Cognitive dysfunction is associated with poor diabetes control in older adults

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.

The effects of whole-body vibration therapy on immune and brain functioning: current insights in the underlying cellular and molecular mechanisms

Whole-body vibration (WBV) therapy is a way of passive exercise in which subjects are exposed to mild and well-controlled mechanical vibrations through a vibrating platform. For a long time, studies have focused on the effects and applications of WBV to enhance musculoskeletal performance in athletes and patients suffering from musculoskeletal disorders. Recent evidence points toward the positive effect of WBV on the brain and its therapeutic potential in brain disorders. Research being done in the field gradually reveals cellular and molecular mechanisms underlying WBV affecting the body and brain. Particularly, the influence of WBV on immune and brain function is a growing field that warrants an up-to-date and integrated review. Immune function is closely intertwined with brain functioning and plays a significant role in various brain disorders. Dysregulation of the immune response is linked to conditions such as neuroinflammation, neurodegenerative diseases, and mood disorders, highlighting the crucial connection between the immune system and the brain. This review aims to explore the impact of WBV on the cellular and molecular pathways involved in immune and brain functions. Understanding the effects of WBV at a cellular and molecular level will aid in optimizing WBV protocols to improve its therapeutic potential for brain disorders.

Cognitive Profile and Cardiovascular Risk Factors in Older Adults with Mild Cognitive Impairment

The prevalence of cardiovascular risk factors (CVRFs) in the older adults population and their specific impact on their cognitive profiles still requires further research. For this purpose, a cross-sectional study was carried out to describe the presence of CVRFs and their association with cognitive performance in a sample of older adults (65-85 years old) with Mild Cognitive Impairment (MCI). Participants (n = 185) were divided into three groups concerning their cardiovascular risk level determined by the presence of different CVRFs, including Type 2 Diabetes (T2D), dyslipidemia, hypertension, and obesity. The primary outcome measures were the participant's scores in the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Sociodemographic, clinical, and psychosocial data were collected. Non-parametrical statistical analyses and effect sizes were calculated. Findings revealed that a greater presence of CVRFs was not associated with a worse overall cognitive performance. High-risk patients were more likely to have significantly worse performance in the attentional domain compared to medium-risk (p = 0.029, r = 0.42) and compared to low-risk (p = 0.041, r = 0.35), specifically in the digits repetition subtest (p = 0.042). T2D alone was the CVRF associated with cognitive differences (p = 0.037, r = 0.32), possibly mediated by the duration of the condition. Consequently, a higher presence of CVRFs did not lead to a worse overall cognitive performance. However, high-risk individuals were more likely to experience cognitive impairment, particularly in the attentional domain. T2D played a significant role in these cognitive profile differences, possibly influenced by its duration.

Insulin-like growth factor-1 and cognition in normoglycemia, prediabetes, and type 2 diabetes mellitus

BACKGROUND

The relationship between insulin-like growth factor-1 (IGF-1) and cognition has been studied in healthy individuals, but not extensively with regards to insulin resistance and type 2 diabetes mellitus (T2DM). In this retrospective observational study, we investigated relationships of IGF-1 with memory and executive function across people with normoglycemia, prediabetes, and T2DM.

METHODS

Data from the Midlife in the United States (MIDUS) study were used. Episodic memory and executive function were assessed using the Brief Test of Adult Cognition by Telephone approximately 21.42 ± 12.10 months prior to measuring IGF-1 levels from a fasting blood sample. Normoglycemia was identified as individuals without a physician diagnosis of diabetes and glycated hemoglobin (HbA1c) ≤5.6%. Prediabetes was identified as those without a physician diagnosis of diabetes and HbA1c between 5.7%-6.4%. T2DM was identified as anyone with a physician diagnosis of diabetes, or HbA1c ≥6.5%, or anyone using an oral hypoglycemic medication. The associations were assessed using linear regressions controlling for age, sex, education, body mass index, C-reactive protein, HbA1c or homeostatic model of insulin resistance, MIDUS wave, exercise, smoking status, sleep quality, alcohol intake, oral hypoglycemic use, and insulin use.

RESULTS

The study included 1400 participants, which consisted of 583 normoglycemic (48.4% female, mean age 51.0 ± 12.2 years), 512 prediabetes (58.4% female, mean age 57.3 ± 11.8 years), and 305 T2DM participants (53.8% female, mean age 57.6 ± 11.5 years). Peripheral IGF-1 concentrations were lower (F2,1397 = 28.29, p < 0.001) in people with prediabetes or T2DM, vs. normoglycemia. Participants with prediabetes or T2DM had lower episodic memory (F2,1397 = 9.21, p < 0.001) and executive function (F2,1397 = 20.29, p < 0.001) composite z-scores than people with normoglycemia. Higher IGF-1 concentrations were associated with better executive performance in individuals with prediabetes (β = 0.115 [0.028, 0.202], p = 0.010), but not in individuals with normoglycemia or T2DM. An interaction between IGF-1 and sex in predicting executive function was observed in the prediabetes group (β = -0.344, p = 0.042), where the relationship was weaker in females (β = 0.106 [-0.012, 0.224], p = 0.077) than males (β = 0.251 [0.123, 0.380], p < 0.001). No associations were seen between IGF-1 and memory.

CONCLUSION

The results suggest that peripheral IGF-1 concentrations may be related to executive function, and that the relationship may be sex-specific and dependent on diabetes status.

Hippocampal proteins discovery of Panax quinquefolius and Acorus gramineus ameliorating cognitive impairment in diabetic rats

RATIONALE

Early diagnosis of diabetic cognitive impairment (DCI) and investigation of effective medicines are significant to prevent or delay the occurrence of irreversible dementia.

OBJECTIVES

In this study, proteomics was applied to investigate the changes of hippocampal proteins after administration of Panax quinquefolius-Acorus gramineus (PQ-AG) to DCI rats, with a view to discover the differentially expressed proteins of PQ-AG action and elucidated the potential biological relationships.

METHODS

The model and PQ-AG group rats were injected intraperitoneally with streptozotocin, and the PQ-AG group rats were continuously administered with PQ-AG. Social interaction and Morris water maze were performed to evaluate the behavior of rats on the 17th week after the model was established, and DCI rats were screened out from the model group by a screening approach. The hippocampal protein differences were investigated with proteomics in DCI and PQ-AG-treated rats.

RESULTS

The learning and memory abilities and contact duration of DCI rats were improved after 16 weeks of PQ-AG administration. Altogether, 9 and 17 differentially expressed proteins were observed in control versus DCI rats and in DCI versus PQ-AG-treated rats, respectively. Three proteins were confirmed with western blotting analyses. These proteins were mainly involved in the pathways of JAK-STAT, apoptosis, PI3K/AKT, fork-head box protein O3, fructose, and mannose metabolism.

CONCLUSIONS

This suggested that PQ-AG ameliorated cognitive impairment of diabetic rats by influencing the above pathways and providing an experimental basis for the mechanism of DCI and PQ-AG.

Geriatric Syndromes in Older Adults with Diabetes

Over one-quarter of adults ≥65 years old have diabetes in the United States. Guidelines recommend individualization of glycemic targets in older adults with diabetes as well as implementing treatment strategies that minimize risk for hypoglycemia. Patient-centered management decisions should be informed by comorbidities, the individual's capacity for self-care, and the presence of key geriatric syndromes that may impact self-management and patient safety. Key geriatric syndromes include cognitive impairment, depression, functional impairments (eg, vision, hearing, and mobility challenges), falls and fractures, polypharmacy, and urinary incontinence. Screening for geriatric syndromes in older adults is recommended to inform treatment strategies and optimize outcomes.

