Low intakes of carotene, vitamin B2, pantothenate and calcium predict cognitive decline among elderly patients with diabetes mellitus: The Japanese Elderly Diabetes Intervention Trial

Correlation between gut microbiome and cognitive impairment in patients undergoing peritoneal dialysis

BACKGROUND

Growing evidence has demonstrated that patients undergoing peritoneal dialysis (PD) are more likely to experience cognitive impairment than patients with non-dialysis end-stage renal disease (ESRD); however, the underlying mechanisms remain unclear. This study aimed to identify the role and predictive significance of gut microbiome alterations in PD-associated cognitive impairment.

METHODS

A total of 29 non-dialysis ESRD patients and 28 PD patients were enrolled in this study and divided into subgroups according to the Montreal Cognitive Assessment (MoCA). Faecal samples were analyzed using 16 S rRNA. Mini-Mental State Examination (MMSE) and MoCA scores were used to assess the degree of cognitive impairment in patients.

RESULTS

The 16 S rRNA analysis demonstrated differences in gut microbiome abundance and structure between PD and non-dialysis ESRD patients and between PD patients with cognitive impairment (PCI) and PD patients with normal cognition (PNCI). At family and genus levels, Prevotellaceae exhibited the greatest structure difference, while Lactobacillus exhibited the greatest abundance difference between PCI and PNCI. Altered microbiota abundance significantly correlated with cognitive function and serum indicators in PD. In addition, different modules related to fatty acid, lipid, pantothenate, and coenzyme A biosynthesis, and tyrosine and tryptophan metabolism were inferred from 16 S rRNA data between PCI and PNCI. Both groups could be distinguished using models based on the abundance of Lactobacillaceae (Area under curve [AUC] = 0.83), Actinomycetaceae (AUC = 0.798), and Prevotellaceae (AUC = 0.778) families and Lactobacillus (AUC = 0.848) and Actinomyces (AUC = 0.798) genera.

CONCLUSION

Gut microbiome evaluation could aid early cognitive impairment diagnosis in patients undergoing PD.

Association of vitamin B2 intake with cognitive performance in older adults: a cross-sectional study

BACKGROUND

To scrutinize the relationship between vitamin B2 consumption and cognitive function based on the NHANES database.

METHODS

This cross-sectional study included eligible older adults from the NHANES 2011-2014. Vitamin B2 intake was determined from dietary interview data for two 24-h periods. Cognitive function was evaluated through the Consortium to Establish a Registry for Alzheimer's Disease (CERAD), Animal Fluency Test (AFT), and Digit Symbol Substitution Test (DSST). The regression analyses were used to evaluate the association of vitamin B2 intake with cognitive performance. Stratified analyses based on gender, race, and body mass index (BMI) were conducted.

RESULTS

Higher vitamin B2 intake was correlated with higher scores on each test. As compared to the lowest quartile, the highest quartile of vitamin B2 intake was related to a 45.1-fold increase (P = 0.004) on the DSST test sores. Moreover, those who were males, non-Hispanic whites, or had a BMI of 18.5 to 30 kg/m2 had a stronger relationship between total vitamin B2 consumption and cognitive function.

CONCLUSION

It's possible that older persons who consume more vitamin B2 have enhanced performance in some areas of cognitive function. To determine the causal link between vitamin B2 consumption and cognitive performance, further long-term research is required.

Association between Mineral Intake and Cognition Evaluated by Montreal Cognitive Assessment (MoCA): A Cross-Sectional Study

BACKGROUND

Mineral intake may protect against cognitive impairment (CI) and all-cause dementia, which affects a large number of adults worldwide. The aim of this study was to investigate the association between mineral intake and Montreal Cognitive Assessment (MoCA), which is a sensitive and specific test.

METHODS

In total, 201 adults were included in a cross-sectional study. They completed a three-day dietary record to estimate their average daily intake of minerals. Contributions to dietary reference intakes (DRIs) were also calculated. The participants were divided into tertiles according to their mineral intake. CI classifications were determined via the MoCA (score < 26). Apolipoprotein E (APOE) genotyping was carried out, and the patients' anthropometric measurements and physical activity, health and personal data were collected.

