2.0.0.0 NEU­ROCOG­NI­TIVE FUNC­TION

Older adults with di­a­betes are at high­er risk of cog­ni­tive de­cline and in­sti­tu­tion­al­iza­tion (6,7). The pre­sen­ta­tion of cog­ni­tive im­pair­ment ranges from sub­tle ex­ec­u­tive dys­func­tion to mem­o­ry loss and overt de­men­tia. Peo­ple with di­a­betes have high­er in­ci­dences of all-‍cause de­men­tia, Alzheimer dis­ease, and vas­cu­lar de­men­tia than peo­ple with nor­mal glu­cose tol­er­ance (8). The ef­fects of hy­per­glycemia and hy­per­in­su­line­mia on the brain are areas of in­tense re­search. Clin­i­cal tri­als of specific in­ter­ven­tions- in­clud­ing cholinesterase in­hibitors and glu­ta­mater­gic an­tag­o­nists­d-have not shown pos­i­tive ther­a­peu­tic benefit in main­tain­ing or significant­ly im­prov­ing cog­ni­tive func­tion or in pre­vent­ing cog­ni­tive de­cline (9). Pilot stud­ies in pa­tients with mild cog­ni­tive im­pair­ment eval­u­at­ing the po­ten­tial benefits of in­tranasal in­sulin ther­a­py and met­formin ther­a­py pro­vide in­sights for fu­ture clin­i­cal tri­als and mech­a­nis­tic stud­ies (10-12).

The pres­ence of cog­ni­tive im­pair­ment can make it chal­leng­ing for clin­i­cians to help their pa­tients reach in­di­vid­u­al­ized glycemic, blood pres­sure, and lipid tar­gets. Cog­ni­tive dys­func­tion makes it dif- ficult for pa­tients to per­form com­plex self-‍care tasks, such as glu­cose mon­i­tor­ing and ad­just­ing in­sulin doses. It also hin­ders their abil­i­ty to ap­pro­pri­ately main­tain the tim­ing and con­tent of diet. When clin­i­cians are man­ag­ing pa­tients with cog­ni­tive dys­func­tion, it is crit­i­cal to sim­pli­fy drug reg­i­mens and to in­volve care­givers in all as­pects of care.

Poor glycemic con­trol is as­so­ci­at­ed with a de­cline in cog­ni­tive func­tion (13), and longer du­ra­tion of di­a­betes is as­so­ci­at­ed with wors­en­ing cog­ni­tive func­tion. There are on­go­ing stud­ies eval­u­at­ing whether pre­vent­ing or de­lay­ing di­a­betes onset may help to main­tain cog­ni­tive func­tion in older adults. How­ev­er, stud­ies ex­am­in­ing the ef­fects of in­ten­sive glycemic and blood pres­sure con­trol to achieve specific tar­gets have not demon­strat­ed a re­duc­tion in brain func­tion de­cline (14,15).

Older adults with di­a­betes should be care­ful­ly screened and mon­i­tored for cog­ni­tive im­pair­ment (2) (see Table 4.1 for de­pres­sion and cog­ni­tive screen­ing rec­om­men­da­tions). Sev­er­al or­ga­ni­za­tions have re­leased sim­ple as­sess­ment tools, such as the Mini- Men­tal State Ex­am­i­na­tion (16) and the Mon­tre­al Cog­ni­tive As­sess­ment (17), which may help to iden­ti­fy pa­tients re­quir­ing neuropsy­cho­log­i­cal eval­u­a­tion, par­tic­u­lar­ly those in whom de­men­tia is sus­pect­ed (i.e., ex­pe­ri­enc­ing mem­o­ry loss and de­cline in their basic and in­stru­men­tal ac­tiv­i­ties of daily liv­ing). An­nu­al screen­ing for cog­ni­tive im­pair­ment is in­di­cat­ed for adults 65 years of age or older for early de­tec­tion of mild cog­ni­tive im­pair­ment or de­men­tia (4,18). Screen­ing for cog­ni­tive im­pair­ment should ad­di­tion­al­ly be con­sid­ered in the pres­ence of a sig­nif­i­cant de­cline in clin­i­cal sta­tus, in­clu­sive of in­creased difficulty with self-‍care ac­tiv­i­ties, such as er­rors in cal­cu­lat­ing in­sulin dose, difficulty count­ing car­bo­hy­drates, skip­ping meals, skip­ping in­sulin doses, and difficulty rec­og­niz­ing, pre­vent­ing, or treat­ing hy­po­glycemia. Peo­ple who screen pos­i­tive for cog­ni­tive im­pair­ment should re­ceive di­ag­nos­tic as­sess­ment as ap­pro­pri­ate, in­clud­ing re­fer­ral to a be­hav­ioral health pro­vider for for­mal cog­ni­tive/neuropsy­cho­log­i­cal eval­u­a­tion (19).