Amygdala activity and amygdala-hippocampus connectivity: Metabolic diseases, dementia, and neuropsychiatric issues

With rapid aging of the population worldwide, the number of people with dementia is dramatically increasing. Some studies have emphasized that metabolic syndrome, which includes obesity and diabetes, leads to increased risks of dementia and cognitive decline. Factors such as insulin resistance, hyperglycemia, high blood pressure, dyslipidemia, and central obesity in metabolic syndrome are associated with synaptic failure, neuroinflammation, and imbalanced neurotransmitter levels, leading to the progression of dementia. Due to the positive correlation between diabetes and dementia, some studies have called it "type 3 diabetes". Recently, the number of patients with cognitive decline due to metabolic imbalances has considerably increased. In addition, recent studies have reported that neuropsychiatric issues such as anxiety, depressive behavior, and impaired attention are common factors in patients with metabolic disease and those with dementia. In the central nervous system (CNS), the amygdala is a central region that regulates emotional memory, mood disorders, anxiety, attention, and cognitive function. The connectivity of the amygdala with other brain regions, such as the hippocampus, and the activity of the amygdala contribute to diverse neuropathological and neuropsychiatric issues. Thus, this review summarizes the significant consequences of the critical roles of amygdala connectivity in both metabolic syndromes and dementia. Further studies on amygdala function in metabolic imbalance-related dementia are needed to treat neuropsychiatric problems in patients with this type of dementia.

A critical review of the relationship between type 1 diabetes mellitus, inhibition, and behavioral management

Type 1 diabetes mellitus (T1DM) is a chronic and lifelong condition that requires adequate behavior management in order to meet desired health outcomes. The effects of T1DM on the neurocognitive functioning of affected individuals raise concerns about how the disease may influence executive functioning. Inhibition is a core component of executive functioning, and plays a vital role in self-regulation and the restriction of impulsive behaviors. Inhibition may thus play a vital role in the behavior management of people with T1DM. The aim of this study was to identify current gaps in existing knowledge regarding the relationship between T1DM, inhibition, and behavior management. This study employed a critical review design to analyze and synthesize the current scientific literature. Twelve studies were identified through an appraisal process, and the data extracted were thematically analyzed and integrated. The findings of this study indicate that a possible cycle arises between these three constructs, in which T1DM affects inhibition, inhibition affects behavior management, and poor behavior management affects inhibition. It is recommended that future research should focus more specifically on this relationship.

Type 2 diabetes mellitus and cognitive function: understanding the connections

PURPOSE OF REVIEW

To review the connection between type 2 diabetes and cognitive dysfunction, including its epidemiology, potential mechanisms of pathophysiology, risk factors, possible prevention, and treatment considerations.

RECENT FINDINGS

Diabetes is a risk factor for mild cognitive decline, in addition to Alzheimer's disease and vascular dementia. Duration of diabetes, concomitant vascular or associated co-morbidities, hyper- and hypoglycemia may lead to worsening cognitive dysfunction. Unfortunately, there is a lack of evidence-based guidance on the prevention of cognitive dysfunction in the diabetes population. Studies of diabetes medications, including metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose cotransporter-2 inhibitors (SGLT2) have shown some benefit with cardiovascular morbidity and may affect cognition. In the absence of clearly defined preventive tools, diabetes practice guidelines recommend annual cognitive screening as standard of care in adults with diabetes aged 65 years or older.

SUMMARY

People living with diabetes are at risk for significant decline in cognitive function. Epidemiology and risk factors are well defined. Prevention and treatment strategies are limited and require further study.

Association between dietary inflammatory index and cognitive impairment: A meta-analysis

Aims

Cognitive impairment is an increasingly urgent global public health challenge. Dietary Inflammatory Index (DII) is a literature-derived score that links diet to inflammation. The relationship between DII and cognitive impairment remains controversial. Therefore, our study aimed to analysis the role of DII on the risk of cognitive impairment by meta-analysis.

Methods

PubMed, Cochrane Library, MEDLINE, Web of Science and EMBASE databases were searched up to July 2022. Newcastle-Ottawa scale (NOS) and Joanna Briggs Institute (JBI) Checklist were performed to estimate the quality of studies.

Results

Nine observational studies with 19,379 subjects were included. Our study found that higher DII could elevate the risk of cognitive impairment (OR = 1.46, 95%CI = 1.26, 1.69). Meanwhile, the OR of cognitive impairment was 1.49 (95%CI = 1.21, 1.83) for cross-sectional studies and 1.42 (95%CI = 1.12, 1.79) for cohort studies, respectively.

Conclusion

Our meta-analysis indicated that higher DII (indicating a more pro-inflammatory diet) is related to increased risk of cognitive impairment.

Comorbidities Incorporated to Improve Prediction for Prevalent Mild Cognitive Impairment and Alzheimer's Disease in the HABS-HD Study

BACKGROUND

Blood biomarkers have the potential to transform Alzheimer's disease (AD) diagnosis and monitoring, yet their integration with common medical comorbidities remains insufficiently explored.

OBJECTIVE

This study aims to enhance blood biomarkers' sensitivity, specificity, and predictive performance by incorporating comorbidities. We assess this integration's efficacy in diagnostic classification using machine learning, hypothesizing that it can identify a confident set of predictive features.

METHODS

We analyzed data from 1,705 participants in the Health and Aging Brain Study-Health Disparities, including 116 AD patients, 261 with mild cognitive impairment, and 1,328 cognitively normal controls. Blood samples were assayed using electrochemiluminescence and single molecule array technology, alongside comorbidity data gathered through clinical interviews and medical records. We visually explored blood biomarker and comorbidity characteristics, developed a Feature Importance and SVM-based Leave-One-Out Recursive Feature Elimination (FI-SVM-RFE-LOO) method to optimize feature selection, and compared four models: Biomarker Only, Comorbidity Only, Biomarker and Comorbidity, and Feature-Selected Biomarker and Comorbidity.

RESULTS

The combination model incorporating 17 blood biomarkers and 12 comorbidity variables outperformed single-modal models, with NPV12 at 92.78%, AUC at 67.59%, and Sensitivity at 65.70%. Feature selection led to 22 chosen features, resulting in the highest performance, with NPV12 at 93.76%, AUC at 69.22%, and Sensitivity at 70.69%. Additionally, interpretative machine learning highlighted factors contributing to improved prediction performance.

CONCLUSIONS

In conclusion, combining feature-selected biomarkers and comorbidities enhances prediction performance, while feature selection optimizes their integration. These findings hold promise for understanding AD pathophysiology and advancing preventive treatments.

Medical comorbidities and ethnicity impact plasma Alzheimer's disease biomarkers: Important considerations for clinical trials and practice

INTRODUCTION

Despite the clinical implementation, there remain significant gaps in our knowledge regarding the impact of race/ethnicity or common medical comorbidity on plasma Alzheimer's disease (AD) biomarkers.

METHODS

Plasma biomarkers of amyloid beta (Aβ)_40, Aβ₄₂ , total tau, and neurofilament light chain (NfL) were measured across cognitively normal Mexican Americans (n = 445) and non-Hispanic Whites (n = 520).

RESULTS

Dyslipidemia was associated with elevated Aβ₄₀ (P = .01) and Aβ₄₂ (P = .001) while hypertension was associated with elevated Aβ₄₀ (P = .003), Aβ₄₂ (P < .001), and total tau (P = .002) levels. Diabetes was associated with higher Aβ₄₀ (P < .001), Aβ₄₂ (P < .001), total tau (P < .001), and NfL (P < .001) levels. Chronic kidney disease (CKD) was associated with elevations in Aβ₄₀ (P < .001), Aβ₄₂ (P < .001), total tau (P < .001), and NfL (P < .001) levels. Mexican Americans had significantly lower Aβ₄₀ (P < .001) and higher total tau (P = .005) levels.

DISCUSSION

Plasma AD biomarkers vary significantly in association with common medical comorbidities as well as ethnicity. These findings are important for those using these biomarkers in clinical practice and clinical trials.

Association of early-onset Type 2 diabetes with cognitive impairment is partially mediated by increased pulse pressure

AIMS

Type 2 diabetes mellitus (T2DM) has been shown to be associated with cognitive decline and dementia. As earlier onset of diabetes implies a longer disease duration and an increased risk to complications, we sought to investigate the effect of T2DM onset on cognitive function of our patients.

METHODS

We administered the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to T2DM patients aged 45-85 from our SMART2D cohort. We assessed the association of the T2DM onset age (both continuous and stratified into 3 groups: early-onset ≤40 (n = 326), middle-aged onset 41-64 (n = 703) and late-onset ≥65 years old (n = 38)) and RBANS cognitive indices in 1067 patients. Potential mediation of this association by vascular compliance using mediation analysis was investigated.

