Attentional functioning in children and adolescents with IDDM

Effect of metabolic control on cognitive functions in children and adolescents with type 1 diabetes mellitus

OBJECTIVES

Neurocognitive functions of children with type 1 diabetes mellitus (T1D) are reported to be poorer than those of healthy peers. The aim was to investigate the effects of age of onset of diabetes, metabolic control, and type of insulin regimen on neurocognitive functions in children and adolescents with T1D.

METHODS

Forty-seven children aged 6-18 years, with T1D for at least five years, were included. Children with a known psychiatric disorder or chronic diseases other than T1D were excluded. Intelligence via the Wechsler children's intelligence scale (WISC-R), short-term memory via the audio-auditory digits form B (GISD-B) test, visual motor perception via the Bender Gestalt test, and attention via the Moxo continuous attention and performance test, timing, hyperactivity, and impulsivity (Moxo-dCPT) were assessed.

RESULTS

Compared with the T1D group, healthy controls had higher scores in terms of verbal intelligence quotient (IQ), performance IQ, and total IQ mean scores on WISC-R (p=0.01, p=0.05 and p=0.01, respectively). On the MOXO-dCPT test, the T1D group had higher impulsivity compared to the control group (p=0.04). Verbal IQ was better in the moderate control group than in the poorer metabolic control (p=0.01). Patients with no history of diabetic ketoacidosis (DKA) had higher performance, verbal and total intelligence scores than the group with history of DKA.

CONCLUSIONS

Poor metabolic control and a history of DKA in children with T1D adversely affected neurocognitive functions. It would be beneficial to consider the assessment of neurocognitive functions in T1D and to take the necessary precautions in follow-up.

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.

Sweet but sour: Impaired attention functioning in children with type 1 diabetes mellitus

Children diagnosed with type 1 diabetes mellitus (T1DM) are at risk for neurocognitive sequelae, including impaired attention functioning. The specific nature of the cognitive deficit varies; current literature underscores early age of diabetes diagnosis and increased disease duration as primary risk factors for this neurocognitive decline. Forty-three children with T1DM were evaluated for Attention Deficit/Hyperactivity Disorder (ADHD) symptomatology using the MOXO continuous performance test (MOXO-CPT) performed during a routine outpatient evaluation. The study cohort demonstrated a significant decline in all four domains of attention functioning. The effect was most pronounced with early age at T1DM diagnosis, a longer disease duration and with poorer glycemic control (represented by higher HbA1c values). With increased disease duration (of 5 plus years), acute hyperglycemia was associated with inattention in the real-time setting. These findings highlight the need for routine screening of neurocognitive function in children with T1DM so that early intervention can be employed during this crucial period of cognitive development.

Diabetes and associated cognitive disorders: Role of the Hypothalamic-Pituitary Adrenal axis

Both diabetes types, types 1 and 2, are associated with cognitive impairments. Each period of life is concerned, and this is an increasing public health problem. Animal models have been developed to investigate the biological actors involved in such impairments. Many levels of the brain function (structure, volume, neurogenesis, neurotransmission, behavior) are involved. In this review, we detailed the part potentially played by the Hypothalamic-Pituitary Adrenal axis in these dysfunctions. Notably, regulating glucocorticoid levels, their receptors and their bioavailability appear to be relevant for future research studies, and treatment development.

Monitoring Glucose Concentrations in Children with Epilepsy on a Ketogenic Diet

Ketogenic diet (KD) and pulsatile dexamethasone therapy (PDT) are commonly used in the treatment of children with drug resistant epilepsy. Potential side effects of the KD are hypoglycemia, whereas PDT might lead to hyperglycemia. One practical option to measure glucose concentrations regularly is the flash glucose monitoring system (FGM). In this single-center study in Germany, two pediatric patients with epilepsy (age: 6.0 and 6.8 years) received FGM from the beginning of the KD over six months, in the year 2020, and one patient (9.8 years) was observed for one month on PDT and switched to the KD thereafter. Glucose concentrations were measured by using an FGM system and capillary blood measurement. Seizure frequency, changes in cognition, motor performance, social behavior, and sleep quality were evaluated. The mean hypoglycemia rate per day (65 mg/dL and lower) declined significantly in patient 1 and 2 after three months. Patient 3 showed in total seven hyperglycemic events during PDT. Patient 1 became seizure free. Improvement of attention and memory performance were reported. FGM during the KD as a treatment for drug resistant epilepsies in childhood is a practical option to explore and to avoid hypoglycemia during the KD and hyperglycemia during PDT.

The Relationship Between Executive Functioning, Type 1 Diabetes Self-Management Behaviors, and Glycemic Control in Adolescents and Young Adults

PURPOSE OF REVIEW

Understanding barriers to self-management behaviors and glycemic stability may inform specific needs for behavior change in adolescents and young adults with type 1 diabetes (T1D). The current review aims to systematically synthesize the literature on the relationships between executive functioning, self-management, and A1C in adolescents and young adults with T1D. Fifteen studies were retained in the current review. Study quality assessment for the majority of the studies were "Fair" or "Good."

RECENT FINDINGS

This review highlights several advances in research design, including use of longitudinal designs, data from multiple informants, and use of objective measures. Adolescents and young adults reported that more executive functioning weaknesses were related to decreased self-management behaviors and higher A1C. The current review demonstrated that self-perceived executive functioning weaknesses negatively impact self-management behaviors and A1C. Future research is needed to determine the utility of objective measures in assessing the relationships between executive functioning, T1D self-management, and A1C.