RESULTS

The prevalence of CI in this selective sample was 54.2% (34.3% females and 19.9% males). In women, being in the third tertiles of iron and manganese intake was associated with lower odds of having CI (OR [95% CI]: 0.32 [0.11 ± 0.93]; 0.33 [0.12 ± 0.93], p < 0.05). No significant differences were observed for any of the nutrients studied in men.

CONCLUSIONS

These findings suggest that a low mineral intake, especially low iron and manganese intake in women, is associated with a worse cognition as assessed by MoCA.

Biomimetic Remodeling of Microglial Riboflavin Metabolism Ameliorates Cognitive Impairment by Modulating Neuroinflammation

Neuroinflammation, for which microglia are the predominant contributors, is a significant risk factor for cognitive dysfunction. Riboflavin (also known as vitamin B2) ameliorates cognitive impairment via anti-oxidative stress and anti-inflammation properties; however, the underlying mechanisms linking riboflavin metabolism and microglial function in cognitive impairment remain unclear. Here, it is demonstrated that riboflavin kinase (RFK), a critical enzyme in riboflavin metabolism, is specifically expressed in microglia. An intermediate product of riboflavin, flavin mononucleotide (FMN), inhibited RFK expression via regulation of lysine-specific methyltransferase 2B (KMT2B). FMN supplementation attenuated the pro-inflammatory TNFR1/NF-κB signaling pathway, and this effect is abolished by KMT2B overexpression. To improve the limited anti-inflammatory efficiency of free FMN, a biomimetic microglial nanoparticle strategy (designated as MNPs@FMN) is established, which penetrated the blood brain barrier with enhanced microglial-targeted delivery efficiency. Notably, MNPs@FMN ameliorated cognitive impairment and dysfunctional synaptic plasticity in a lipopolysaccharide-induced inflammatory mouse model and in a 5xFAD mouse model of Alzheimer's disease. Taken together, biomimetic microglial delivery of FMN may serve as a potential therapeutic approach for inflammation-dependent cognitive decline.

Dairy Product Consumption and Changes in Cognitive Performance: Two-Year Analysis of the PREDIMED-Plus Cohort

SCOPE

Dairy consumption has been suggested to impact cognition; however, evidence is limited and inconsistent. This study aims to longitudinally assess the association between dairy consumption with cognitive changes in an older Spanish population at high cardiovascular disease risk.

METHODS AND RESULTS

Four thousand six hundred sixty eight participants aged 55-75 years, completed a validated food frequency questionnaire at baseline and a neuropsychological battery of tests at baseline and 2-year follow-up. Multivariable linear regression models are used, scaled by 100 (i.e., the units of β correspond to 1 SD/100), to assess associations between baseline tertile daily consumption and 2-year changes in cognitive performance. Participants in the highest tertile of total milk and whole-fat milk consumption have a greater decline in global cognitive function (β: -4.71, 95% CI: -8.74 to -0.69, p-trend = 0.020 and β: -6.64, 95% CI: -10.81 to -2.47, p-trend = 0.002, respectively) compared to those in the lowest tertile. No associations are observed between low fat milk, yogurt, cheese or fermented dairy consumption, and changes in cognitive performance.

CONCLUSION

Results suggest there are no clear prospective associations between consumption of most commonly consumed dairy products and cognition, although there may be an association with a greater rate of cognitive decline over a 2-year period in older adults at high cardiovascular disease risk for whole-fat milk.

The Layered Encapsulation of Vitamin B2 and β-Carotene in Multilayer Alginate/Chitosan Gel Microspheres: Improving the Bioaccessibility of Vitamin B2 and β-Carotene

This research underlines the potential of alginate multilayered gel microspheres for the layered encapsulation and the simultaneous delivery of vitamin B₂ (VB) and β-carotene (BC). Chitosan was used to improve the stability and controlled release ability of alginate-based gel microspheres. It was shown that a clear multilayered structure possessed the characteristics of pH response, and excellent thermal stability. The sodium alginate concentration and the number of layers had notable effects on mechanical properties and particle size of gel microspheres. Fourier-transform infrared spectroscopy and X-ray diffraction analyses further proved that VB and BC were encapsulated within the gel microspheres. Compared with the three-layer VB-loaded gel microspheres, the total release of VB from the three-layer VB and BC-loaded gel decreased from 93.23% to 85.58%. The total release of BC from the three-layer VB and BC-loaded gel increased from 66.11% to 69.24% compared with three-layer BC-loaded gel. The simultaneous encapsulation of VB and BC in multilayered gel microspheres can markedly improve their bioaccessibility and bioavailability. These results showed the multilayer gel microspheres synthesized herein have potential for applications in the layered encapsulation and simultaneous delivery of various bioactive substances to the intestinal tract.