RESULTS

T2DM onset associates significantly with RBANS total score. Patients with early T2DM onset have lower RBANS total score as compared to patients with middle-aged onset (β = -2.01, p = 0.0102) and those with late-onset (β = -5.80, p = 0.005). This association was partially mediated by pulse pressure index (25.8%), with indirect effect of 0.028 (Bootstrapped-CI: 0.008-0.047).

CONCLUSIONS

Association of early-onset T2DM with cognitive impairment is partly mediated by diminished vascular compliance. Appropriate screening and assessment of cognitive function is important for early intervention and management of cognitive impairment.

ASSOCIATION BETWEEN RISK FACTORS AND COGNITIVE IMPAIRMENT AMONG TYPE 2 DIABETES MELLITUS PATIENTS

Background: Diabetes mellitus type 2 is considered as one of the leading causes of illness and mortality through over the globe. Diabetic retinopathy, neuropathy, and nephropathy are all effectively screened on a regular basis. Recent research have shown that cognitive deterioration can occur in patients with diabetes and that it can go unnoticed for a long time, implying that routine screening is necessary. Methodology: An observational cross sectional study was conducted among 158 patients with complaint of T2DM aged between 60-79 years of age were found with cognitive impairment on the basis of MMSE score in a tertiary care centre. Detailed history along with laboratory and biochemical data were taken from patients after taking written informed consent and approval of Institutional Ethical committee through the pre-structured questionnaire. Results: Mild cognitive impairment was noted in 88 (55.69%) type 2 diabetes mellitus patients and Normal cognitive function in 70 (44.30%). Those with MCI had higher HbA1c (6.57 ± 1.27 vs. 6.13 ± 1.22), higher FBS (148.34 ± 18.61 vs. 145.25 ± 16.31), PPBS (173.91 ± 42.64 vs. 167.47 ± 38.15) and TNF-α (79.32 ± 8.74 vs. 72.98 ± 6.76), which were statistically significant. The cognitive domains of executive function, naming, attention, language, and memory showed a statistically significant difference between those with Mild cognitive impairment and Normal cognitive function. There were no differences in the mean age, duration of disease, and education level between the groups. Conclusion: The significant prevalence of Mild cognitive impairment in type 2 diabetes patients emphasizes the value of routine screening of cognitive functions. Further research into the link between cognitive impairment and poor blood glucose control is needed to see if improving blood glucose control can assist in enhancing cognitive functions.

Low serum apelin levels are associated with mild cognitive impairment in Type 2 diabetic patients

BACKGROUND

Apelin is a new adipokine that is secreted by adipocytes, and is associated with insulin resistance (IR), inflammation, and obesity. This study was designed to investigate the role of apelin in type 2 diabetes mellitus (T2DM) patients with mild cognitive impairment (MCI).

METHODS

A total of 235 patients with T2DM were included. The cognitive function of patients was evaluated using Montreal Cognitive Assessment (MoCA) tool, then patients were divided into MCI group and non-MCI group according to the MoCA score. Blood sample was analyzed for the level of apelin by enzyme-linked immunosorbent assay (ELISA).

RESULTS

The MCI group (n = 73) presented lower serum apelin levels compared with the patients with normal cognitive function (P < 0.001). Apelin levels showed significantly negative correlation with diabetes duration, triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C, creatinine and high sensitivity C-reactive protein (hs-CRP), and positive correlation with high-density lipoprotein cholesterol (HDL-C) and brain-derived neurotrophic factor (BDNF). Multivariable logistic regression analysis indicated that serum apelin (OR = 0.304, 95%CI: 0.104-0.886, P = 0.029), as well as education levels, diabetes duration, cardiovascular disease, serum HbA1c, HDL-C, creatinine, and BDNF, were independent risk factors of MCI in patients with T2DM.

CONCLUSIONS

Serum apelin level is reduced in T2DM patients with MCI. Apelin might has protective effect against cognitive impairment and serve as a serum biomarker of T2DM.

Aberrant Brain Spontaneous Activity and Synchronization in Type 2 Diabetes Mellitus Subjects Without Mild Cognitive Impairment

Objective: We aimed to explore whether the percent amplitude of fluctuation (PerAF) measurement could provide supplementary information for amplitude of low-frequency fluctuation (ALFF) about spontaneous activity alteration in type 2 diabetes mellitus (T2DM) subjects without mild cognitive impairment (MCI). Then we further evaluated the synchronization through the method of functional connectivity (FC) to better demonstrate brain changes in a more comprehensive manner in T2DM. Methods: Thirty T2DM subjects without MCI and thirty well-matched healthy subjects were recruited in this study. Subjects' clinical data, neuropsychological test results, and resting-state functional magnetic resonance imaging (rs-fMRI) data were acquired. Voxel-based group difference comparisons between PerAF and ALFF were conducted. Then, seed-based FC between the recognized brain regions based on PerAF and ALFF and the rest of the whole brain was performed. Results: Compared with healthy group, T2DM group had significantly decreased PerAF in the bilateral middle occipital gyrus and the right calcarine, increased ALFF in the right orbital inferior frontal gyrus and decreased ALFF in the right calcarine. Seed-based FC analysis showed that the right middle occipital gyrus of T2DM subjects exhibited significantly decreased FC with the right caudate nucleus and right putamen. According to the partial correlation analyses, hemoglobin A1c (HbA1c) and immediate memory scores on the auditory verbal learning test (AVLT) were negatively correlated in the T2DM group. However, we found that total cholesterol was positively correlated with symbol digit test (SDT) scores. Conclusion: PerAF and ALFF may have different sensitivities in detecting the abnormal spontaneous brain activity in T2DM subjects. We suggest PerAF values may add supplementary information and indicate additional potential neuronal spontaneous activity in T2DM subjects without MCI, which may provide new insights into the neuroimaging mechanisms underlying early diabetes-associated cognitive decline.

Glycemic control is not associated with neurocognitive decline after cardiac surgery

BACKGROUND

Whether perioperative glycemic control is associated with neurocognitive decline (NCD) after cardiac surgery was examined.

METHODS

Thirty patients undergoing cardiac surgery utilizing cardiopulmonary bypass (CPB) were screened for NCD preoperatively and on postoperative day 4 (POD4). Indices of glucose control were examined. Serum cytokine levels were measured and human transcriptome analysis was performed on blood samples. Neurocognitive data are presented as a change from baseline to POD4 in a score standardized with respect to age and gender.

RESULTS

A decline in neurocognitive function was identified in 73% (22/30) of patients on POD4. There was no difference in neurocognitive function between patients with elevated HbA1c levels preoperatively (p = .973) or elevated fasting blood glucose levels the morning of surgery (>126 mg/dl, p = .910), or a higher maximum blood glucose levels during CPB (>180 mg/dl, p = .252), or higher average glucose levels during CPB (>160 mg/dl, p = .639). Patients with postoperative leukocytosis (WBC ≥ 10.5) had more NCD when compared to their baseline function (p = .03). Patients with elevated IL-8 levels at 6 h postoperatively had a significant decline in NCD at POD4 (p = .04). Human transcriptome analysis demonstrated unique and differential patterns of gene expression in patients depending on the presence of DM and NCD.

CONCLUSIONS

Perioperative glycemic control does not have an effect on NCD soon after cardiac surgery. The profile of gene expression was altered in patients with NCD with or without diabetes.

Kidney Function and Risk of Physical and Cognitive Impairment in Older Persons with Type 2 Diabetes at an Outpatient Clinic with Geriatric Assessment Implementation

PURPOSE

Diabetes is associated with an increased risk of cognitive and physical functional decline that may impede disease self-management. By incorporating cognitive and physical function assessment, this study aimed to evaluate prevalence and factors associated with cognitive and physical dysfunction in older diabetic people.

METHODS

The cross-sectional study was performed from August 1, 2017 to November 30, 2018. The patients aged 65 years or older with type 2 diabetes mellitus were enrolled and the disease was routinely evaluated by blood hemoglobin A1c (A1C), blood pressure, lipids, and kidney function measured by estimated glomerular filtration rate (eGFR) and urinary albumin-creatinine rate (UACR). Besides, cognitive dysfunction through Mini-mental State Examination (MMSE), and functional disabilities by Activities of Daily Living (ADL) questionnaire were assessed simultaneously.