Priorities in the Interdisciplinary Approach of Specific Learning Disorders (SLD) in Children with Type I Diabetes Mellitus (T1DM). From Theory to Practice

BACKGROUND

A considerable endeavor had taken place in order to understand the associated challenges for children and adolescents with Specific Learning Disorder (SLD) and Type 1 Diabetes Mellitus (T1DM) but also in order to describe the necessary skills and approaches that the care givers have to develop to assist both children and parents. (1) Aim: The aim of this review is twofold. Firstly, to highlight the T1DM's potential impact on psychological well-being, on cognitive functioning and on school performance in children and adolescents who confront SLD. Secondly, to discuss the necessity of a multidiscipline approach of poor school performance in students with SLD and T1DM, presenting the serious contribution of care providers: (a) parents/carers in the family setting, (b) teachers and psychologists in the school setting and (c) health specialists (pediatricians, nutricians, nurses, child psychiatrists and psychologists) in the medical setting. (2) Methods: In this narrative literature review of 12 selected articles, each one studies a special aspect of approach, during the diagnosis and the treatment of individuals with T1DM and SLD. The review concerns the arising problems and difficulties in the adherence to diagnosis, the management of insulin, the mental and physical wellbeing, the school performance, the cognitive functioning and learning difficulties of patients. We tried to synthesize an interdisciplinary approach that involves collaboration between family, school and medical frame; facilitating children's and adolescents' difficulties management, as well as parent and teacher involvement during the intervention implementation. (3) Results: The main issues of concern were examined through the available literature, as different factors had to be re-examined in the previous studies, regarding the potential impact of T1DM in cognitive and psychological functioning, as well as the effects of the intervention/approach/treatment of children and adolescents with SLD and T1DM. (4) Conclusions: Although T1DM diagnosis and demanding treatment are a heavy burden for children and their families, T1DM may or may not be associated with a variety of academic and psychological outcomes. Despite the variability of the reviewed research design quality, it was clearly defined that the impact of T1DM is not uniform across educational and mental variables. Strengthening the children's physical, psychological and social wellbeing is an especially important factor, as it facilitates the insulin's management as well as the learning difficulties. This is possible by supporting the parental and teacher involvement in the intervention process. This review highlights the need to reduce the distance between theory/research and practice, in some of the proposed areas in this field of knowledge.

A systematic review of the effect of prior hypoglycaemia on cognitive function in type 1 diabetes

BACKGROUND

The effect of prior hypoglycaemia on cognitive function in type 1 diabetes is an important unresolved clinical question. In this systematic review, we aimed to summarize the studies exploring the impact of prior hypoglycaemia on any aspect of cognitive function in type 1 diabetes.

METHODS

We used a multidatabase search platform Healthcare Database Advanced Search to search Medline, PubMed, EMBASE, EMCARE, CINAHL, PsycINFO, BNI, HMIC, and AMED from inception until 1 May 2019. We included studies on type 1 diabetes of any age. The outcome measure was any aspect of cognitive function.

RESULTS

The 62 studies identified were grouped as severe hypoglycaemia (SH) in childhood (⩽18 years) and adult-onset (>18 years) diabetes, nonsevere hypoglycaemia (NSH) and nocturnal hypoglycaemia (NH). SH in early childhood-onset diabetes, especially seizures and coma, was associated with poorer memory (verbal and visuospatial), as well as verbal intelligence. Among adult-onset diabetes, SH was associated with poorer cognitive performance in the older age (>55 years) group only. Early versus late exposure to SH had a significant association with cognitive dysfunction (CD). NSH and NH did not have any significant association with CD, while impaired awareness of hypoglycaemia was associated with poorer memory and cognitive-processing speeds.

CONCLUSION

The effect of SH on cognitive function is age dependent. Exposure to SH in early childhood (<10 years) and older age groups (>55 years) was associated with a moderate effect on the decrease in cognitive function in type 1 diabetes [PROSPERO ID: CRD42019141321].

Subclinical Auditory Neural Deficits in Patients With Type 1 Diabetes Mellitus

Supplemental Digital Content is available in the text.

Objectives:

Diabetes mellitus (DM) is associated with a variety of sensory complications. Very little attention has been given to auditory neuropathic complications in DM. The aim of this study was to determine whether type 1 DM (T1DM) affects neural coding of the rapid temporal fluctuations of sounds, and how any deficits may impact on behavioral performance.

Design:

Participants were 30 young normal-hearing T1DM patients, and 30 age-, sex-, and audiogram-matched healthy controls. Measurements included electrophysiological measures of auditory nerve and brainstem function using the click-evoked auditory brainstem response, and of brainstem neural temporal coding using the sustained frequency-following response (FFR); behavioral tests of temporal coding (interaural phase difference discrimination and the frequency difference limen); tests of speech perception in noise; and self-report measures of auditory disability using the Speech, Spatial and Qualities of Hearing Scale.

Results:

There were no significant differences between T1DM patients and controls in the auditory brainstem response. However, the T1DM group showed significantly reduced FFRs to both temporal envelope and temporal fine structure. The T1DM group also showed significantly higher interaural phase difference and frequency difference limen thresholds, worse speech-in-noise performance, as well as lower overall Speech, Spatial and Qualities scores than the control group.

