence of other causes of elevated aminotransferase levels. The outcome was assessed with the modified Rankin scale score at discharge.

RESULTS

NAFLD was found in 42.5% of the study population. The prevalence of diabetes was significantly higher among patients with NAFLD than those without NAFLD (P = .001). Waist circumference was significantly higher among patients with NAFLD than those without NAFLD (P < .05). Patients with NAFLD had significantly higher glucose, Triglycerides, Low density lipoprotein, serum alanine aminotransferase and aspartate aminotransferase than those without NAFLD (P < .05 for each comparison). National Institutes of Health Stroke Scale score at admission and modified Rankin scale score at discharge were significantly higher in patients with NAFLD than those without NAFLD (P < .05 for each comparison).

CONCLUSION

NAFLD was found in 42.5% of acute ischemic stroke patients. NAFLD might be associated with more severe stroke and worse outcome.

Stress hyperglycemia and acute ischemic stroke in-hospital outcome

BACKGROUND AND AIMS

Stress hyperglycemia is frequent in patients with acute ischemic stroke. However, it is unclear whether stress hyperglycemia only reflects stroke severity or if it is directly associated with adverse outcome. We aimed to evaluate the prognostic significance of stress hyperglycemia in acute ischemic stroke.

METHODS

We prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0% males, age 79.4±6.8years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Stress hyperglycemia was defined as fasting serum glucose levels at the second day after admission ≥126mg/dl in patients without type 2 diabetes mellitus (T2DM). The outcome was assessed with adverse outcome rates at discharge (modified Rankin scale between 2 and 6) and with in-hospital mortality.

RESULTS

In the total study population, 8.6% had stress hyperglycemia. Patients with stress hyperglycemia had more severe stroke. Independent predictors of adverse outcome at discharge were age, prior ischemic stroke and NIHSS at admission whereas treatment with statins prior to stroke was associated with favorable outcome. When the NIHSS was removed from the multivariate model, independent predictors of adverse outcome were age, heart rate at admission, prior ischemic stroke, log-triglyceride (TG) levels and stress hyperglycemia, whereas treatment with statins prior to stroke was associated with favorable outcome. Independent predictors of in-hospital mortality were atrial fibrillation (AF), diastolic blood pressure (DBP), serum log-TG levels and NIHSS at admission. When the NIHSS was removed from the multivariate model, independent predictors of in-hospital mortality were age, AF, DBP, log-TG levels and stress hyperglycemia.

CONCLUSION

Stress hyperglycemia does not appear to be directly associated with the outcome of acute ischemic stroke. However, given that patients with stress hyperglycemia had higher prevalence of cardiovascular risk factors than patients with normoglycemia and that glucose tolerance was not evaluated, more studies are needed to validate our findings.

Risk Factors for Stroke among Young-Old and Old-Old Community-Dwelling Adults in Japan: The Ohasama Study

AIM

Few studies have addressed stroke risk factors in older populations, particularly among the old-old. We examined differences in traditional risk factors for stroke among the old-old compared with the young-old in community-dwelling Japanese adults.

METHODS

We followed 2,065 residents aged ≥ 60 years who had no history of stroke. Traditional risk factors for stroke were obtained from a self-administered questionnaire at baseline. We classified participants into two age categories, 60-74 years (n=1,502) and ≥ 75 years (n=563), and assessed whether traditional risk factors were differentially associated with stroke incidence according to age category. Hazard ratios were calculated by the Cox proportional hazards model, adjusting for confounding factors and competing risk of death.

RESULTS

During a median follow-up of 12.8 and 7.9 years, 163 and 111 participants aged 60-74 and ≥ 75 years, respectively, developed a first stroke. Hypertension was consistently associated with increased risk of stroke, regardless of age category. Diabetes mellitus was associated with increased risk of stroke in those aged 60-74 years (hazard ratio, 1.50; 95% confidence interval, 1.00-2.25), but not in those aged ≥ 75 years (hazard ratio, 0.65; 95% confidence interval, 0.33-1.29), with significant interaction by age (P=0.035). No traditional risk factor other than hypertension was associated with stroke among those aged ≥ 75 years.

CONCLUSION

Those with hypertension had significantly higher stroke risk among old people, while diabetes mellitus was differentially associated with stroke according to age category. Our findings indicate the importance of different prevention strategies for stroke incidence according to age category.