RESULTS

Among 863 patients (48.3% men) with a median age of 72.0 years (interquartile range or IQR: 67.0-78.0 years), 159 (18.5%) had cognitive impairment assessed by MMSE, while 40 (4.6%) experienced at least one problem in ADL. With different A1C stratifications, it was shown that both MMSE and ADL scores were associated with glycemic control. Patients with impaired MMSE and ADL scores were older, had lower eGFR, lower blood pressure, and higher UACR levels. After adjustment of possible confounders, it was shown that age and eGFR predicted MMSE and ADL score impairment.

CONCLUSION

By incorporating physical and cognitive function screening program into routine care at a diabetes outpatient clinic, our study found that both cognitive and physical function impairment were common in older diabetic patients, and their relevant factors, including older age, and lower eGFR. It was recommended that in older individuals with diabetes, particularly those with risk factors, an additional assessment of cognitive and physical functions can be integrated into routine clinical process to provide more comprehensive management plans.

Truncal Fat and Frailty Are Important Predictors of Cognitive Performance among Aging Adults with Obesity

OBJECTIVES

To explore associations among cognition, frailty, and obesity in older adults.

DESIGN

Descriptive, secondary analysis of baseline data from two related lifestyle intervention trials.

SETTING

Clinical study open to civilian population through the Center for Translational Research on Inflammatory Diseases at the Veterans Affairs Medical Center in Houston, TX.

PARTICIPANTS

One hundred eight community-dwelling adults with obesity, aged 65 or older, recruited consecutively from two lifestyle intervention trials.

MEASUREMENTS

Cognition was assessed using Composite Age-Adjusted Scale Score from the National Institutes of Health Toolbox Cognition Battery: Obesity was assessed by body mass index (BMI) and also by truncal fat mas via dual energy x-ray absorptiometry. Frailty was assessed using the Physical Performance Test.

RESULTS

A significant linear regression model for cognition revealed frailty as the strongest predictor, followed by sex, and then truncal fat (R2=0.340, p<0.001).

CONCLUSION

Cognition among community-dwelling older adults with obese BMI may worsen with greater truncal fat mass. Frailty appears to be an important predictor of cognitive performance in this population.

Management of Hyperglycemia in Older Adults with Type 2 Diabetes

The increasing incidence of type 2 diabetes in the general population as well as enhanced life expectancy has resulted in a rapid rise in the prevalence of diabetes in the older population. Diabetes causes significant morbidity and impairs quality of life. Managing diabetes in older adults is a daunting task due to unique health and psychosocial challenges. Medical management is complicated by polypharmacy, cognitive impairment, urinary incontinence, injurious falls, and persistent pain. Health care providers now have several traditional and contemporary pharmacologic agents to manage diabetes. Avoidance of hypoglycemia is critical; however, evidence-based guidelines are lacking due to the paucity of clinical trials in older adults. For many in this population, maintaining independence is more important than adherence to published guidelines to prevent diabetes complications. The goal of diabetes care in older adults is to enhance the quality of life without subjecting these patients to intrusive and complicated interventions. Recent technological advancements such as continuous glucose monitoring systems can have crucial supplementary benefits in the geriatric population.

Spot Urine Albumin Creatinine Ratio can be a Predictor of Cognitive Function in Type 2 Diabetes Mellitus

Introduction

In diabetes mellitus (DM), the underlying pathophysiology of albuminuria and cognitive dysfunction is similar. So, we hypothesized that urinary albumin excretion (UAE) could be linked to cognitive dysfunction in type 2 diabetes mellitus.

Methods and Materials

It was a hospital-based observational study. Patient aged 40-60 years with type 2 DM were included in this study. Complete assessment with detailed history, physical examination, and necessary biochemical investigations including spot urine albumin creatinine ratio (uACR) was done. Cognitive status was determined in all the individuals with the application of Hindi translated version of the mini-mental status examination (MMSE) questionnaire.

Results

In 80 patients, the mean MMSE score was 25.37 ± 3.34. Cognitive dysfunction (score <26) was present in 45% of individuals. Spot uACR, estimated glomerular filtration rate (eGFR), glycated hemoglobin (HbA1c), presence of retinopathy and dyslipidemia were significantly different between the normal and subnormal scoring groups. On multivariate analysis spot uACR was found to be independently predicting odds of developing cognitive dysfunction (OR 1.01, CI 1.004-1.022; P = 0.001). The mean MMSE scores in normo-albuminuric (n = 15), moderately increased albuminuric (n = 48) and severely albuminuric (n = 17) patients were 28.00 ± 1.60, 25.54 ± 3.33 and 22.58 ± 2.31, respectively, which were significantly different among the three groups (P < 0.001).

Conclusions

Spot uACR could be helpful in predicting cognitive decline in people with type 2 DM.

Type 2 diabetes mellitus in older adults: clinical considerations and management

The past 50 years have seen a growing ageing population with an increasing prevalence of type 2 diabetes mellitus (T2DM); now, nearly half of all individuals with diabetes mellitus are older adults (aged ≥65 years). Older adults with T2DM present particularly difficult challenges. For example, the accentuated heterogeneity of these patients, the potential presence of multiple comorbidities, the increased susceptibility to hypoglycaemia, the increased dependence on care and the effect of frailty all add to the complexity of managing diabetes mellitus in this age group. In this Review, we offer an update on the key pathophysiological mechanisms associated with T2DM in older people. We then evaluate new evidence relating particularly to the effects of frailty and sarcopenia, the clinical difficulties of age-associated comorbidities, and the implications for existing guidelines and therapeutic options. Our conclusions will focus on the effect of T2DM on an ageing society.

Legacy of a 10-Year Multidomain Lifestyle Intervention on the Cognitive Trajectories of Individuals with Overweight/Obesity and Type 2 Diabetes Mellitus

INTRODUCTION

Weight loss and increased physical activity interventions are commonly recommended for individuals with type 2 diabetes (T2D) and overweight or obesity. We examined the impact of randomization to an intensive lifestyle intervention (ILI) on trajectories of cognitive function over 10 years in a cohort of participants in a randomized clinical trial who had T2D and overweight/obesity at baseline.

METHODS

Participants aged 45-76 years were enrolled in 2001-2004 and were randomized to the ILI or a diabetes support and education (DSE) condition. Cognitive function was assessed in 3,938 participants at up to 4 time points 8-18 years after randomization. General linear mixed effects models examined cognitive trajectories over time. Subgroup analyses focused on sex, individuals with baseline body mass index >30, those carrying the APOE ε4 allele, and those with a baseline history of cardiovascular disease (CVD).

RESULTS

Overall, there were no differences in the rate of cognitive decline by intervention arm. Subgroup analyses showed that participants who had a baseline history of CVD and were randomized to the ILI arm of the study performed significantly worse on the Stroop Color Word Test than those in the DSE arm.

DISCUSSION/CONCLUSIONS

The ILI did not result in preserved cognitive function or slower rates of cognitive decline in this cohort of individuals who had T2D and were overweight or obese at baseline.

Diabetes Distress, Daily Functioning, and A1C in Older Black Individuals With Diabetes and Mild Cognitive Impairment

OBJECTIVE

The purpose of the cross-sectional study was to identify associations of diabetes distress, physical functioning, and cognition with A1C in older Black individuals with diabetes and mild cognitive impairment.

METHODS

The investigators analyzed previously collected data from 101 older Black individuals with diabetes and mild cognitive impairment. Participants were administered surveys at baseline to assess diabetes distress, physical functioning, and cognitive functioning and had A1C testing.

RESULTS

The mean age of participants was 68.4 years, and 62% were women. Participants with higher A1C showed worse self-reported daily functioning (r = -0.28, P <0.01). Three of four diabetes distress factors were positively correlated with A1C: emotional (r = 0.28, P <0.01), regimen-related (r = 0.33, P <0.01), and interpersonal distress (r = 0.27, P <0.01). In a multivariate regression with A1C as the dependent variable, only regimen-related diabetes distress (β = 0.32, P = 0.008) and self-reported daily functioning (β = -0.33, P = 0.019) were significant.