Higher circulating α-carotene was associated with better cognitive function: an evaluation among the MIND trial participants

There is emerging evidence linking fruit and vegetable consumption and cognitive function. However, studies focusing on the nutrients underlying this relationship are lacking. We aim to examine the association between plasma nutrients and cognition in a population at risk for cognitive decline with a suboptimal diet. The Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) trial is a randomized controlled intervention that examines the effects of the MIND diet to prevent cognitive decline. The primary outcome is global cognition. A multivariate linear model was used to investigate the association between blood nutrients and global and/or domain-specific cognition. The model was adjusted for age, sex, education, study site, smoking status, cognitive activities and physical activities. High plasma α-carotene was associated with better global cognition. Participants in the highest tertile of plasma α-carotene had a higher global cognition z score of 0⋅17 when compared with individuals in the lowest tertile (P 0⋅002). Circulating α-carotene levels were also associated with higher semantic memory scores (P for trend 0⋅007). Lutein and zeaxanthin (combined) was positively associated with higher semantic memory scores (P for trend 0⋅009). Our study demonstrated that higher α-carotene levels in blood were associated with higher global cognition scores in a US population at risk for cognitive decline. The higher α-carotene levels in blood reflected greater intakes of fruits, other types of vegetables and lesser intakes of butter and margarine and meat. The higher circulating levels of lutein plus zeaxanthin reflected a dietary pattern with high intakes of fruits, green leafy, other vegetables and cheese, and low consumption of fried foods. Objective nutrient markers in the blood can better characterize dietary intake, which may facilitate the implementation of a tailored dietary intervention for the prevention of cognitive decline.

The Multi-Domain Intervention Trial in Older Adults With Diabetes Mellitus for Prevention of Dementia in Japan: Study Protocol for a Multi-Center, Randomized, 18-Month Controlled Trial

Background: The Japan-Multi-domain Intervention Trial for Prevention of Dementia in Older Adults with Diabetes (J-MIND-Diabetes) is an 18-month, multi-centered, open-labeled, randomized controlled trial designed to identify whether multi-domain intervention targeting modifiable risk factors for dementia could prevent the progression of cognitive decline among older adults with type 2 diabetes mellitus (T2DM). This manuscript describes the study protocol for the J-MIND-Diabetes trial. Materials and Methods: Subjects of this trial will comprise a total of 300 T2DM outpatients aged 70-85 years with mild cognitive impairment. Subjects will be centrally randomized into intervention and control groups at a 1:1 allocation ratio using the stratified permuted-block randomization methods. The intervention group will participate in multi-domain intervention programs aimed at: (1) management of metabolic and vascular risk factors; (2) physical exercise and self-monitoring of physical activity; (3) nutritional guidance; and (4) social participation. The control group will receive usual T2DM care and general instructions on dementia prevention. The primary and secondary outcomes will be assessed at baseline, at 6- and 18-month follow-up. The primary outcome is change from baseline at 18 months in a global composite score combining several neuropsychological domains, including global cognitive function, memory, attention, executive function, processing speed and language. Secondary outcomes include: (1) cognitive changes in neuropsychological tests; (2) changes in geriatrics assessments; (3) metabolic control and diabetic complications; (4) changes in blood and urinary markers. Discussion: This trial will be the first trial to demonstrate the effectiveness of multi-domain intervention in preventing cognitive decline in older adults with T2DM at increased risk of dementia in Japan. Trial Registration: UMIN000035911; Registered on the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) 18 February 2019. (https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000040908).