Conclusions:

These findings suggest that T1DM is associated with degraded neural temporal coding in the brainstem in the absence of an elevation in audiometric threshold, and that the FFR may provide an early indicator of neural damage in T1DM, before any abnormalities can be identified using standard clinical tests. However, the relation between the neural deficits and the behavioral deficits is uncertain.

Priming effect in children with Type 1 Diabetes Mellitus

Previous studies have evidenced cognitive difficulties across various domains in Type 1 Diabetes Mellitus (T1DM) children, but the implicit memory system has not yet been systematically explored.Taking into account that the interplay between memory and perception may be modulated by the semantic category of the stimuli and their salience, we explored explicit and implicit memory using both object and food stimuli to verify whether for T1DM children there is a feebleness in performing the function of memory as a function of the stimuli used.Eighteen T1DM children and 47 healthy children performed an explicit recognition task in which they were requested to judge whether the presented image had already been shown ("old") or not ("new") and an identification priming task in which they were asked to name new and old pictures presented at nine ascending levels of spatial filtering.Results did not reveal any differences between controls and T1DM children in the explicit memory recognition task, whereas some differences between the two groups were found in the identification priming task. In T1DM children, the priming effect was observed only for food images.The dissociation between implicit and explicit memory observed in children with diabetes seems to be modulated by the category of the stimuli, and these results underscore the relevance of taking into account this variable when exploring cognitive functions.

Association of attention deficit hyperactivity disorder with recurrent hypoglycemia in type 1 diabetes mellitus

OBJECTIVE

Data regarding the association between hypoglycemia and attention deficit hyperactivity disorder (ADHD) in children and adolescents with type 1 diabetes mellitus (T1DM) are limited. This study investigated whether hypoglycemia was associated with the risk of ADHD in young people with T1DM.

METHODS

Children and adolescents with a diagnosis of T1DM were identified from the Longitudinal National Health Insurance Database in Taiwan from 1998 to 2011. Among them who were newly diagnosed with hypoglycemia during 2000 to 2007 were selected for the hypoglycemia cohort. The hypoglycemia diagnosis date was defined as the index date. Those who were diagnosed with ADHD before the index date were excluded. The main outcome was the development of ADHD. In total, 726 participants with hypoglycemia and 2852 participants without hypoglycemia were included in this study.

RESULTS

The overall incidence density of ADHD was markedly increased among cohort with hypoglycemia compared with cohort without hypoglycemia (4.74 vs 1.65 per 1000 person-years), with an adjusted hazard ratio (aHR) of 2.73 (95% confidence interval [CI] = 1.50-4.98). Cohort with hypoglycemia who had experienced a hypoglycemic coma had a significantly higher risk of ADHD (aHR = 6.54, 95% CI = 1.89-22.7) compared with cohort without hypoglycemia.

CONCLUSIONS

Hypoglycemia, especially hypoglycemic coma, is significantly associated with a subsequent risk of ADHD in young people with T1DM.

Glycemic extremes are related to cognitive dysfunction in children with type 1 diabetes: A meta-analysis

Aims/Introduction

To examine the magnitude and pattern of cognitive dysfunction in children with type 1 diabetes, and the possible effects associated with other disease variables, such as early onset diabetes, severe hypoglycemia and hyperglycemia.

Materials and Methods

We carried out a meta‐analysis using the Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. We searched MedLine, Embase and PsycINFO to identify studies on cognitive function in children with type 1 diabetes that were published up until 30 September 2016. Effect sizes understood as the standardized mean differences between groups with diabetes and control groups (i.e., Hedges’ g) were calculated to quantify the extent of cognitive dysfunction in those groups consisting of children with diabetes.

Results

A total of 19 studies met our inclusion criteria, comprising 1,355 participants with type 1 diabetes and 696 controls. Compared with non‐diabetic controls, children with type 1 diabetes showed a significantly poorer cognitive performance overall (g = −0.46), as well as specific deficits in full‐scale intelligence (g = −1.06), attention (g = −0.60) and psychomotor speed (g = −0.46). Glycemic extremes were associated with poorer overall cognition (g = −0.18), as well as slightly lower performance in memory (g = −0.27).

Conclusions

We found that type 1 diabetes was associated with cognitive dysfunction characterized by a lowered intelligence, diminished attention and a slowing of psychomotor speed. Glycemic extremes, which are described as a period of high glucose levels and severe hypoglycemia, were related to cognitive dysfunction in children with type 1 diabetes.

A Systematic Review and Meta-analysis of Executive Function Performance in Type 1 Diabetes Mellitus

OBJECTIVE

The aims of the study were to examine the current evidence for executive function (EF) performance differences between groups with type 1 diabetes mellitus (T1DM) and nondiabetic control groups during adolescence and early adulthood and to explore the relationships between EF and diabetes-related risk factors.

METHODS

A systematic review of the literature examining EF performance in groups with T1DM was conducted according to the PRISMA guidelines. Electronic database searches for published and unpublished literature yielded a final set of 26 articles after application of inclusion and exclusion criteria. A meta-analysis was conducted on a subset of these articles (n = 17) comparing EF performance in T1DM and control groups, across a total sample size of 1619.

RESULTS

Sixteen of 26 studies found significantly lower EF on at least one task in groups with T1DM. Meta-analyses of the performance difference between T1DM groups and control groups without diabetes showed that inhibition (g = -0.28, p < .001), working memory (g = -0.34, p < .001), set-shifting (g = -0.31, p = .012), and overall EF performance across these domains (g = -0.42, p < .001) were all significantly lower in groups with T1DM. Performance on specific EF domains also seemed to be differentially associated with early age of diabetes onset, chronic hyperglycemia and its complications, and severe hypoglycemia.