Prior treatment with dipeptidyl peptidase 4 inhibitors is associated with better functional outcome and lower in-hospital mortality in patients with type 2 diabetes mellitus admitted with acute ischaemic stroke

It is unclear whether prior antidiabetic treatment affects stroke severity and outcome. To evaluate this association, we prospectively studied all patients who were admitted in our Department with acute ischaemic stroke (n = 378, mean age = 78.8 ± 6.5 years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale. The outcome was assessed with the modified Rankin Scale at discharge and with in-hospital mortality. A total of 123 patients had type 2 diabetes mellitus. At admission, there was a trend for lower National Institutes of Health Stroke Scale in patients treated with dipeptidyl peptidase 4 inhibitors compared with patients treated with other antidiabetic agents (6.1 ± 7.5 vs 10.0 ± 9.2, respectively; p = 0.079). At discharge, patients treated with dipeptidyl peptidase 4 inhibitors had lower modified Rankin Scale than patients treated with other antidiabetic agents (2.1 ± 1.9 vs 3.2 ± 2.1, respectively; p < 0.05). Patients treated with dipeptidyl peptidase 4 inhibitors also had lower in-hospital mortality than patients treated with other antidiabetic agents (0.0% vs 15.1%, respectively; p < 0.05). In conclusion, prior treatment with dipeptidyl peptidase 4 inhibitors in patients with acute ischaemic stroke appears to be associated with better functional outcome and lower mortality risk.

The REVEAL Study: Ranibizumab Monotherapy or Combined with Laser versus Laser Monotherapy in Asian Patients with Diabetic Macular Edema

OBJECTIVE

The primary study hypothesis was that ranibizumab 0.5 mg monotherapy or combined with laser is superior to laser monotherapy based on mean average change in best-corrected visual acuity (BCVA) over 12 months in Asian patients with visual impairment resulting from diabetic macular edema (DME).

DESIGN

A 12-month, randomized, double-masked, multicenter, laser-controlled, phase III study.

PARTICIPANTS

Three hundred ninety-six patients aged ≥18 years, with type 1 or 2 diabetes mellitus, BCVA of 78-39 Early Treatment Diabetic Retinopathy Study (ETDRS) letters, and visual impairment resulting from DME.

METHODS

Patients were randomized to ranibizumab + sham laser (n = 133), ranibizumab + active laser (n = 132), or sham injection + active laser (n = 131). Ranibizumab/sham injections were administered on day 1 and continued monthly. As of month 3, monthly injections were continued if stable vision was not reached. Treatment was reinitiated if BCVA decreased because of DME progression. Active/sham laser was administered on day 1 and thereafter according to ETDRS guidelines.

MAIN OUTCOME MEASURES

Average change in BCVA from baseline to months 1 through 12, central retinal subfield thickness (CRST), and safety over 12 months.

RESULTS

Ranibizumab monotherapy or combined with laser was superior to laser in improving mean average change in BCVA from baseline to months 1 through 12 (+5.9 and +5.7 vs +1.4 letters). At month 12, greater proportion of patients gained ≥15 letters with ranibizumab and ranibizumab + laser compared with laser (18.8% and 17.8% vs 7.8%). Mean CRST reduced significantly from baseline to month 12 with ranibizumab (-134.6 μm) and ranibizumab + laser (-171.8 μm) versus laser (-57.2 μm). Patients received a mean of 7.8 and 7.0 ranibizumab injections in the ranibizumab and ranibizumab + laser arms, respectively, and 1.5-1.9 active laser across treatment arms over 12 months. Conjunctival hemorrhage was the most common ocular, whereas nasopharyngitis and hypertension were the most common nonocular adverse events. Ranibizumab was not associated with any cases of cerebrovascular hemorrhage and cerebrovascular ischemia. No death related to study treatment was reported.

CONCLUSIONS

Ranibizumab monotherapy or combined with laser showed superior BCVA improvements over laser treatment alone in Asian patients with visual impairment resulting from DME. No new ocular or nonocular safety findings were observed and treatment was well tolerated over 12 months.

Type 2 diabetes is associated with a worse functional outcome of ischemic stroke

AIM: To assess whether ischemic stroke severity and outcome is more adverse in patients with type 2 diabetes mellitus (T2DM).

METHODS: Consecutive patients hospitalized for acute ischemic stroke between September 2010 and June 2013 were studied prospectively (n = 482; 40.2% males, age 78.8 ± 6.7 years). T2DM was defined as self-reported T2DM or antidiabetic treatment. Stroke severity was evaluated with the National Institutes of Health Stroke Scale (NIHSS) score at admission. The outcome was assessed with the modified Rankin scale (mRS) score at discharge and with in-hospital mortality. Adverse outcome was defined as mRS score at discharge ≥ 2 or in-hospital death. The length of hospitalization was also recorded.