Is milk and dairy intake a preventive factor for elderly cognition (dementia and Alzheimer's)? A quality review of cohort surveys

Milk and dairy (M&D) is a longstanding human food with widespread use. Many studies showed the preventive capacity of M&D in several human health disorders, but its utility in others is under discussion. Aging has been associated to elderly cognitive decline including dementia-Alzheimer syndrome (Dem-AD). The absence of a therapy to impede or postpone Dem-AD determines the need for its prevention, including nutritional factors. To evaluate the preventive capacity of M&D consumption in elderly Dem-AD we performed a systematic review in the main biomedical databases and information resources, but we present this study as a narrative review to discuss better the complexity of this subject. The elderly Dem-AD has a long pre-symptomatic period and the M&D intake has a widespread use. These determinants and the quality flaws of published studies impeach us to answer whether M&D consumption is preventive for Dem-AD. Moreover, two long Japanese cohorts suggest that M&D intake could prevent Dem-AD. Prospective cohorts beginning in midlife (or early life) could answer this question in the future.

Association of Antioxidant Vitamins A, C, E and Carotenoids with Cognitive Performance over Time: A Cohort Study of Middle-Aged Adults

Carotenoids may strengthen the association of antioxidant vitamins A, C, and E with favorable cognitive outcomes over time, though a few prospective studies have examined this hypothesis. We evaluated the longitudinal data from 1251 participants in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study (Age at visit 1 in 2004–2009 (v₁): 30–65 years). Vitamins A, C, and E dietary intakes and total and individual dietary carotenoids were computed using two 24-h recalls at v₁. Cognitive tests, covering global mental status and domains of memory/learning, attention, psychomotor speed, visuo-spatial, language/verbal, and executive function were conducted at v₁ and/or v₂ (2009–2013); mean ± SD follow-up: 4.66 ± 0.93 years. Mixed-effects linear regression models detected an interaction between vitamin E and total (and individual) carotenoids for three of 11 cognitive tests at v₁, with only one meeting the statistical significance upon multiple testing correction whereby vitamin E was linked with greater verbal memory performance in the uppermost total carotenoid tertile (γ_0a = +0.26 ± 0.08, p = 0.002), a synergism largely driven by carotenoid lycopene. Vitamins A and C showed no consistent interactions with carotenoids. In conclusion, we provide partial evidence for synergism between vitamin E and carotenoids in relation to better baseline cognitive performance, pending further studies with time-dependent exposures and randomized trials directly examining this synergism.

Nutrition Management in Older Adults with Diabetes: A Review on the Importance of Shifting Prevention Strategies from Metabolic Syndrome to Frailty

The increasing prevalence of older adults with diabetes has become a major social burden. Diabetes, frailty, and cognitive dysfunction are closely related to the mechanisms of aging. Insulin resistance, arteriosclerosis, chronic inflammation, oxidative stress, and mitochondrial dysfunction may be common mechanisms shared by frailty and cognitive impairment. Hyperglycemia, hypoglycemia, obesity, vascular factors, physical inactivity, and malnutrition are important risk factors for cognitive impairment and frailty in older adults with diabetes. The impact of nutrients on health outcomes varies with age; thus, shifting diet therapy strategies from the treatment of obesity/metabolic syndrome to frailty prevention may be necessary in patients with diabetes who are over 75 years of age, have frailty or sarcopenia, and experience malnutrition. For the prevention of frailty, optimal energy intake, sufficient protein and vitamin intake, and healthy dietary patterns should be recommended. The treatment of diabetes after middle age should include the awareness of proper glycemic control aimed at extending healthy life expectancy with proper nutrition, exercise, and social connectivity. Nutritional therapy in combination with exercise, optimal glycemic and metabolic control, and social participation/support for frailty prevention can extend healthy life expectancy and maintain quality of life in older adults with diabetes mellitus.

Cognitive Dysfunction in Older Adults with Type 2 Diabetes: Links, Risks, and Clinical Implications

The prevalence of comorbid diabetes and cognitive dysfunction increases as the population ages. Diabetes increases the risk of progression of cognitive dysfunction through a spectrum of cognitive decline to mild cognitive impairment then to dementia. Cognitive dysfunction, especially impairment in the executive domain, has a negative impact on patients' self-care tasks. With further progression of dementia and the development of behavioral problems, the challenge to carers and health care professionals looking after these patients is significant. Therefore, clinical trials are needed to explore the impact of novel hypoglycemic therapy on cognitive function as an important outcome in this population.

Association between Dietary Protein Intake and Cognitive Function in Adults Aged 60 Years and Older

OBJECTIVES

The aim of this study was to examine the association of dietary protein intake and protein sources with cognitive function in population aged 60 years and older.

DESIGN

Cross-sectional study.