CONCLUSIONS

T1DM and its associated risk factors are related to subtle impairments across the inhibition, working memory, and set-shifting domains of EF. Lower EF may be a key factor contributing to behavioral and clinical problems experienced by individuals with T1DM.

Recurrent Hypoglycemia Exacerbates Cerebral Ischemic Damage in Diabetic Rats via Enhanced Post-Ischemic Mitochondrial Dysfunction

Diabetes significantly increases the risk of stroke and post-stroke mortality. Recurrent hypoglycemia (RH) is common among diabetes patients owing to glucose-lowering therapies. Earlier, we showed that RH in a rat model of insulin-dependent diabetes exacerbates cerebral ischemic damage. Impaired mitochondrial function has been implicated as a central player in the development of cerebral ischemic damage. Hypoglycemia is also known to affect mitochondrial functioning. The present study tested the hypothesis that prior exposure of insulin-treated diabetic (ITD) rats to RH exacerbates brain damage via enhanced post-ischemic mitochondrial dysfunction. In a rat model of streptozotocin-induced diabetes, we evaluated post-ischemic mitochondrial function in RH-exposed ITD rats. Rats were exposed to five episodes of moderate hypoglycemia prior to the induction of cerebral ischemia. We also evaluated the impact of RH, both alone and in combination with cerebral ischemia, on cognitive function using the Barnes circular platform maze test. We observed that RH exposure to ITD rats leads to increased cerebral ischemic damage and decreased mitochondrial complex I activity. Exposure of ITD rats to RH impaired spatial learning and memory. Our results demonstrate that RH exposure to ITD rats potentially increases post-ischemic damage via enhanced post-ischemic mitochondrial dysfunction.

Attention Problems as a Predictor of Type 1 Diabetes Adherence and Metabolic Control Across Adolescence

Objective

Management of type 1 diabetes is a difficult self-regulatory process requiring continued attention to complex regimen tasks. The purpose of this study was to examine whether youths' attention problems were associated with poorer adherence and HbA1c across time, and whether higher parental involvement reduced these associations.

Methods

Adolescents with type 1 diabetes (N = 199, M age  = 12.43 years, SD = 1.50) and their mothers rated youths' attention problems and adherence at three time points. Adolescents rated parents' diabetes-specific monitoring and behavioral involvement. HbA1c was collected from medical records.

Results

Adolescents' (but not mothers') greater reports of attention problems compared with their average related to lower adherence across time. Adolescents' (but not mothers') reports of greater attention problems compared with their average related to lower adherence across time.

Conclusions

Youth attention problems may help us understand poor adherence, and interventions to promote parental involvement may buffer this risk.

A longitudinal investigation of cognitive function in children and adolescents with type 1 diabetes mellitus

OBJECTIVE

Cross-sectional studies find altered cognition in youth with type 1 diabetes mellitus (T1DM). However, few longitudinal studies have examined the trajectories of their cognitive performance over time. The aims of this study were to explore longitudinal change in cognitive function in youth with T1DM as compared with nondiabetic sibling controls, and how glycemic control and age of onset influence cognitive performance over time.

METHODS

We assessed crystallized intelligence, visual-spatial ability, delayed memory, and processing speed at 3 time points using the same cognitive tasks in youth with T1DM and sibling controls. Hierarchical linear modeling examined relationships between diabetes, hyperglycemia (HbA1c values), age of onset, and cognition over 5.5 y.

RESULTS

Youth with diabetes performed worse than controls on visual-spatial ability and memory tasks over time, and did not improve as much in processing speed. Greater hyperglycemia was associated with lower crystallized intelligence and slower processing speed but better memory across all time points. There was a stronger negative relationship between hyperglycemia and visual-spatial ability for youth with earlier compared with later onset diabetes. Importantly, within-person decreases in hyperglycemia between time points were associated with improved visual-spatial ability and faster processing speed.

CONCLUSIONS

On average, differences in cognitive function between youth with T1DM and nondiabetic relatives are maintained or increase during childhood and adolescence. Hyperglycemia and age of onset can have negative effects on the developmental trajectories of cognitive processes in youth with T1DM. However, treatments that lower hyperglycemia may lead to improved cognitive function in youth with T1DM.

Perceptions of Adolescent Patients of the "Lived Experience" of Type 1 Diabetes

The care and management of adolescents with type 1 diabetes presents numerous challenges that are inherent to the fears, attitudes, and perceptions of their illness. This qualitative study aimed to explore the "lived experience" of individuals with type 1 diabetes. In-depth interviews were conducted with 20 patients diagnosed with type 1 diabetes in their adolescent years to elicit their views, perceptions, and concerns regarding living with diabetes. All interviews were conducted and analyzed using the principles of grounded theory. Five categories defining the patients' lived experience were elicited: Barriers, Develop Skills, Manage Emotion, Social World, and Health Care Professionals. The problems experienced by adolescents with type 1 diabetes are multifactorial. Existentially, type 1 diabetes affects their daily activities and impinges on their academic achievement and personal aspirations. They have great difficulty coping with their health status and highlight a lack of empathy from health care professionals (HCPs). Their major fear is of hypoglycemia, resulting in their subsequent focus of preventing hypoglycemic episodes. Indeed, regardless of consequence, blood glucose levels are often deliberately kept above recommended levels, which serves to decrease the effectiveness of their health care management. This study shows that the quality of care provided for adolescent patients with type 1 diabetes is failing to meet their expectations and falls short of the essential standards commensurate with current health care policy. Improvements in long-term care management for these patients require changes in both patients' and professionals' understanding of the disease and of the ways it is managed.