RESULTS: T2DM was present in 32.2% of the study population. Patients with T2DM had a larger waist circumference, higher serum triglyceride and glucose levels and lower serum high-density lipoprotein cholesterol levels as well as higher prevalence of hypertension, coronary heart disease and congestive heart failure than patients without T2DM. On the other hand, diabetic patients had lower low-density lipoprotein cholesterol levels and reported smaller consumption of alcohol than non-diabetic patients. At admission, the NIHSS score did not differ between patients with and without T2DM (8.7 ± 8.8 and 8.6 ± 9.2, respectively; P = NS). At discharge, the mRS score also did not differ between the two groups (2.7 ± 2.1 and 2.7 ± 2.2 in patients with and without T2DM, respectively; P = NS). Rates of adverse outcome were also similar in patients with and without T2DM (62.3% and 58.5%, respectively; P = NS). However, when we adjusted for the differences between patients with T2DM and those without T2DM in cardiovascular risk factors, T2DM was independently associated with adverse outcome [relative risk (RR) = 2.39; 95%CI: 1.21-4.72, P = 0.012]. In-hospital mortality rates did not differ between patients with T2DM and those without T2DM (9.0% and 9.8%, respectively; P = NS). In multivariate analysis adjusting for the difference in cardiovascular risk factors between the two groups, T2DM was again not associated with in-hospital death.

CONCLUSION: T2DM does not appear to affect ischemic stroke severity but is independently associated with a worse functional outcome at discharge.

HCdc14A is involved in cell cycle regulation of human brain vascular endothelial cells following injury induced by high glucose, free fatty acids and hypoxia

Cell cycle processes play a vital role in vascular endothelial proliferation and dysfunction. Cell division cycle protein 14 (Cdc14) is an important cell cycle regulatory phosphatase. Previous studies in budding yeast demonstrated that Cdc14 could trigger the inactivation of mitotic cyclin-dependent kinases (Cdks), which are required for mitotic exit and cytokinesis. However, the exact function of human Cdc14 (hCdc14) in cell cycle regulation during vascular diseases is yet to be elucidated. There are two HCdc14 homologs: hCdc14A and hCdc14B. In the current study, we investigated the potential role of hCdc14A in high glucose-, free fatty acids (FFAs)-, and hypoxia-induced injury in cultured human brain vascular endothelial cells (HBVECs). Data revealed that high glucose, FFA, and hypoxia down-regulated hCdc14A expression remarkably, and also affected the expression of other cell cycle-related proteins such as cyclin B, cyclin D, cyclin E, and p53. Furthermore, the combined addition of the three stimuli largely blocked cell cycle progression, decreased cell proliferation, and increased apoptosis. We also determined that hCdc14A was localized mainly to centrosomes during interphase and spindles during mitosis using confocal microscopy, and that it could affect the expression of other cycle-related proteins. More importantly, the overexpression of hCdc14A accelerated cell cycle progression, enhanced cell proliferation, and promoted neoplastic transformation, whereas the knockdown of hCdc14A using small interfering RNA produced the opposite effects. Therefore, these findings provide novel evidence that hCdc14A might be involved in cell cycle regulation in cultured HBVECs during high glucose-, FFA-, and hypoxia-induced injury.

Antidiabetic treatment, stroke severity and outcome

Ischemic stroke is a leading cause of mortality and long-term disability worldwide. Given the detrimental effects of acute stroke, several neuroprotective agents have been evaluated in these patients. However, the benefits of the evaluated agents appear to be limited and none is currently recommended for clinical use. On the other hand, prior treatment with agents that are used for the primary and secondary prevention of stroke, including statins and antiplatelets, has been associated with better outcome in patients who experience an acute stroke. In contrast, there are limited data as to whether prior treatment with antidiabetic agents is beneficial in diabetic patients who suffer a stroke. In this context, the findings of a recent study that showed reduced stroke size following pretreatment with linagliptin, a dipeptidyl peptidase-4 (DDP-4) inhibitor, compared with glimepiride, in both diabetic and non-diabetic mice, appear promising. Despite these preclinical findings suggesting neuroprotective effects of DPP-4 inhibitors in acute stroke, it is still unclear whether these actions will also be observed in humans. Of note, two recent large randomized, placebo-controlled studies did not show any effect of DPP-4 inhibitors on cardiovascular events, including stroke. Several other ongoing trials are evaluating the effects of DPP-4 inhibitors on cardiovascular morbidity and mortality. These studies also provide a major opportunity to assess whether patients treated with this class of antidiabetic agents will suffer from less severe strokes and whether their outcome after stroke will be more favorable.

