Management of diabetes and dementia

Abstract

Continued advances in medicine have contributed to an ageing population in most countries, with a resultant increased prevalence of dementia as well as type 2 diabetes. Consequently, the combined co-morbidity of diabetes and dementia is on the increase. While there is a wealth of therapeutic options for diabetes in general, we need to adapt these medications and strategies to suit those with dementia. The intricacies of managing diabetes in patients with cognitive dysfunction are multiple and require a sound understanding of the patient, living environment and available therapeutic options. With the exception of metformin, dipeptidyl peptidase-4 inhibitors and to some extent insulin secretagogues, non-insulin therapy has a limited role. Insulin therapy, if initiated with a specified goal in mind and concentration on avoidance of hypoglycaemic episodes with relatively lax glycaemic targets, is the most straightforward way of managing glycaemia. Therapy should be individualised with involvement of the patient's care team and clear instructions to define roles, goals of therapy and need for regular review. In this article we discuss the effect of dementia on diabetes management and vice versa, glycaemic goals based on available evidence and recommendations including drug and regimen selection to safely achieve this. Br J Diabetes 2017;17:93-99

Diabetes duration and the risk of dementia: a cohort study based on German health claims data

“…Cognitive decline may worsen self-management of T2D therapy, even in early and undetected stages of dementia. This is a vulnerable phase, as cognitive changes may be aggravated by incorrect self-management of T2D as a consequence of hypo- or hyperglycaemia [ 47 , 48 ].…”

Diabetes-Related Topics in an Online Forum for Caregivers of Individuals Living With Alzheimer Disease and Related Dementias: Qualitative Inquiry

“…This is unsurprising, as diabetes is largely a self-managed disease that necessitates high-level cognitive capabilities for patients to properly adhere to medication and lifestyle regimens. However, memory loss, impaired problem-solving, and other ADRD symptoms make diabetes management extremely difficult for people living with ADRD and their family caregivers [ 14 , 60 ]. Previous recommendations and studies have suggested that for people with cognitive impairment, diabetes care should be individualized and patient-centered [ 60 ].…”

“…Previous recommendations and studies have suggested that for people with cognitive impairment, diabetes care should be individualized and patient-centered [ 60 ]. The glycemic target (eg, hemoglobin A 1c , fasting glucose, and postprandial glucose) should also be relaxed [ 14 ]. However, the incorporation of these recommendations into daily care regimens has rarely been studied in individuals living with ADRD and diabetes.…”

“…For those living with ADRD, the complexity of these regimens is often exacerbated by disease progression. Increased forgetfulness and confusion associated with the mid to late stages of dementia can result in improper meal choices or medication mismanagement [ 14 ]. This inability to participate in diabetes management as clinically instructed can result in harmful effects on the renal, cardiovascular, and peripheral nervous systems.…”

Improvement of cognitive function, glucose and lipid homeostasis and serum osteocalcin levels by liraglutide in diabetic rats

“…The widespread distribution of GLP-1 receptors in gastrointestinal tract, brain and bone extends their role beyond their use as anti-diabetic agents to far greater potentials. Indeed, improvement of cognitive function by liraglutide, via its effects on glucose and lipid metabolism, both directly and through an increase in osteocalcin, suggests that the drug might may have the benefit of reducing cognitive impairment that is commonly associated with diabetes [54,55].…”