CONCLUSION

Regimen-related diabetes distress and self-reported daily functioning were found to compromise glycemic control in Black individuals with mild cognitive impairment and diabetes. This finding suggests that diabetes interventions should be multifaceted to improve glycemic control in the high-risk population of Black individuals with diabetes.

A Link Between Brain Insulin Resistance and Cognitive Dysfunctions: Targeting Ca2+/cAMP Signalling

BACKGROUND

A correlation between cognitive dysfunctions and brain insulin resistance has been established by several clinical and experimental studies. Consistent data support that people diagnosed with brain insulin resistance, resulted from diabetes, have shown an increased risk of presenting cognitive dysfunctions, clinical signs of dementia and depression, then speculating a role of dysregulations related to insulin signalling in these diseases. Furthermore, it is currently discussed that Ca2+ signalling, and its dysregulations, may be a factor which could correlate with brain insulin resistance and cognitive dysfunctions.

OBJECTIVE

Following this, revealing this interplay between these diseases may provide novel insights into the pathogenesis of such diseases.

METHODS

Publications covering topics such as Ca2+ signalling, diabetes, depression and dementia (alone or combined) were collected by searching PubMed and EMBASE.

RESULTS

The controlling of both neurotransmitters/hormones release and neuronal death could be achieved through modulating Ca2+ and cAMP signalling pathways (Ca2+/cAMP signalling).

CONCLUSION

Taking into account our previous reports on Ca2+/cAMP signalling, and considering a limited discussion in the literature on the role of Ca2+/cAMP signalling in the link between cognitive dysfunctions and brain insulin resistance, this article has comprehensively discussed the role of these signalling pathways in this link (between cognitive dysfunctions and brain insulin resistance).

Life satisfaction and emotional distress in people living with type 2 diabetes mellitus: The mediating effect of cognitive function

AIMS AND OBJECTIVES

To explore the relationships among emotional distress, cognitive function and life satisfaction in people living with type 2 diabetes mellitus (T2DM), and to verify the mediating role of cognitive function.

BACKGROUND

People with T2DM face cognitive decline caused by age and disease complications. Emotional distress will reduce their life satisfaction, and cognitive function will also affect the life satisfaction, but whether cognitive function mediates the effect of emotional distress on life satisfaction has not been verified.

DESIGN

A cross-sectional study.

METHODS

A total of 200 people living with T2DM in the community by convenience sampling were enrolled from November-December 2018. Data collection involved a demographic and disease characteristic questionnaire, Problem Areas in Diabetes Scale, Subjective and Objective Cognitive Function Evaluation and Life Satisfaction Questionnaire. Data analysis included descriptive statistics and structural equation modelling. This report followed the STROBE guideline.

RESULTS

The emotional distress and subjective memory complaints of cognitive function had a significant positive correlation, while both emotional distress and cognitive function showed significant negative correlations with life satisfaction. In addition, cognitive function completely mediated the relationship between emotional distress and life satisfaction.

CONCLUSION

The cognitive function played a mediating role in life satisfaction and explains how emotional distress affects life satisfaction of people with T2DM. Therefore, it is suggested that diabetes nurses should early identify the decline of cognitive function, and to intervene at an early stage.

RELEVANCE TO CLINICAL PRACTICE

This study provides opinions on the mediating factors of cognitive function. Coping strategies and supporting resources to help the T2DM people to improve their life satisfaction are suggested.

Diabetes and inflammatory diseases: An overview from the perspective of Ca2+/3'-5'-cyclic adenosine monophosphate signaling

A large amount of evidence has supported a clinical link between diabetes and inflammatory diseases, e.g., cancer, dementia, and hypertension. In addition, it is also suggested that dysregulations related to Ca²⁺ signaling could link these diseases, in addition to 3'-5'-cyclic adenosine monophosphate (cAMP) signaling pathways. Thus, revealing this interplay between diabetes and inflammatory diseases may provide novel insights into the pathogenesis of these diseases. Publications involving signaling pathways related to Ca²⁺ and cAMP, inflammation, diabetes, dementia, cancer, and hypertension (alone or combined) were collected by searching PubMed and EMBASE. Both signaling pathways, Ca²⁺ and cAMP signaling, control the release of neurotransmitters and hormones, in addition to neurodegeneration, and tumor growth. Furthermore, there is a clear relationship between Ca²⁺ signaling, e.g., increased Ca²⁺ signals, and inflammatory responses. cAMP also regulates pro- and anti-inflammatory responses. Due to the experience of our group in this field, this article discusses the role of Ca²⁺ and cAMP signaling in the correlation between diabetes and inflammatory diseases, including its pharmacological implications. As a novelty, this article also includes: (1) A timeline of the major events in Ca²⁺/cAMP signaling; and (2) As coronavirus disease 2019 (COVID-19) is an emerging and rapidly evolving situation, this article also discusses recent reports on the role of Ca²⁺ channel blockers for preventing Ca²⁺ signaling disruption due to COVID-19, including the correlation between COVID-19 and diabetes.

Metabolic syndrome and cognitive performance across the adult lifespan

Metabolic Syndrome (MetS) is associated with increased rates of mortality and increased risk for developing dementia. Changes in brain structure and cognitive functioning have been reported within the literature. However, research examining cognitive performance in individuals with MetS is limited, inconclusive, and focuses primarily on older cohorts. As such, the effect of MetS on cognitive functioning earlier in the lifespan is unclear. This study aimed to investigate cognitive performance in young, middle-aged, and older adults with multiple metabolic and vascular risk factors in a sample of community dwelling participants (N = 128). Participants were administered a comprehensive neuropsychological battery and self-report measures. As expected, older adults performed more poorly than young and middle-aged adults across most assessments. Relative to controls, individuals with MetS reported greater hunger and disinhibited eating. MetS participants performed more poorly on Color-Word Interference: Inhibition. Additionally, when weight was accounted for, there was a significant relationship between MetS and select executive functioning tasks in middle-aged adults. These findings suggest that aspects of executive functioning may be impaired in MetS and could be further impacted by excess weight in middle-age. Future studies aimed at investigating potential causal relationships between metabolic and vascular risk factors, disinhibited eating, and executive dysfunction may provide insight into effective intervention targets to prevent MetS.

Emergency department visits in African Americans with mild cognitive impairment and diabetes

AIMS

Dementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes.

METHODS

This study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101).

RESULTS

Over one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons).

CONCLUSIONS

This study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Foot Examination for Older Adults

The foot changes with age. Foot disorders in older adults are associated with falls, lower limb ulcers, and pain. Physical examination of the feet as part of the routine assessment of older adults is imperative to detect foot problems. Foot pain and pathologies are common in older adults. Regular foot care is important to prevent these issues. However, some older adults may find it difficult to complete foot care, including cutting toenails. Regular foot examination can detect common foot problems, functional decline, and is recommended for preventing falls. We describe a technique for performing a focused examination of the feet for older adults. This review addresses current podiatric issues in older patient populations and describes a method for foot examination to address the needs of older adults that can be incorporated into patient assessments in any clinical setting.

Relationships Between Cognitive Impairment and Self-Management in Older Adults With Type 2 Diabetes: An Integrative Review

Cognitive impairment is common in older adults with diabetes and is likely to negatively affect their daily diabetes self-management behaviors (DSMB). The primary aim of this integrative review was to summarize and synthesize the current state of knowledge about relationships between cognitive impairment and DSMB in older adults with type 2 diabetes. The review was guided by Whittemore and Knafl's 2005 framework, and study quality was evaluated using the Crowe Critical Appraisal Tool. Of 27 studies reviewed, 24 were quantitative, and three were qualitative. Heterogeneity was noted in study design, participant characteristics, and measures of cognitive function and DSMB. Overall, global cognitive impairment and executive function impairment related particularly to poor medication management and glucose self-monitoring. The findings supported the need for routine cognitive assessment of older adults with diabetes, but more longitudinal and interventional studies are needed to better define cognitive impairment-DSMB relationships. [Research in Gerontological Nursing, 14(2), 104-112.].