Association between nonalcoholic fatty liver disease and acute ischemic stroke severity and outcome

AIM: To evaluate the association of nonalcoholic fatty liver disease (NAFLD) with acute ischemic stroke severity and in-hospital outcome.

METHODS: We prospectively studied all patients who were admitted in our Department with acute ischemic stroke between September 2010 and August 2012 (n = 415; 39.5% males, mean age 78.8 ± 6.6 years). The severity of stroke was assessed with the National Institutes of Health Stroke Scale (NIHSS) score at admission. NALFD was defined as serum alanine aminotransferase and/or aspartate aminotransferase levels above the upper limit of normal in the absence of other causes of elevated aminotransferases levels [chronic hepatitis B or C, drug toxicity, increased alcohol consumption (> 21 and > 14 drinks per week in men and women, respectively), cholestatic diseases or rhabdomyolysis]. The outcome was assessed with the modified Rankin scale (mRS) score at discharge and in-hospital mortality. Adverse outcome was defined as mRS score at discharge ≥ 2. Dependency at discharge was defined as mRS score between 2 to 5.

RESULTS: NAFLD was present in 7.7% of the study population. Patients with NAFLD had lower serum high-density lipoprotein cholesterol and higher triglyceride levels than patients without NAFLD (P < 0.05 for both comparisons). Demographic data, the prevalence of other cardiovascular risk factors and the prevalence of established CVD did not differ between the two groups. At admission, the NIHSS score did not differ between patients with and without NAFLD (6.3 ± 6.4 and 8.8 ± 9.6, respectively; P = NS). At discharge, the mRS score did not differ between the two groups (1.9 ± 2.2 and 2.6 ± 2.2 in patients with and without NAFLD, respectively; P = NS). Rates of dependency at discharge were also similar in patients with and without NAFLD (36.8% and 55.0%, respectively; P = NS) as were the rates of adverse outcome (42.9% and 58.6%, respectively; P = NS). In-hospital mortality rates also did not differ between the 2 groups (8.0% and 7.0% in patients with and without NAFLD, respectively; P = NS).

CONCLUSION: The presence of NAFLD in patients admitted for acute ischemic stroke does not appear to be associated with more severe stroke or with worse in-hospital outcome.

Relationship between blood pressure, cognitive function and education level in elderly patients with diabetes: a preliminary study

AIMS

This study aimed to assess the relationship between blood pressure and cognitive function in elderly patients with diabetes mellitus (DM).

METHODS

A total of 32 patients with DM aged ≥ 65 years (seven women and 25 men; mean ± SD age: 74.3 ± 6.4 years) were included in this cross-sectional study. Relationships between blood pressure and neuropsychological tests were determined using Spearman's rank correlations (ρ) and multivariable linear regression models.

RESULTS

Lower diastolic blood pressure was associated with lower scores on the Frontal Assessment Battery (ρ=0.32, P=0.02), longer times to complete the Trail Making Test Part B (ρ=0.51, P=0.003), lower scores for the Finger Tapping Test (ρ=0.36, P=0.046) and less verbal fluency (ρ=0.36, P=0.047). In multivariable models, these relationships were attenuated after adjusting for levels of education.

CONCLUSION

There was an association between lower diastolic blood pressure and poorer executive function in this cohort of elderly DM patients. These results underline the importance of systematic cognitive evaluation in elderly patients with DM, and suggest that a too-low diastolic blood pressure may have deleterious effects on mental function. Larger studies in the future are required to confirm these preliminary results.

The diagnosis and management of cerebrovascular disease in diabetes

Cerebrovascular disease is a leading cause of morbidity and mortality in diabetes. Compared with nondiabetic patients, diabetic patients have at least twice the risk for stroke, earlier onset of symptoms, and worse functional outcomes. Approximately 20 % of diabetic patients will die from stroke, making it one of the leading causes of death in this population. Effective strategies for primary and secondary prevention of stroke have been developed in research cohorts that included both diabetic and nondiabetic patients. Nevertheless, prevention in diabetes has some specific considerations. In this paper, we summarize evidence to guide the diagnosis and management of stroke in diabetic patients. We propose that diabetic stroke patients should have a robust risk assessment to target interventions, like other patients with cerebrovascular disease, but with special attention to glycemic control and lifestyle modification.