Cognition and Type 1 Diabetes in Children and Adolescents

IN BRIEF In children and adolescents with type 1 diabetes, exposure to glycemic extremes (severe hypoglycemia, chronic hyperglycemia, and diabetic ketoacidosis) overlaps with the time period of most active brain and cognitive development, leading to concerns that these children are at risk for cognitive side effects. This article summarizes the existing literature examining the impact of glycemic extremes on cognitive function and brain structure in youth with type 1 diabetes and points out areas for future research.

Evaluation of Pre-Treatment and Post-Treatment S100B, Oxidant and Antioxidant Capacity in Children with Diabetic Ketoacidosis

OBJECTIVE

The study aimed to evaluate the pre-treatment and post-treatment oxidant capacity, antioxidant capacity and S100B protein levels in cases of diabetic ketoacidosis (DKA).

METHODS

The study included 49 pediatric patients diagnosed with DKA and a control group comprising 49 healthy children. Blood samples were obtained after confirmation of the DKA diagnosis and also after treatment. S100B, total oxidant (TOL) and total antioxidant levels (TAL) were measured and the oxidative stress index (OSI) was calculated.

RESULTS

When the pre-treatment and post-treatment values of patients with DKA were compared with those of the healthy control group, the S100B level, TOL, TAL and OSI were found to be significantly higher in the diabetes group (p<0.001). Pre-treatment TOL and TAL were also significantly higher than post-treatment levels (p<0.001), while no statistically significant difference was found in the S100B levels or the OSI (p>0.05).

CONCLUSION

We believe that long-term exposure to high blood glucose concentrations leads to an increase in TOL in patients with DKA and that the neurotransmitter changes that develop in response to this exposure lead to an increase in S100B levels, which is an indicator of neuronal damage.

Risk factors for incident major depressive disorder in children and adolescents with attention-deficit/hyperactivity disorder

The greater burden of illness in youth with co-occurring attention-deficit/hyperactivity disorder (ADHD) and major depressive disorder (MDD) deserves further investigation, specifically regarding the influence of other psychiatric or medical conditions and the pharmacotherapies prescribed. A retrospective cohort design was employed, using South Carolina's (USA) Medicaid claims' dataset covering outpatient and inpatient medical services, and medication prescriptions between January, 1996 and December, 2006 for patients ≤17 years of age. The cohort included 22,452 cases diagnosed with ADHD at a mean age 7.8 years; 1,259 (5.6 %) cases were diagnosed with MDD at a mean age of 12.1 years. The probability of a child with ADHD developing MDD was significantly associated with a comorbid anxiety disorder (aOR = 3.53), CD/ODD (aOR = 3.45), or a substance use disorder (aOR = 2.31); being female (aOR = 1.77); being treated with pemoline (aOR = 1.69), atomoxetine (aOR = 1.31), or mixed amphetamine salts (aOR = 1.28); a comorbid obesity diagnosis (aOR = 1.29); not being African American (aOR = 1.23), and being older at ADHD diagnosis (aOR = 1.09). Those developing MDD also developed several comorbid disorders later than the ADHD-only cohort, i.e., conduct disorder/oppositional-defiant disorder (CD/ODD), at mean age of 10.8 years, obesity at 11.6 years, generalized anxiety disorder at 12.2 years, and a substance use disorder at 15.7 years of age. Incident MDD was more likely in individuals clustering several demographic, clinical, and treatment factors. The phenotypic progression suggested herein underscores the need for coordinated early detection and intervention to prevent or delay syndromal MDD, or to minimize its severity and associated impairment over time.

Hypoglycemia induced by insulin as a triggering factor of cognitive deficit in diabetic children

This paper provides an overview of insulin-induced hypoglycemia as a triggering factor of cognitive deficit in children with type 1 diabetes mellitus. For this purpose, databases from 1961 to 2013 were used with the objective of detecting the primary publications that address the impact of hypoglycemia on cognitive performance of diabetic children. The results obtained from experimental animals were excluded. The majority of studies demonstrated that the cognitive deficit in diabetic children involves multiple factors including duration, intensity, severity, and frequency of hypoglycemia episodes. Additionally, age at the onset of type 1 diabetes also influences the cognitive performance, considering that early inception of the disease is a predisposing factor for severe hypoglycemia. Furthermore, the results suggest that there is a strong correlation between brain damage caused by hypoglycemia and cognitive deterioration. Therefore, a more cautious follow-up and education are needed to impede and treat hypoglycemia in children with diabetes mellitus.

Management of Type 1 Diabetes in Older Adults

Older adults with type 1 diabetes are at high risk for severe hypoglycemia and may have serious comorbid conditions. Problems with cognition, mobility, dexterity, vision, hearing, depression, and chronic pain interfere with the ability to follow complex insulin regimens. With the development of geriatric syndromes, unpredictable eating, and frailty, treatment regimens must be modified with the goal of minimizing hypoglycemia and severe hyperglycemia and maximizing quality of life.