Evolution in geriatric syndromes and association with survival over 5 years in the GERODIAB cohort of older French diabetic patients

PURPOSE

Although one in three patients with diabetes in Western countries is over 70 years-old, geriatric syndromes and their relationship with survival remain seldom studied. The present aim of the GERODIAB study was to examine the evolution of geriatric disorders and their relationship with survival in older type 2 patients with diabetes with initial sufficient autonomy.

METHODS

We performed a prospective, observational study over 5 years in patients with diabetes aged 70 years or above. A total of 987 consecutive type 2 patients with diabetes (mean age 77 years, range 70-94 years, 65.2% were 75 years and above, 52.1% women) were included from 56 French diabetic centres. Individual characteristics, diabetes parameters and geriatric parameters (autonomy, nutrition, cognitive alteration, depression, orthostatic hypotension, falls) were annually recorded. Survival was analysed using the Kaplan-Meier method and proportional hazards regression models.

RESULTS

Institutional living, impaired activity and difficulties in instrumental daily activity, cognitive disorders, malnutrition, depression, orthostatic hypotension and hypoglycaemia strongly increased during the follow-up. Institutional living, impaired activity and difficulties in instrumental daily activity, cognitive disorders and hypoglycaemia were strongly associated with reduced survival, but not falls. In hazard ratio models, living in an institution (HR = 2.39; CI = 1.77-3.24; p < 0.0001) and impaired Activity of Daily Living scale score were the most significant and independent predictors of death (HR = 1.59; CI = 1.19-2.13; p = 0.0016), associated with HbA1c ≥ 70 mmol/mol (HR = 1.62; CI = 1.12-2.36; p = 0.011).

CONCLUSION

Our findings show the considerable alteration of geriatric parameters and their relationship with decreased survival after a 5-year follow-up in type 2 patients with diabetes, independent of HbA1c and age. They, therefore, confirm the prognostic interest of using yearly geriatric markers in older diabetic patient management, especially the ADL, IADL and MMSE scales. Taking into account these prognostic parameters should contribute to target appropriate HbA1c goals.

TRIAL REGISTRATION

Registered at clinicaltrials.gov (21/01/2011): NCT01282060.

Efficacy of community-based self-care interventions to improve biophysical, psychosocial or behavioural outcomes among community-dwelling older adults with type 2 diabetes: A systematic review and meta-analysis

AIMS

This review assessed the efficacy of self-care interventions to improve biophysical, psychosocial or behavioural outcomes among older adults with diabetes.

METHODS

Computerised and manual searches were performed. A total of 18 randomised control trials were included in the review, of which eight were subsequently included in the meta-analysis.

RESULTS

Most studies were from the United States of America and adopted a collaborative approach with participants. The specific needs of older adults were often not considered, and there was a predominance of biophysical measures. Meta-analysis revealed that among intervention condition participants, there were improvements in HbA1c (pooled weighted mean difference (WMD) -0.33, 95%CI -0.48 to -0.17), systolic blood pressure (WMD -1.55, 95%CI -2.93 to -0.18), diastolic blood pressure (WMD -1.41 95%CI -2.08 to -0.20), triglyceride (WMD -13.25, 95%CI -23.31 to -3.20), high-density lipoprotein (WMD 2.05, 95%CI 1.04 to 3.06) and Diabetes Self-Care Activities score (mean 4.10, 95%CI 3.11 to 5.10) compared to the control group. There was no significant change for low-density lipoprotein (WMD -5.93, 95%CI -12.08 to 0.22).

CONCLUSIONS

While continuing to adopt a collaborative approach, future self-care interventions should incorporate psychosocial and behavioural outcomes, consider the specific needs of older adults, and focus on more ethnically diverse populations.

Glycemic Control is Related to Cognitive Dysfunction in Elderly People with Type 2 Diabetes Mellitus in a Rural Chinese Population

BACKGROUND

There is an increasing interest on Cognitive Impairment (CI) in patients with type 2 diabetes mellitus (T2DM), but evidence is conflicting regarding the association between CI and glycemic control.

OBJECTIVE

The present study aimed to estimate the prevalence of CI in patients with T2DM from northern rural China in order to determine whether cognitive dysfunction is related to glycemic control.

METHODS

First, we conducted a study with a cross-sectional design. We performed cluster random sampling of 1848 residents who were aged 60 years or older and lived in the countryside in China. All eligible participants with and without T2DM were interviewed and screened for cognitive function status. Diagnoses for dementia and Cognitive Impairment No Dementia (CIND) were based on the standard criteria. Second, on the basis of the results of the cross-sectional survey, we conducted a case-control study. In the T2DM group, we identified cases of T2DM with Cognitive Impairment (T2DM-CI), as well as cases of T2DM with normal cognition (T2DM-NC) to be used as controls. The effects of specific diabetes-related variables were examined. After matching for sex, age, and education level in the T2DM-CI and T2DM-NC groups, multivariate logistic regression analyses were performed to evaluate risk factors for T2DM-CI.

RESULTS

In the cross-sectional study, the prevalence of T2DM with CIND and dementia were 28.3% (95% CI: 23.5-33.2) and 9.5% (95% CI: 6.3-12.6), respectively. Compared with subjects without DM, the prevalence of CI in T2DM patients was more frequent than the prevalence of CI in the general population in almost every age group. In the case-control study, the multivariate logistic regression analyses showed that variables, including duration from diabetes onset, glycosylated hemoglobin A1c level (HbA1c), and severe hypoglycemia history, were significantly associated with an increased risk of CI in patients with T2DM (odds ratios [ORs] [95%CIs]: 1.67 [1.03-2.70], 1.40 [1.15-1.72], and 2.72 [1.02- 7.21], respectively [P <0.05]).

CONCLUSION

The present study demonstrates a high prevalence of CI in patients with T2DM among the elderly population of rural China. Glycemic control, including HbA1c and exposure to severe hypoglycemia, affected cognitive function in patients with T2DM.

Regional Brain Gray Matter Changes in Patients with Type 2 Diabetes Mellitus

Patients with Type 2 diabetes mellitus (T2DM) show cognitive and mood impairment, indicating potential for brain injury in regions that control these functions. However, brain tissue integrity in cognition, anxiety, and depression regulatory sites, and their associations with these functional deficits in T2DM subjects remain unclear. We examined gray matter (GM) changes in 34 T2DM and 88 control subjects using high-resolution T1-weighted images, collected from a 3.0-Tesla magnetic resonance imaging scanner, and assessed anxiety [Beck Anxiety Inventory], depressive symptoms [Beck Depression Inventory-II], and cognition [Montreal Cognitive Assessment]. We also investigated relationships between GM status of cognitive and mood control sites and these scores in T2DM. Significantly increased anxiety (p = 0.003) and depression (p = 0.001), and reduced cognition (p = 0.002) appeared in T2DM over controls. Decreased GM volumes appeared in several regions in T2DM patients, including the prefrontal, hippocampus, amygdala, insular, cingulate, cerebellum, caudate, basal-forebrain, and thalamus areas (p < 0.01). GM volumes were significantly associated with anxiety (r = -0.456,p = 0.009), depression (r = -0.465,p = 0.01), and cognition (r = 0.455,p = 0.009) scores in regions associated with those regulations (prefrontal cortices, hippocampus, para hippocampus, amygdala, insula, cingulate, caudate, thalamus, and cerebellum) in T2DM patients. Patients with T2DM show brain damage in regions that are involved in cognition, anxiety, and depression control, and these tissue alterations are associated with functional deficits. The findings indicate that mood and cognitive deficits in T2DM patients has brain structural basis in the condition.

Effects of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus: A systematic review and meta-analysis

Introduction

Previous evidence has shown significant effects of exercise, cognitive and dual-task training for improving cognition in healthy cohorts. The effects of these types of interventions in type 2 diabetes mellitus is unclear. The aim of this research was to systematically review evidence, and estimate the effect, of exercise, cognitive, and dual-task interventions on cognition in type 2 diabetes mellitus.

Method

Electronic databases including PubMed, EMBASE, CINAHL, PsycINFO, SPORTDiscus, and MEDLINE were searched for ongoing and completed interventional trials investigating the effect of either an exercise, cognitive or dual-task intervention on cognition in type 2 diabetes mellitus.

