Spotlight on Diabetes

As we observe Diabetes Awareness Month, it’s important to focus attention on a disease that continues to exact a devastating toll on older adults. Diabetes management is critical to the overall health and function of older patients.

During my training in the late 1990s, patients who suffered the worst end-organs damage from diabetes fell into the ominous sounding category “triple-opathy.” That was house officer-speak for the presence of the three most common end-organ conditions: nephropathy, neuropathy, and retinopathy. Unfortunately, as bad as we thought diabetes was at that time, we now know we were underrecognizing the ravages attributable to this illness.

There is a growing understanding that the cascade of insulin-involved pathologies along with other cardiometabolic risk factors affects cerebral tissues in ways similar to the destruction of renal and retinal tissues, and ultimately contribute to cerebral dysfunction and dementia. As the size of the expansive elderly population continues to soar, so too does the number of individuals with diabetes and dementia.

The care of a patient with both of these conditions can present some of the most vexing management challenges we will ever face.

In caring for patients with diabetes, continue to manage aspects of diabetes on the following fronts:

• Complete baseline and annual cognitive screening. Keep in mind patients’ increased risk of developing dementia and plan to complete a baseline and annual Montreal Cognitive Assessment (www.mocatest.org) or Saint Louis University Mental Status Evaluation (www.elderguru.com) to assess and track changes over time.

If you’re pressed for time, the most efficient and effective cognitive screening is the MiniCog exam. (Find full details at www.alz.org. See the “Professionals” section regarding this three-minute validated screen.)

It is known that diabetes increases the risk for vascular dementia by a significant degree. A US study reported in 2015 found a 16% increased risk.

There is some evidence suggesting that insulin resistance at the level of the brain leads to tau hyperphosphorylation and β-amyloid accumulation, both of which may promote the development of Alzheimer’s disease.1

A recent imaging study of Japanese patients with diabetes showed “Individuals with midlife diabetes had significantly greater hippocampal atrophy (hallmark pathology of Alzheimer’s disease) than did individuals without diabetes or those with late-life diabetes.”2

• In diabetic patients diagnosed with dementia, complete periodic reviews of their self-management abilities to ensure safety. Encourage patients to partner early on with a family/friend caregiver who can provide supervision as needed and alert the physician to changing abilities.

Watch for signs of difficulty with self-management such as nonadherence with therapy, frequent episodes of hypoglycemia, and deterioration of glycemic control without obvious explanation.

• Consider relaxing control and choosing medications specifically to avoid hypoglycemia. In a 2015 study evaluating elderly VA clinic patients with dementia and diabetes, the researchers concluded that clinicians “who care for older patients with diabetes who have dementia should review their glycemic targets and medications and consider relaxing the glycemic targets to moderate levels, maybe an HbA1c of 7% to 9%, and [replacing] sulfonylureas and insulin with agents that have a lower risk of hypoglycemia.” Many guidelines now include metformin as the first-line diabetes agent in the elderly.3

• Find a dietitian or nutritionist who is comfortable with both diabetes and dementia. Managing diabetes is difficult enough for patients with intact cognitive abilities. Factor in a poor memory or difficulty with executive function and the self-management of diabetes can be impossible. A professional who can help a patient and/or family adapt to the range of diabetic and dementia-specific needs can make a big difference for your patients and their caregivers.

• Advise family caregivers to “Take your oxygen first.” Acting as a family caregiver is among the most stressful roles any of us will undertake. Both dementia and diabetes are difficult illnesses. The combination of the two presents real challenges. Keep a special eye on any family caregivers you know and do what you can to ensure they have adequate clinical support, home and community-based resources appropriate to their loved ones’ needs, full understanding of their loved ones’ medical regimen, and options for occasional caregiving respite.

— Rosemary Laird, MD, MHSA, AGSF, is a geriatrician, executive medical director of senior services for Florida Hospital at Winter Park, and past president of the Florida Geriatrics Society. She is a coauthor of Take Your Oxygen First: Protecting Your Health and Happiness While Caring for a Loved One With Memory Loss.

References
1. Haroon NN, Austin PC, Shah BR, Wu J, Gill SS, Booth GL. Risk of dementia in seniors with newly diagnosed diabetes: a population-based study. Diabetes Care. 2015;38(10):1868-1875.

2. Hirabayashi N, Hata J, Ohara T, et al. Association between diabetes and hippocampal atrophy in elderly Japanese: the Hisayama Study. Diabetes Care. 2016;39(9):1543-1549.