Glycemic extremes in youth with T1DM: the structural and functional integrity of the developing brain

The adult brain accounts for a disproportionally large percentage of the body’s total energy consumption (1). However, during brain development,energy demand is even higher, reaching the adult rate by age 2 and increasing to nearly twice the adult rate by age 10, followed by gradual reduction toward adult levels in the next decade (1,2). The dramatic changes in brain metabolism occurring over the first two decades of life coincide with the initial proliferation and then pruning of synapses to adult levels.The brain derives its energy almost exclusively from glucose and is largely driven by neuronal signaling, biosynthesis, and neuroprotection (3–6).Glucose homeostasis in the body is tightly regulated by a series of hormones and physiologic responses. As a result, hypoglycemia and hyperglycemia are rare occurrences in normal individuals, but they occur commonly inpatients with type 1 diabetes mellitus (T1DM) due to a dysfunction of peripheral glucose-insulin-glucagon responses and non-physiologic doses of exogenous insulin, which imperfectly mimic normal physiology. These extremes can occur more frequently in children and adolescents with T1DM due to the inadequacies of insulin replacement therapy, events leading to the diagnosis [prolonged untreated hyperglycemia and diabetic ketoacidosis (DKA)], and to behavioral factors interfering with optimal treatment. When faced with fluctuations in glucose supply the metabolism of the body and brain change dramatically, largely to conserve resources and, at a cost to other organs, to preserve brain function (7). However,if the normal physiological mechanisms that prevent these severe glucose fluctuations and maintain homeostasis are impaired, neuronal function and potentially viability can be affected (8–11).

Association of attention-deficit/hyperactivity disorder with diabetes: a population-based study

BACKGROUND

Cognitive impairment has been documented in adult diabetes but is unclear in pediatric diabetes. No study had been conducted to explore the relationship between attention-deficit/hyperactivity disorder (ADHD) and diabetes. Using a population-based data set, we aimed to examine the association between ADHD and a prior diagnosis of diabetes mellitus (DM) in Taiwan.

METHODS

A total of 4,302 patients with ADHD were selected as cases and 21,510 randomly selected subjects as controls. We used conditional logistic regression to calculate the odds ratio (OR) for having previously received a diagnosis of DM between subjects with and without ADHD.

RESULTS

In this study, 116 of the 25,812 sampled subjects (0.5%) had received a diagnosis of DM prior to their index date. Subjects with ADHD had a higher proportion of prior DM diagnoses than controls (0.9% vs. 0.4%, P < 0.001). After adjusting for age, sex, index year, geographic location, and obesity, ADHD was significantly associated with a prior diagnosis of type 2 DM (OR = 2.75, 95% confidence interval (CI) = 1.82-4.16). However, no significant association was observed between ADHD and type 1 DM.

CONCLUSION

The findings suggest that ADHD was associated with a previous diagnosis of type 2 DM.

Prevention of hypoglycemia-induced neuronal death by minocycline

Diabetic patients who attempt strict management of blood glucose levels frequently experience hypoglycemia. Severe and prolonged hypoglycemia causes neuronal death and cognitive impairment. There is no effective tool for prevention of these unwanted clinical sequelae. Minocycline, a second-generation tetracycline derivative, has been recognized as an anti-inflammatory and neuroprotective agent in several animal models such as stroke and traumatic brain injury. In the present study, we tested whether minocycline also has protective effects on hypoglycemia-induced neuronal death and cognitive impairment. To test our hypothesis we used an animal model of insulin-induced acute hypoglycemia. Minocycline was injected intraperitoneally at 6 hours after hypoglycemia/glucose reperfusion and injected once per day for the following 1 week. Histological evaluation for neuronal death and microglial activation was performed from 1 day to 1 week after hypoglycemia. Cognitive evaluation was conducted 6 weeks after hypoglycemia. Microglial activation began to be evident in the hippocampal area at 1 day after hypoglycemia and persisted for 1 week. Minocycline injection significantly reduced hypoglycemia-induced microglial activation and myeloperoxidase (MPO) immunoreactivity. Neuronal death was significantly reduced by minocycline treatment when evaluated at 1 week after hypoglycemia. Hypoglycemia-induced cognitive impairment is also significantly prevented by the same minocycline regimen when subjects were evaluated at 6 weeks after hypoglycemia. Therefore, these results suggest that delayed treatment (6 hours post-insult) with minocycline protects against microglial activation, neuronal death and cognitive impairment caused by severe hypoglycemia. The present study suggests that minocycline has therapeutic potential to prevent hypoglycemia-induced brain injury in diabetic patients.

Recurrent/moderate hypoglycemia induces hippocampal dendritic injury, microglial activation, and cognitive impairment in diabetic rats

BACKGROUND

Recurrent/moderate (R/M) hypoglycemia is common in type 1 diabetes. Although mild or moderate hypoglycemia is not life-threatening, if recurrent, it may cause cognitive impairment. In the present study, we sought to determine whether R/M hypoglycemia leads to neuronal death, dendritic injury, or cognitive impairment.

METHODS

The experiments were conducted in normal and in diabetic rats. Rats were subjected to moderate hypoglycemia by insulin without anesthesia. Oxidative stress was evaluated by 4-Hydroxy-2-nonenal immunostaining and neuronal death was determined by Fluoro-Jade B staining 7 days after R/M hypoglycemia. To test whether oxidative injury caused by NADPH oxidase activation, an NADPH oxidase inhibitor, apocynin, was used. Cognitive function was assessed by Barnes maze and open field tests at 6 weeks after R/M hypoglycemia.

