Cognitive dysfunction in type 2 diabetes : detection and treatment in primary care

Abstract

A less known complication of type 2 diabetes (T2DM) is cognitive dysfunction. Patients with T2DM already have cognitive decrements in an early stage of their disease. Cognitive dysfunction can lead to problems in diabetes treatment. Diabetes guidelines advise physicians to address patient’s cognitive functioning. However, cognitive dysfunction often remains undiagnosed. We introduce the term ‘diabetes-associated cognitive decrements’ for subtle cognitive changes in patients with T2DM, from all ages, who express concerns about their cognitive performance, typically increased mental effort, but with largely preserved social or occupational functioning. We examined cognitive function in 183 patients with screen-detected type 2 diabetes and subsequently randomized to six years of intensive multifactorial treatment (strict targets for glucose, blood pressure and cholesterol) or standard treatment. Cognitive decline proved not to be influenced by an intensive treatment. We did find that people with undiagnosed cognitive impairment have a lower health status (difference between the groups on physical scale 3.5 out of 100 points; on mental scale 2.9 points) and have depressive symptoms twice as often as diabetes patients without cognitive impairment. However, depressive symptoms did not influence cognitive function of patients with T2DM. All in all, patients with T2DM and cognitive impairment are a vulnerable group of patients; we therefore believe that early recognition of cognitive dysfunction as efficiently as possible is desirable.

After a literature search, we developed a diagnostic algorithm that can guide the primary care physician towards the most probable diagnosis in case of cognitive complaints. We propose to use one of three different tests depending upon the prior probability of cognitive impairment , based on history taking. Additionally, we evaluated the TYM and SAGE questionnaires, tests that can be filled out by patients themselves in a few minutes, in 228 T2DM-patients for the detection of cognitive impairment. With these questionnaires, eight out of ten people can be reassured, substantially reducing the work load of primary care physicians in the suggested case-finding strategy. If primary care physicians approach cognitive dysfunction in patients with T2DM in this way, they can tailor diabetes treatment to the capacities of the patient.