Patients with type 2 diabetes show decline in executive function, memory, learning, attention, and psychomotor efficiency ( 9, 10). Patients with type 1 diabetes are more likely to have diminished mental flexibility and slowing of mental speed, whereas learning and memory are largely not affected ( 8). It is also believed that insulin regulates neurons in the central nervous system and affects amyloid β metabolism, in addition to many other effects, which accelerates Alzheimer-related pathology ( 7).Īlthough cognitive dysfunction is associated with both type 1 and type 2 diabetes, there are several distinct differences observed in the domains of cognition affected in patients with these two types. In vascular dementia, small vessel disease exacerbated by diabetes affects cognitive function. In general, the etiology of cognitive dysfunction in the aging population is likely to be the combination of ischemic and degenerative pathology ( 6). A smaller cohort study of 200 older patients with type 1 diabetes found a 35%–44% prevalence of cognitive dysfunction ( 5). A recent Kaiser Permanente Northern California registry analysis found an 80% (hazard ratio 1.8) higher likelihood of developing cognitive dysfunction in people with type 1 diabetes, compared with those without diabetes ( 4). The prevalence of dementia in type 1 diabetes is less clear. Prediabetes, poor control, and longer duration of the disease were associated with greater late-life cognitive decline ( 3). A large community-based prospective cohort study followed patients over a 20-year period and found that diabetes in midlife was associated with a 19% greater cognitive decline over a 20-year period. Type 2 diabetes is associated with approximately a 1.5- to 2.5-fold increase in the risk of dementia ( 1, 2). Is Diabetes Associated With Cognitive Dysfunction in Older Adults?ĭiabetes is a risk factor for the development of dementia of both vascular as well as neurodegenerative (Alzheimer) etiology. In this Perspective, I will discuss important aspects of managing diabetes in the older population with coexisting cognitive dysfunction. In the older population, in addition to acute cognitive dysfunction during hypoglycemic episodes, there is also the long-term impact of both hyperglycemia and hypoglycemia on cognitive function. In the younger population, acute cognitive dysfunction is typically seen as an immediate manifestation of hypoglycemia. All of these behaviors are important when patients are asked to do complex tasks such as matching insulin dose with carbohydrate content, predicting the impact of physical activity on blood glucose, or even recognizing and treating hypoglycemia appropriately. For patients with diabetes, executive functions are particularly important as they involve behaviors, such as insight into a particular problem, problem-solving, judgment, stopping or changing old habits, and starting new habits. Mild cognitive impairment also puts the patient at risk for delirium, which is a sudden worsening in the cognitive function in the presence of acute medical illness. Although mild cognitive dysfunction may not cause difficulty in self-management activities in many patients, progression of this condition needs to be carefully observed. In addition, patients with cognitive dysfunction can be on a spectrum that extends from a mild cognitive impairment (defined as cognitive dysfunction without difficulty performing daily activities) to severe dysfunction (commonly referred to as dementia). Cognitive dysfunction is a broad term that includes many domains, such as memory, learning, mental flexibility, attention, and executive function. Thus, the presence of cognitive dysfunction (also commonly referred to as cognitive impairment) is an important condition to recognize as it interferes with patients’ participation in their diabetes management. Traditional diabetes management strategies stress the role of the patient as an important member of the diabetes management team and focus on the self-care education needed to care for diabetes and related syndromes. Although patient-centric management strategies are recommended for everyone, some age-related conditions are not well understood and their impact on diabetes management in the aging population is still evolving. As the population ages, all clinicians, whether they are primary care providers or specialists, are faced with challenges on how to manage diabetes in the context of many other coexisting conditions.
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