RESULTS

The present study found that oxidative injury was detected in the dendritic area of the hippocampus after R/M hypoglycemia. Sparse neuronal death was found in the cortex, but no neuronal death was detected in the hippocampus. Significant cognitive impairment and thinning of the CA1 dendritic region was detected 6 weeks after hypoglycemia. Oxidative injury, cognitive impairment, and hippocampal thinning after R/M hypoglycemia were more severe in diabetic rats than in non-diabetic rats. Oxidative damage in the hippocampal CA1 dendritic area and microglial activation were reduced by the NADPH oxidase inhibitor, apocynin.

CONCLUSION

The present study suggests that oxidative injury of the hippocampal CA1 dendritic region by R/M hypoglycemia is associated with chronic cognitive impairment in diabetic patients. The present study further suggests that NADPH oxidase inhibition may prevent R/M hypoglycemia-induced hippocampal dendritic injury.

The effect of recurrent severe hypoglycemia on cognitive performance in children with type 1 diabetes: a meta-analysis

The purpose of this study was to investigate the existence and extent of cognitive impairment in type 1 diabetic children with episodes of recurrent severe hypoglycemia, using meta-analysis to synthesize data across studies. The meta-analysis sample included: 441 children with diabetes and recurrent severe hypoglycemia, 560 children with diabetes and without recurrent severe hypoglycemia. Overall, children with type 1 diabetes and recurrent severe hypoglycemia had slightly lower performance than diabetic children without severe hypoglycemia, only in some cognitive domains: intelligence, memory, learning, and verbal fluency/language. Greater impairment was found in memory and learning. No impairment was found for motor speed. Our results seem to confirm the hypothesis that recurrent severe hypoglycemia has a selective negative effect on the children's cognitive functions. However, these results must be considered with caution taking into account factors such as small sample sizes, the different definitions of severe hypoglycemia, and the variety of neuropsychological tests used.

Neurocognitive functioning in preschool-age children with type 1 diabetes mellitus

Neurocognitive functioning may be compromised in children with type 1 diabetes mellitus (T1DM). The factor most consistently implicated in the long-term neurocognitive functioning of children with T1DM is age of onset. The pediatric literature suggests that glycemic extremes may have an effect on the neurocognitive functioning of children, but findings are mixed. The purpose of this study was to compare the neurocognitive functioning of young children with T1DM diagnosed before 6 yr of age and healthy children (i.e., without chronic illness). Additionally, in the children with T1DM, we examined the relationship between their neurocognitive functioning and glycemic control. Sixty-eight (36 with T1DM and 32 without chronic illness) preschool-age children (M age = 4.4 yr ) were recruited and administered a battery of instruments to measure cognitive, language, and fine motor skills. Children with T1DM performed similar to the healthy controls and both groups' skills fell in the average range. Among children with diabetes, poor glycemic control [higher hemoglobin A1c (HbA1c)] was related to lower general cognitive abilities (r = -0.44,p < 0.04), slower fine motor speed (r = -0.64,p < 0.02), and lower receptive language scores (r = -0.39,p < 0.04). Such findings indicate that young children with T1DM already demonstrate some negative neurocognitive effects in association with chronic hyperglycemia.

Neuropsychological profiles of young people with type 1 diabetes 12 yr after disease onset

BACKGROUND

Lowered neuropsychological performance is evident in youth with type 1 diabetes, although evidence for associations with specific illness variables is inconsistent. This study examined the neuropsychological profiles of a cohort of youth with type 1 diabetes studied prospectively from diagnosis 12 yr previously.

METHODS

A total of 106 youth with type 1 diabetes and 75 healthy controls participated. There were no significant group differences on Full-scale IQ assessed on study entry 12 yr previously, current socioeconomic status, gender distribution, or age. Neuropsychological tests assessed eight cognitive domains: verbal abilities, perceptual reasoning, new learning, working memory, non-verbal processing speed, mental efficiency, divided attention, and sustained attention. Episodes of serious hypoglycemia and HbA(1c) levels were recorded from diagnosis.

RESULTS

Youth with type 1 diabetes performed more poorly than controls on working memory (p < .05). Early onset diabetes was related to poorer sustained (p < .001) and divided attention (p = .001), new learning, and mental efficiency (both p < .05). Hypoglycemia was found to adversely effect verbal abilities, working memory, and non-verbal processing speed (all p < .05). Poorer working memory was associated with hyperglycemia (p < .05). Youth with any combination of two or three illness risk factors (i.e., early onset diabetes, hypo-, hyperglycemia), performed more poorly than controls and youth with no or one risk on verbal abilities, working memory, and mental efficiency.

CONCLUSIONS

This study documents poorer neuropsychological performance and its association with illness risk factors in youth with type 1 diabetes. Findings suggest that early disease onset and hypoglycemia impact on the developing central nervous system, with hyperglycemia playing a lesser role.

Cognitive functions and glycemic control in children and adolescents with type 1 diabetes

BACKGROUND

The relationship between metabolic control and cognitive function in adolescents with type 1 diabetes (DM type 1) is not clear. We compared the quality of glycemic control (GC) and cognitive measures in adolescents with DM type 1 to find out if the quality of diabetes management is related to cognitive impairment.

METHOD

We assessed executive functions (EFs) and other neuropsychological and psychosocial variables in 70 adolescent patients with DM type 1 and 20 age-matched controls. Patients were divided into two groups according to their last hemoglobin A1c (HbA1c): acceptable (HbA1c 5.9-8.0%, mean 6.9%, 36 patients, mean age 14 years) and non-optimal (HbA1c 8.2-11.6%, mean 9.3%, 34 patients, mean age 15.6 years).

