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Managing Cognitive Decline in Older Adults With Diabetes

This Physician’s Weekly feature on managing cognitive decline in older adults with diabetes was completed in cooperation with the experts at the American Diabetes Association. More than 25% of Ameri­cans aged 65 and older has diabetes, and the aging of the overall population has been identified as a significant driver of the diabetes epidemic. “Diabetes in older adults is associated with higher mortality, reduced cogni­tive and functional status, and increased risk of institutionaliza­tion,” explains Hermes Florez, MD, PhD, MPH. “Importantly, diabetes has been linked to sig­nificantly higher risks of cogni­tive impairment, a greater rate of cognitive decline, and increased risk of dementia.” While various complications of diabetes are well known and well researched, the effect diabetes has on the brain has historically received relatively little attention. “The risk of both diabetes and cognitive impairment increases with age,” Dr. Florez says. “The presentation of cognitive impairment in people with diabetes can vary, ranging from subtle executive dysfunction to overt dementia and memory loss. We’re starting to see links between diabetes and dementia and Alzheimer’s disease, but researchers are still conducting analyses to further increase our knowledge on these associations.”  Consensus Report on Diabetes in Older Adults In the December 2012 issue of Diabetes Care, the American Diabetes Association released a consensus report on diabetes and older adults. Dr. Florez, who was on the writing group that developed the report, says that an important component to managing older adults with diabetes is the role of cognitive impairment. “For older patients with diabetes, treatments will need to be simplified whenever possible, and caregivers should be involved during consultations. The presence of cognitive...

Helping Clinicians Determine Cognitive Status

Findings from an ongoing validation study suggest that certain informant-reported cognitive symptoms appear to help healthcare providers determine whether patients have normal cognition or amnestic mild cognitive impairment (aMCI). Strong indicators of an aMCI included: Informant-reported repetition of statements and/or questions. Trouble knowing the day, date, month, year, and time. Difficulty managing finances. Decreased sense of direction. Source: BMC Geriatrics, February 3,...

Hypnotics, Elderly, & the Risk of Falls

Research has shown that the prevalence of insomnia increases with age. The appropriate treatment of insomnia in older patients can be challenging for several reasons, including the prevalence of comorbid conditions, increased use of a variety of medications (espe­cially central nervous system active compounds), and a compromised ability to metabolize and/or excrete these medications. This compromised function has typically resulted in lower recommended doses for many therapies, especially for hypnotic agents for which starting doses for the elderly are often half or less than those for adults. The purpose of using lower doses is to minimize adverse events (eg, amnestic effects or residual sedation) and thereby maxi­mize daytime functioning and patient safety. “Minimizing the risks of falls and fall-related injuries is a paramount consideration in the treatment of insomnia in the elderly.” An important consideration for safety in the elderly popula­tion is the risk for falls and fall-related injuries. A recent article by Frey et al in the Journal of the American Geriatrics Society evaluated the effect of sleep inertia on balance and cognition during nighttime awakenings in both adults and the elderly. The authors found that zolpidem produced clinically significant balance and cognitive impairments upon awakening from sleep. However, the study did not directly evaluate the incidence of falls; instead, it used the results of performance on tandem walking as a predictor of falls. These tandem walks occurred 120 minutes after a scheduled sleep opportunity and, thus, were designed to test the effects of zolpidem and sleep inertia in the first half of the night when those effects would be greatest. While the study is methodologically sound, it...

Managing Diabetes in Older Adults

This Physician’s Weekly feature was completed in cooperation with the experts at the American Diabetes Association. Published research suggests that approximately 30% of people older than 65 have either diagnosed or undiagnosed diabetes, and the disease is of increasing concern for the aging population. It is expected that its incidence will grow rapidly in the coming decades as older individuals are living longer. “When compared with older adults without diabetes, those with the disease have higher rates of premature death, functional disability, and coexisting illnesses,” explains Medha N. Munshi, MD. These coexisting illnesses include coronary heart disease, stroke, peripheral vascular disease, renal failure, neuropathy, and retinopathy. In addition, older adults with diabetes are at greater risk for polypharmacy, depression, cognitive impairment, urinary incontinence, injuries from falls, and persistent pain. The care of older adults with diabetes can be challenging for physicians because of clinical and functional differences from patient to patient, Dr. Munshi says. “Some older individuals develop diabetes at an earlier age and may have complications by this time. Others develop the disease at an older age and present with a few diabetes-related complications.” Frailty, diabetes-related comorbidities, and other underlying chronic conditions are other important considerations for some older patients. Furthermore, the activity levels and comorbidities experienced by older adults vary considerably depending on each individual patient. Studies have shown that the life expectancy is highly variable for older patients, but often longer than clinicians realize. An Important Patient Population According to the American Diabetes Association’s Standards of Medical Care in Diabetes—2011, providers caring for older adults with diabetes must take the diversity of older patients into consideration when setting and...
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