SETTING

The National Health and Nutrition Examination Survey (NHANES) 2011-2014.

PARTICIPANTS

Non-institutionalized US adults aged 60 years and older.

MEASUREMENTS

Cognitive functions were assessed by a series of cognitive tests. Dietary protein intake was assessed by two 24-hour dietary recall interviews. Linear regression analyses were used to assess the associations between quartiles of dietary protein intake and cognitive function.

RESULTS

Protein intake was positively associated with cognitive function. In full-adjusted model, the significant association between dietary protein intake and Recall Test score was observed (quartile (Q) 2 versus Q1, β=0.24, 95%CI: 0.01 to 0.47); the association between protein intake and Animal Fluency test was significant (Q2 versus Q1, β=1.40, 95%CI: 0.51 to 2.29; Q4 versus Q1, β=1.42, 95%CI: 0.37 to 2.48); the positive associations with DSST score and Composite z-score were observed both in Q2 versus Q1 and Q3 versus Q1 of protein intake. Protein intake from total animal, total meat, eggs and legumes were associated with a better performance on certain cognitive tests. However, an adverse association between higher protein intake from milk and milk products and cognitive function was observed.

CONCLUSIONS

We found the positive associations of dietary protein intake and protein intake from total animal, total meat, eggs and legumes with cognitive function in adults aged 60 years and older, while higher milk and milk products were negatively associated with cognitive function.

Dietary Intake of Riboflavin and Unsaturated Fatty Acid Can Improve the Multi-Domain Cognitive Function in Middle-Aged and Elderly Populations: A 2-Year Prospective Cohort Study

Objective

This study was aimed to explore the effects of dietary nutrients on cognitive function among the middle-aged and elderly populations.

Methods

A prospective cohort study of 1,385 middle-aged and elderly people was conducted from January 2014 to December 2017. Dietary nutrients were assessed according to the food frequency questionnaire (FFQ) and China Food Composition Database (CFCD). Montreal cognitive assessment (MoCA) was used to evaluate the participants’ global cognitive function. Six other neuropsychological measures [auditory verbal learning test-immediate recall (AVLT-IR), auditory verbal learning test-short recall (AVLT-SR), auditory verbal learning test-long recall (AVLT-LR), logical memory test (LMT), digit span forward (DST-F), and digit span backward (DST-B)] were used to assess the verbal memory domain and the attention domain by principal component analysis (PCA). Multiple linear regressions were conducted to explore associations between nutrients and cognition. Sensitivity analyses were performed to confirm the results.

Results

Dietary riboflavin was protective for global cognitive function (β = 1.31, 95% CI: 0.26, 2.35) and the verbal memory domain (β = 0.37, 95% CI: 0.02, 0.71). Unsaturated fatty acid (USFA) played a protective role in global cognitive function (β = 1.15, 95% CI: 0.16, 2.14). The protective effects of riboflavin and USFA on cognitive function were consistent and reliable when different confounders were adjusted during sensitivity analyses. During the follow-up, neuropsychological measure scores revealed a reduced decline in the high-riboflavin group (d-MoCA, P = 0.025; d-AVLT-IR, P = 0.001; d-DST-B, P = 0.004; and d-composite score, P = 0.004) and the high-USFA group (d-AVLT-IR, P = 0.007; d-LMT, P = 0.032; d-DST-B, P = 0.002; and d-composite score, P = 0.008).

Conclusion

Higher intake of riboflavin and USFA can improve multi-dimensional cognitive functioning in middle-aged and elderly people. These findings were consistent in different models of sensitivity analyses.

Optimization of an Ultrasound-Assisted Extraction for Simultaneous Determination of Antioxidants in Sesame with Response Surface Methodology