RESULTS

We found impaired EFs, mainly problems of concept formation (p=0.038), cognitive flexibility (p=0.011) and anticipation (p=0.000), in the patients with DM type 1. Both groups did not differ in intelligence, most assessed EFs and adjustment to chronic illness (Youth Self-Report; YSR). Younger patients (<15 years) were cognitively less flexible. GC was worse in older patients and in patients with longer duration of the disease. We also found significant differences between patients with diabetes and controls concerning somatic complaints, internalizing problems (Child Behavior Checklist; CBCL) and social activity (CBCL and YSR).

CONCLUSIONS

DM type 1 is associated with cognitive deficits in adolescents independent of the quality of metabolic control and the duration of the disease. These deficits are probably related to the disease, especially in patients with early-onset diabetes.

Type 1 diabetes mellitus and school: a comparison of patients and healthy siblings

Children and adolescents with type 1 diabetes mellitus (T1DM) are at risk for a variety of problems at school. Well-controlled studies using data collected in schools, however, are limited. The purposes of this study are to determine whether selected school problems are associated with T1DM and to investigate an association between these problems and medical variables. Teachers rated 95 diabetic students (M = 11.8; SD = 3.0 yr old) and 95 of their siblings (M = 12.1; SD = 3.0 yr old) regarding academic skills, work completion, day-to-day variability, and classroom attention. Medical and school records also were accessed. The T1DM group had lower academic skills ratings overall (p < 0.02), especially in writing (p < 0.01), a trend toward poorer classroom attention (p < 0.08), and many more missed school days (p < 0.001). Diabetics on intensive therapy protocols had better academic ratings overall (p < 0.02), including in math (p < 0.03) and fewer missed school days (p < 0.03), but they unexpectedly were rated as having more classroom behaviors that jeopardize work completion (p < 0.05) than counterparts on conventional therapy. Among all diabetics, glycated hemoglobin (HbA(lc)) levels were moderately related to each academic skill rating (r = -0.34 to -0.37; p < 0.01) and strongly related to classroom attention (r = 0.53; p = 0.000). T1DM itself appears to be a relatively minor influence to several important aspects of school. Furthermore, although intensive therapy alone may well promote school success, meticulous glycemic control, however achieved, appears more important in mitigating prospective classroom attention and academic problems.

(Pre)diabetes, brain aging, and cognition

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

Impact of diabetes and its treatment on cognitive function among adolescents who participated in the Diabetes Control and Complications Trial

OBJECTIVE

The purpose of this study was to evaluate whether severe hypoglycemia or intensive therapy affects cognitive performance over time in a subgroup of patients who were aged 13-19 years at entry in the Diabetes Control and Complications Trial (DCCT).

RESEARCH DESIGN AND METHODS

This was a longitudinal study involving 249 patients with type 1 diabetes who were between 13 and 19 years old when they were randomly assigned in the DCCT. Scores on a comprehensive battery of cognitive tests obtained during the Epidemiology of Diabetes Interventions and Complications follow-up study, approximately 18 years later, were compared with baseline performance. We assessed the effects of the original DCCT treatment group assignment, mean A1C values, and frequency of severe hypoglycemic events on eight domains of cognition.

RESULTS

There were a total of 294 reported episodes of coma or seizure. Neither frequency of hypoglycemia nor previous treatment group was associated with decline on any cognitive domain. As in a previous analysis of the entire study cohort, higher A1C values were associated with declines in the psychomotor and mental efficiency domain (P < 0.01); however, the previous finding of improved motor speed with lower A1C values was not replicated in this subgroup analysis.

CONCLUSIONS

Despite relatively high rates of severe hypoglycemia, cognitive function did not decline over an extended period of time in the youngest cohort of patients with type 1 diabetes.

Prevalence of structural central nervous system abnormalities in early-onset type 1 diabetes mellitus

OBJECTIVE

To characterize the effects of severe hypoglycemia on the developing brain in children with early-onset type 1 diabetes mellitus (T1DM).

STUDY DESIGN

Children diagnosed with T1DM before age 6 years were studied. Those with prospectively monitored severe hypoglycemia (coma/seizure; n = 32) were compared with age-matched peers (n = 30) with no history of such events using magnetic resonance imaging. Glycemic control (evaluated based on glycated hemoglobin [HbA(lc)] level), episodes of diabetic ketoacidosis (DKA), and clinical variables were monitored continuously since diagnosis in all subjects.

RESULTS

Mean HbA(lc) from diagnosis and the duration of T1DM were similar in those with and without a history of severe hypoglycemia (9.0% +/- 0.9% vs 8.8% +/- 0.9%; 7.2 +/- 2.7 years vs 6.7 +/- 2.3 years). A high prevalence of central nervous system (CNS) structural abnormalities was detected (29%), and mesial temporal sclerosis (MTS) was detected in 16% of the total sample (n = 62). The presence of MTS was not associated with a history of severe hypoglycemia or DKA. Analysis of brain matter volumes suggested relatively less gray matter density in those subjects with a history of severe hypoglycemia.

CONCLUSIONS

Early age of onset of T1DM per se is associated with a high incidence of CNS abnormalities, particularly MTS, suggesting hippocampal damage. Early-onset severe hypoglycemia may have an effect on gray matter volume.

Cognitive dysfunction and diabetes mellitus

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