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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...
Managing Delirium Among Elderly Patients in the ED

Managing Delirium Among Elderly Patients in the ED

National estimates demonstrate that elderly patients are increasingly presenting for care at EDs throughout the United States each year, and by current projections, this trend is expected to increase significantly as Americans are living longer than ever. Between 10% and 30% of the elderly who are evaluated in the ED will present with delirium, but the prevalence may be higher. “The causes of delirium in elderly patients presenting to EDs are multifactorial,” explains Medley O’Keefe Gatewood, MD (Table 1). “While it’s difficult to discern exactly what’s going on clinically, delirium is oftentimes the only sign of underlying serious and potentially life-threatening illnesses. Much like myocardial infarction and sepsis, delirium is a high-stakes entity.” Research has suggested that emergency physicians are inconsistent in recognizing mental status impairment and the signs and symptoms indicative of a delirium diagnosis in the elderly. Recent analyses have shown that emergency physicians correctly diagnose delirium in only about 24% to 35% of elderly patients, and many of these individuals are discharged with little consideration of delirium as an indicator of more serious medical conditions. Diagnosing Delirium Among the Elderly “Failing to detect delirium among the elderly in the ED and then discharging them can increase mortality within the first few months of discharge and up to a year,” says Dr. Gatewood, who coauthored an article in the May 2012 Western Journal of Emergency Medicine on the topic. “Even when delirium is diagnosed, some patients are still inappropriately discharged. Considering the high prevalence of impaired mental status and the increasing number of elderly patients who have delirium and are still discharged, emergency physicians must make greater...

Managing Common Diabetes Comorbidities: Going Beyond Standard Care

This Physician’s Weekly feature covering the management of common diabetes comorbidities was completed in cooperation with the experts at the American Diabetes Association. Throughout the medical literature, it has been well documented that patients with type 2 diabetes are at increased risk for developing cardiovascular disorders, including coronary artery disease and stroke. The constellation of symptoms that includes insulin resistance and obesity greatly increases the likelihood of additional comorbidities emerging. “In addition to the commonly appreciated comorbidities of obesity, hypertension, and dyslipidemia,” says Medha N. Munshi, MD, “diabetes is also associated with other diseases or conditions at rates higher than those of people without diabetes.” In keeping with patient-centered approaches to care, physicians should be aware of the wide spectrum of comorbidities their patients face when managing them throughout their disease course. When the risk for these comorbidities is elevated, patients should be treated accordingly. The American Diabetes Association reports that some of the more common comorbidities outside the realm of obesity, hypertension, and dyslipidemia include obstructive sleep apnea (OSA), fatty liver disease, cancer, and fractures (Table 1). “Clinicians should consider these other comorbidities during their care of patients with diabetes to optimize outcomes,” says Dr. Munshi. Obstructive Sleep Apnea OSA is the most common form of sleep-disordered breathing in patients with type 2 diabetes, accounting for over 80% of cases. In people with diabetes, the prevalence of OSA has been documented to be as high as 23% and the prevalence of some form of sleep disordered breathing may be as high as 58%. “Treating sleep apnea can significantly improve quality of life and blood pressure control,” Dr. Munshi...
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