Diabetes with Dementia: How to Address This Compound Condition in Older Adults

While diabetes and dementia each increase in incidence with age, it’s the combination of the two that is a growing challenge in geriatric care.

“There’s a bidirectional relationship: Diabetes is a risk factor of Alzheimer disease and vascular dementias, and cognitive dysfunction can affect how well a patient manages diabetes,” says Ardeshir Hashmi, MD, Director of Cleveland Clinic’s Center for Geriatric Medicine. “More and more we are seeing patients with intertwined diabetes and cognitive dysfunction.”

Nearly one in four adults age 75 and older with diabetes also has dementia or cognitive impairment, found one study of 498,000 U.S. veterans.

“Geriatricians need to be aware of the interplay of these conditions so we can be more proactive in how we care for older patients with diabetes,” says Dr. Hashmi.

He and Cleveland Clinic geriatrician Sathya Reddy, MD, stress the importance of cognitive assessments and personalized care plans in a recent article in Clinics in Geriatric Medicine.

The connection between diabetes and cognitive impairment

People with type 2 diabetes have a 1.5-fold to 2-fold increase in dementia, suggest multiple studies. Potential links include:

• Hyperglycemia in poorly controlled diabetes, which can lead to microvascular changes in the brain and neuronal toxicity.
• Hypoglycemic episodes and severe hypoglycemia, which is also linked to delirium and fall risk.

Conversely, patients with cognitive impairment have a higher risk of developing both hyperglycemia and hypoglycemia.

“These patients may not reliably follow a diabetes care plan,” says Dr. Reddy. “They may inadvertently take the wrong dose of medication, incorrectly administer insulin or forget to eat, for example.”

Assessing cognitive dysfunction

According to recent Medicare guidelines, all patients with diabetes who are older than age 65 should be tested annually for memory loss.

“Sometimes early cognitive impairment is difficult to detect,” says Dr. Hashmi. “Memory loss can be subtle, especially if the patient has a relatively simple care plan and seems to be functioning well.”

Drs. Hashmi and Reddy recommend these screening tools for evaluating cognitive impairment:

• Mini-Cog, which takes just three minutes to complete and consists of a three-item recall test plus a clock-drawing component.
• Montreal Cognitive Assessment (MoCA), a 30-question test that assesses short-term recall, executive function, abstract reasoning, language and more in about 10 minutes.
• Mini-Mental State Examination (MMSE), a brief questionnaire that assesses orientation to time and place, attention, recall, language and more in five to 10 minutes.

“Cognitive screening is necessary, especially when a patient is showing signs of poorly controlled diabetes, can’t recall medication use or has begun missing appointments,” says Dr. Reddy.

Tailoring care plans

Diabetes care plans for older adults are not one-size-fits-all, he says. Plans should be tailored according to age, comorbidities, cognitive function, physical autonomy, frailty and overall goals of care.

Even glycemic goals will vary. Older adults with few comorbidities, normal cognitive function and the ability to perform activities of daily living (ADLs) may be advised to maintain hemoglobin A1c <7.5%. Those with more comorbidities and reduced cognitive function, requiring more assistance with ADLs, may be advised to maintain hemoglobin A1c <8-8.5%.

“Above all, ‘what matters most’ to the patient should influence the diabetes care plan,” says Dr. Hashmi. “Quality of life is defined differently by each individual. For one patient, it may involve preventing long-term complications of diabetes and staying functionally independent. For another, it may involve merely avoiding symptomatic hyperglycemia.”

Patient-centered care, with individualized goals and patient- or family-selected care preferences, will revolutionize quality metrics for older adults with multiple comorbidities, including diabetes and dementia, concludes Dr. Hashmi.