Sesame is a nutritional agricultural product with medicinal properties. Accurate determination of micronutrients is important for the improvement of sesame quality and nutrition assessments. Our previous study showed that 10 antioxidants—d-homoproline, vitamin B₂, coniferyl aldehyde, hesperidin, phloretin, N-acetyl-l-leucine, l-hyoscyamine, ferulic acid, 5-methoxypsoralen, and 8-methoxypsoralen—in sesame were potential characteristic nutrients in sesame. Herein, simultaneous detection of 10 different types of antioxidants was developed by using ultrasound-assisted extraction coupled with liquid chromatography-tandem mass spectrometry (UAE-LC-MS/MS) with the help of response surface methodology. The significant variables and levels were screened and optimized by combining the single factor experiment, Plackett–Burman test, and Box–Behnken design. The optimal conditions for extraction of target antioxidants in sesame were methanol solution of 75.0%, liquid-to-material ratio of 20:1 (mL/g), extraction temperature of 50 °C, extraction power of 410.0 W, extraction time of 65 min. The total yield of targets was 21.74 μg/g under the optimized conditions. The mobile phase used was 0.1% formic acid in acetonitrile and 0.1% formic acid in water, and the column was a Thermo Syncronis C18 reverse phase column (100 mm × 2.1 mm, 3 μm). All targets required only one injection and could be quickly separated and assayed within 7 min. The limits of detection and limits of quantification for these 10 nutritional compounds ranged from 0.01 to 0.11 µg/kg and from 0.04 to 0.34 µg/kg, respectively. The validation results indicated that the method had reasonable linearity (R² ≥ 0.9990), good recoveries (71.1%–118.3%), satisfactory intra-day precision (≤9.6%) and inter-day precision (≤12.9%), and negligible matrix effects (≤13.8%). This simultaneous quantification method was accurate, fast, and robust for the assessment of sesame nutrition.

Role of milk and dairy intake in cognitive function in older adults: a systematic review and meta-analysis

BACKGROUND

As aging populations increase across the globe, research on lifestyle factors that prevent cognitive decline and dementia is urgently needed. Therefore, a systematic review was conducted to examine the effects of varying levels of milk intake alone or in combination with other dairy products on the outcomes of cognitive function and disorders in adults.

METHODS

A comprehensive search was conducted across 3 databases (PUBMED, CINAHL, and EMBASE) from their inception through October 2017. Prospective cohort studies and randomized controlled trials (RCTs) that enrolled adults were included. Studies with follow-up durations of less than 4 weeks and studies including schizophrenic patients were excluded. Two independent investigators conducted abstract and full-text screenings, data extractions, and risk-of-bias (ROB) assessments using validated tools. Studies were synthesized qualitatively using a strength of evidence (SoE) rating tool. A random-effects model for meta-analysis was conducted when at least 3 unique studies reported sufficient quantitative data for the same outcome.

RESULTS

A total of 1 RCT and 7 cohort studies were included. One medium-quality small RCT (n = 38 participants) showed that only spatial working memory was marginally better in the high dairy diet group compared to the low dairy diet group. Two of the 7 cohort studies were rated as having a high ROB, and only 1 cohort study was rated as having a low ROB. There were large methodological and clinical heterogeneities, such as the methods used to assess milk or dairy intake and the characteristics of the study populations. It was impossible to conduct a dose-response meta-analysis because the studies utilized different categories of exposures (e.g., different frequencies of milk consumption or the amount of dairy intake). Thus, the overall SoE was rated as insufficient regarding the associations between milk intake and cognitive decline, dementia, and Alzheimer's disease outcomes. Our meta-analysis of 3 cohort studies showed no significant association between milk intake and cognitive decline outcome (pooled adjusted risk ratio = 1.21; 95% CI: 0.81, 1.82; for highest vs. lowest intake) with large statistical heterogeneity (I2 = 64.1%).

CONCLUSIONS

The existing evidence (mostly observational) is too poor to draw a firm conclusion regarding the effect of milk or dairy intake on the risk of cognitive decline or disorders in adults.

Practical considerations for managing patients with diabetes and dementia

Diabetes and dementia appear to be linked epidemiologically and share a common pathogenetic mechanism. The development of dementia in older people with diabetes will have a significant impact on diabetes self-care and will increase the risk of hypoglycaemia and frailty which ultimately lead to disability and poor outcome. Areas covered: We performed a Medline and Embase search from 1997 to present on relevant dementia and diabetes studies published in English language. Expert commentary: Older people with comorbid diabetes and dementia are functionally heterogeneous and interventions should be proportionate to patients 'functional capacity. Metabolic targets can be tightened in fit persons and relaxed when cognitive abilities continue to decline and overall function deteriorates. A holistic multidisciplinary team approach that involves patients, their carers and integrated primary and secondary care services at one point of care that focuses on improving function and maintaining quality of life is needed.