Results

Nine trials met the inclusion criteria–one dual-task, two cognitive, and six exercise. Meta-analyses of exercise trials showed no significant effects of exercise on measures of executive function (Stroop task, SMD = -0.31, 95% CI -0.71–0.09, P = 0.13, trail making test part A SMD = 0.28, 95% CI -0.20–0.77 P = 0.25, trail making test part B SMD = -0.15, 95% CI -0.64–0.34 P = 0.54, digit symbol SMD = 0.09, 95% CI -0.39–0.57 P = 0.72), and memory (immediate memory SMD = 0.20, 95% CI -0.28–0.69, P = 0.41 and delayed memory SMD = -0.06, 95% CI -0.55–0.42, P = 0.80). A meta-analysis could not be conducted using cognitive or dual-task data, but individual trials did report a favourable effect of interventions on cognition. Risk of bias was considered moderate to high for the majority of included trials.

Conclusions

Meta-analyses of exercise trials identified a small effect size (0.31), which whilst not significant warrants further investigation. Larger and more robust trials are needed that report evidence using appropriate reporting guidelines (e.g. CONSORT) to increase confidence in the validity of results.

Trial registration

Protocol was registered (CRD42017058526) on the International Prospective Register of Systematic Reviews (http://www.crd.york.ac.uk/PROSPERO).

Computerized Cognitive Training for Older Adults at Higher Dementia Risk due to Diabetes: Findings From a Randomized Controlled Trial

BACKGROUND

To evaluate the effects of adaptive and tailored computerized cognitive training on cognition and disease self-management in older adults with diabetes.

METHODS

This was a single-blind trial. Eighty-four community-dwelling older adults with diabetes were randomized into a tailored and adaptive computerized cognitive training or a generic, non-tailored or adaptive computerized cognitive training condition. Both groups trained for 8 weeks on the commercially available CogniFit program and were supported by a range of behavior change techniques. Participants in each condition were further randomized into a global or cognition-specific self-efficacy intervention, or to a no self-efficacy condition. The primary outcome was global cognition immediately following the intervention. Secondary outcomes included diabetes self-management, meta-memory, mood, and self-efficacy. Assessments were conducted at baseline, immediately after the training, and at a 6-month follow-up.

RESULTS

Adherence and retention were lower in the generic computerized cognitive training condition, but the self-efficacy intervention was not associated with adherence. Moderate improvements in performance on a global cognitive composite at the posttreatment assessments were observed in both cognitive training conditions, with further small improvement observed at the 6-month follow-up. Results for diabetes self-management showed a modest improvement on self-rated diabetes care for both intervention conditions following the treatment, which was maintained at the 6-month follow-up.

CONCLUSIONS

Our findings suggest that older adults at higher dementia risk due to diabetes can show improvements in both cognition and disease self-management following home-based multidomain computerized cognitive training. These findings also suggest that adaptive difficulty and individual task tailoring may not be critical components of such interventions.

TRIAL REGISTRATION

NCT02709629.

The assessment and management of quality of life of older adults with diabetes mellitus

Introduction: As the population ages, the number of older adults with diabetes mellitus will continue to rise. The burden of diabetes on older adults is significant due to the disease itself, its complications, and its treatments. This is compounded by geriatric syndromes such as frailty and cognitive dysfunction. Consequently, health and diabetes-related quality of life (QoL) are diminished.Areas covered: This article reviews the value of assessing QoL in providing patient-centered care and the associations between QoL measures and health outcomes. The determinants of QoL particular to diabetes and the older population are reviewed, including psychosocial, physical, and cognitive burdens of diabetes and aging and the impact of hypoglycemia on QoL. Strategies are described to alleviate these burdens and improve QoL, and barriers to multidisciplinary patient-centered care are discussed. QoL measurement instruments are reviewed.Expert opinion: The goals of treating diabetes and its complications should be considered carefully along with each patient's capacity to withstand the burdens of treatment. This capacity is reduced by socioeconomic, psychological, cognitive, and physical factors reduces this capacity. Incorporating measurement of HRQoL into clinical practices is possible, but deficiencies in the systems of health-care delivery need to be addressed to facilitate their use.

Cynomolgus Monkeys With Spontaneous Type-2-Diabetes-Mellitus-Like Pathology Develop Alpha-Synuclein Alterations Reminiscent of Prodromal Parkinson's Disease and Related Diseases

Available evidence suggests that diabetes mellitus (DM) is a non-genetic risk factor for Parkinson’s disease (PD). PD and DM have shared similarities in pathogenetic mechanisms, including age, environmental factors, inflammatory reaction, and protein aggregation, etc. α-Synuclein is the primary protein component in the protein inclusions in PD, while islet amyloid polypeptide (IAPP) aggregates to form amyloid structures in β cells in type 2 diabetes mellitus (T2DM). Pancreatic and cerebral functions, pancreas and brain α-synuclein deposition as well as striatal alterations, were assessed in spontaneously developed T2DM monkeys and age-matched normal monkeys. We demonstrated increased accumulation, aggregation, and phosphorylation of α-synuclein, and IAPP in the pancreatic islets of spontaneously developed T2DM monkeys, compared to the age-matched normal subjects. Double immunofluorescence analyses showed complete overlap between α-synuclein and IAPP in the pancreatic islets. In addition, in T2DM monkeys’ brain, we observed concomitantly increased accumulation and phosphorylation of α-synuclein in the cortex, pre-commissural putamen and dopaminergic neurons in the substantia nigra, which interestingly showed high correlation with levels of fasting plasma glucose (FPG), triglyceride (TG), and high density lipoprotein (HDL). Our data indicates the close association between IAPP and α-synuclein and the potential link between T2DM and PD, which implies that T2DM may facilitate PD disease onset and progress by interfering with the pathological protein aggregation both in the pancreatic islets and the brain.

Memory advancement by intranasal insulin in type 2 diabetes (MemAID) randomized controlled clinical trial: Design, methods and rationale

BACKGROUND

Type 2 diabetes mellitus (T2DM) accelerates brain aging and increases the risk for dementia. Insulin is a key neurotrophic factor in the brain, where it modulates energy metabolism, neurovascular coupling, and regeneration. Impaired insulin-mediated brain signaling and central insulin resistance may contribute to cognitive and functional decline in T2DM. Intranasal insulin (INI) has emerged as a potential therapy for treating T2DM-related cognitive impairment.

METHODS/DESIGN

Ongoing from 2015, a prospective, two-center, randomized, double-blind, placebo-controlled trial of 210 subjects (120 T2DM and 90 non-diabetic older adults) randomized into four treatment arms (60 T2DM-INI, 60 T2DM-Placebo, 45 Control-INI, and 45 Control-Placebo) evaluating the long-term effects of daily intranasal administration of 40 International Units (IU) of human insulin, as compared to placebo (sterile saline) over 24 weeks and 24 weeks of post-treatment follow-up. Study outcomes are: 1) long-term INI effects on cognition, daily functionality, and gait speed; 2) identifying a clinically relevant phenotype that predicts response to INI therapy; 3) long-term safety.

CONCLUSION

This study addresses an important knowledge gap about the long-term effects of intranasal insulin on memory and cognition in older people with T2DM and non-diabetic controls, and may provide a novel therapeutic target for prevention and treatment of cognitive and functional decline and dementia. Trial Registration NCT02415556.

Association between depression and disease-specific treatment

BACKGROUND

Depression is a known risk factor for noncompliance to medical treatment. However, it remains unclear whether comorbidities alter the relationship between depression and treatment compliance. We explored whether depression is associated with disease-specific treatment service utilization.

METHODS

This cross-sectional study utilized data from 499,492 individuals who had at least one comorbidity in the Korean Community Health Survey, 2009-2013. Self-reported lifetime depression diagnosis by a physician, current depressive symptoms, and utilization of medical services were queried. The association between depression status and the use of overall treatment services was investigated using multiple logistic regression models and further stratified by use of specific medical treatment under conditions predefined with the Charlson Comorbidity Index (CCI).

RESULTS

Compared with non-depressed people, individuals with a "lifetime history of depression with current depressive symptom" showed higher odds of using overall medical treatment services in both men (OR=1.21, 95%CI: 1.00-1.47) and women (OR=1.13, 95% CI: 1.02-1.25). However, depressed individuals with CCI comorbidities (e.g., diabetes mellitus or angina) exhibited less utilization of treatment services than non-depressed individuals.

LIMITATIONS

The nature of the cross-sectional study limits the ability to infer a temporal causal relationship.

CONCLUSION

Overall, depressed individuals with a lifetime history of depression used treatment services more frequently than non-depressed individuals; however, depressed individuals with major illnesses tended to seek treatment for their medical conditions less. The mental health of patients who seek for medical services should be carefully considered in primary care for the proper health service utilization.

FRAX (Australia) scores in women with impaired fasting glucose and diabetes

BACKGROUND

Diabetes is associated with higher fracture risk despite higher bone mineral density (BMD), with FRAX® underestimating risk. This study aimed to investigate FRAX score with and without BMD for women with normoglycaemia, impaired fasting glucose (IFG) and diabetes.

METHODS

Among 566 women, aged 40-90 years, enrolled in the Geelong Osteoporosis Study, IFG was defined as fasting plasma glucose (FPG) ≥5.5 mmol/L and diabetes as FPG ≥ 7.0 mmol/L, use of antihyperglycaemic medication and/or self-report. FRAX (Australia) 10-year probabilities of major osteoporotic (MOF) and hip fracture were calculated, with and without BMD, producing four FRAX scores per participant. Kruskal-Wallis test for non-parametric data was used to examine differences between the three glycaemia groups. Fractures over 10 years were ascertained using radiological reports. The number of fractures predicted by FRAX was compared with the number of fractures observed using Chi-square tests.

RESULTS

For MOF FRAX calculated without BMD, women with diabetes (n = 67) tended to have a higher median score 7.1 (IQR 2.7-12.0) than normoglycaemia (n = 252) (4.3 (IQR 1.9-9.9) and IFG (n = 247) (5.1 (IQR 2.2-9.6)). For hip FRAX without BMD, diabetes tended to have a higher score (2.5 (IQR 06-4.3)) than normoglycaemia (1.2 (IQR 0.3-4.1)) and IFG (1.3 (IQR 0.3-4.1)). In the normoglycaemia and IFG groups, MOFs were underestimated; 15 predicted vs 28 observed, p = 0.038; and 16 predicted vs 31 observed, p = 0.021, respectively. Fractures were accurately estimated in all other groups.When including BMD, the association with diabetes was non-significant for both MOF FRAX (normoglycaemia 3.7 (IQR 1.9-8.0), IFG 4.3 (IQR 2.2-8.1) and diabetes 5.3 (IQR 2.7-9.4)) and hip FRAX scores (normoglycaemia 0.6 (IQR 0.2-2.5), IFG 0.8 (IQR 0.2-2.7) and diabetes 1.0 (IQR 0.3-3.0)). For normoglycaemia and IFG, MOFs were underestimated (normoglycaemia: 13 predicted vs 28 observed and IFG: 13 vs 31). For diabetes, both MOFs and hip fractures tended to be underestimated by FRAX with BMD (MOF: 4 predicted vs 11 observed, p = 0.055, hip: 1 predicted vs 6 observed, p = 0.052). Hip fractures were accurately estimated in the normoglycaemia and IFG groups.

CONCLUSIONS

Compared with women who had normoglycaemia or IFG, women with diabetes tended to have a higher FRAX score for both MOF and hip fractures when BMD was not included. When BMD was included, there was no difference. Fractures in diabetes tended to be underestimated by FRAX with BMD. This suggests that FRAX calculations including BMD may not be accurate for estimating fractures in those with diabetes.

Higher GABA concentration in the medial prefrontal cortex of Type 2 diabetes patients is associated with episodic memory dysfunction

Type 2 diabetes (T2D) is associated with an accelerated episodic memory decline, but the underlying pathophysiological mechanisms are not well understood. Hallmarks of T2D comprise impairment of insulin secretion and insulin sensitivity. Insulin signaling modulates cerebral neurotransmitter activity, including the excitatory glutamate and inhibitory gamma-aminobutyric acid (GABA) systems. Here we tested the hypothesis that the glutamate and GABA systems are altered in T2D patients and this relates to memory decline and insulin resistance. Using 1 H-magnetic resonance spectroscopy (MRS), we examined glutamate and GABA concentrations in episodic memory relevant brain regions (medial prefrontal cortex and precuneus) of T2D patients and matched controls. Insulin sensitivity was measured by hyperinsulinemic-euglycemic clamps and memory performance was assessed using a face-profession associations test. T2D patients exhibited peripheral insulin resistance and had a decreased memory for face-profession associations as well as elevated GABA concentration in the medial prefrontal cortex but not precuneus. In addition, medial prefrontal cortex GABA concentration was negatively associated with memory performance suggesting that abnormal GABA levels in the medial prefrontal cortex are linked to the episodic memory decline that occurs in T2D patients.

Cognitive Dysfunction Among Adults With Type 2 Diabetes Mellitus in Karnataka, India

Background: Type 2 diabetes mellitus is a chronic metabolic disease characterized by hyperglycemia that affects various body systems. Elevated blood glucose levels cause brain malfunction, sorbitol-induced blood vessel damage, and degeneration of the nerves that can lead to dementia or cognitive impairment. Cognitive impairment can result in nonadherence of patients to diabetes treatment, such as diet, medication, and exercise. Methods: We used a cross-sectional design to individually interview 194 patients with type 2 diabetes in a rural field practice area in India. A questionnaire was used to collect sociodemographic and diabetes disease characteristics; anthropometric measurements were also collected. Cognitive dysfunction was assessed with the Kannada version (local language) of the Montreal Cognitive Assessment (MoCA) tool. Blood pressure was measured for all subjects using a standardized sphygmomanometer on the right arm with the patient in a sitting position. Results: Among the 194 diabetic subjects interviewed, 98 (50.5%) were cognitively impaired. More than half of the subjects (56.2%) were ≥65 years, and female participants (53.6%) outnumbered males (46.4%). The majority of patients (62.4%) had had diabetes for <10 years. The sociodemographic characteristics age, sex, education, occupation, and socioeconomic status and the anthropometric measurement of waist-to-hip ratio were significantly associated (P<0.05) with cognitive impairment. Disease characteristics, religion, and blood pressure showed no significant association with cognitive impairment. Conclusion: One in two individuals with type 2 diabetes mellitus in our study population had mild cognitive impairment. Older individuals in the low socioeconomic strata and with low levels of education were identified to be at high risk of cognitive impairment. Hence, screening and appropriate care need to be provided.

Cognitive dysfunctions in individuals with diabetes mellitus

Some patients with type 1 and type 2 diabetes mellitus (DM) present with cognitive dysfunctions. The pathophysiology underlying this complication is not well understood. Type 1 DM has been associated with a decrease in the speed of information processing, psychomotor efficiency, attention, mental flexibility, and visual perception. Longitudinal epidemiological studies of type 1 DM have indicated that chronic hyperglycemia and microvascular disease, rather than repeated severe hypoglycemia, are associated with the pathogenesis of DM-related cognitive dysfunction. However, severe hypoglycemic episodes may contribute to cognitive dysfunction in high-risk patients with DM. Type 2 DM has been associated with memory deficits, decreased psychomotor speed, and reduced frontal lobe/executive function. In type 2 DM, chronic hyperglycemia, long duration of DM, presence of vascular risk factors (e.g., hypertension and obesity), and microvascular and macrovascular complications are associated with the increased risk of developing cognitive dysfunction. The pathophysiology of cognitive dysfunction in individuals with DM include the following: (1) role of hyperglycemia, (2) role of vascular disease, (3) role of hypoglycemia, and (4) role of insulin resistance and amyloid. Recently, some investigators have proposed that type 3 DM is correlated to sporadic Alzheimer's disease. The molecular and biochemical consequences of insulin and insulin-like growth factor resistance in the brain compromise neuronal survival, energy production, gene expression, plasticity, and white matter integrity. If patients claim that their performance is worsening or if they ask about the effects of DM on functioning, screening and assessment are recommended.