Development and first-stage validation of a digital version of the Digit Symbol Substitution test for use in assessing cognitive function in older people with diabetes.

AIMS: To describe the development and report the first-stage validation of a digital version of the digit symbol substitution test (DSST), for assessment of cognitive function in older people with diabetes. MATERIALS AND METHODS: A multidisciplinary team of experts was convened to conceptualize and build a digital version of the DSST and develop a machine-learning (ML) algorithm to analyse the inputs. One hundred individuals with type 2 diabetes (aged ≥ 60 years) were invited to participate in a one-time meeting in which both the digital and the pencil-and-paper (P&P) versions of the DSST were administered. Information pertaining to demographics, laboratory measurements, and diabetes indices was collected. The correlation between the digital and P&P versions of the test was determined. Additionally, as part of the validation process, the performance of the digital version in people with and without known risk factors for cognitive impairment was analysed. RESULTS: The ML model yielded an overall accuracy of 89.1%. A strong correlation was found between the P&P and digital versions (r = 0.76, p < 0.001) of the DSST, as well as between the ML model and the manual reading of the digital DSST (r = 0.99, p < 0.001). CONCLUSIONS: This study describes the development of and provides first-stage validation data for a newly developed digital cognitive assessment tool that may be used for screening and surveillance of cognitive function in older people with diabetes. More studies are needed to further validate this tool, especially when self-administered and in different clinical settings.

Supporting a comprehensive and coordinated evaluation of the elderly with diabetes by integrating cognitive and physical assessment in the evaluation process.

BACKGROUND: Successful ageing with diabetes is challenged by co-morbidities, which may present barriers to self-care. Currently, measurement of physical and cognitive status is not part of routine care of the older person with diabetes, and these are not taken into account when devising the treatment plan. OBJECTIVE: To describe a novel approach that integrates cognitive and physical assessment into the routine evaluation of the older person with diabetes and the tailor-made treatment plan devised accordingly. To provide estimates of the relative contribution of cognitive and physical disabilities in this population. METHODS: Cognitive and physical assessments were added to the standard evaluation. A composite measure of cognitive and of physical status categorizing each individual to intact, mild, or severe impairment was generated. In addition, all recommendations provided were categorized and tabulated. RESULTS: Of 119 individuals, over the age of 60 with type 2 diabetes who were referred because of difficulties in managing their disease, 16% and 3% of individuals met the criteria for severe cognitive/physical impairment, respectively, and 42% and 21% met the criteria for mild cognitive/physical impairment; 72%, 12.5%, 61% received recommendations related to intensification of physical activity, cognitive treatment, change in pharmacological agents, respectively. 25% were referred for further emotional treatment. CONCLUSIONS: These data suggest that a substantial proportion of individuals with diabetes over the age of 60 may have cognitive/physical impairment. It highlights the importance of measuring these as part of the multidisciplinary evaluation and being able to provide a tailor made treatment plan.

The diabetic brain and cognition.

The prevalence of both Alzheimer's disease (AD) and vascular dementia (VaD) is increasing with the aging of the population. Studies from the last several years have shown that people with diabetes have an increased risk for dementia and cognitive impairment. Therefore, the authors of this consensus review tried to elaborate on the role of diabetes, especially diabetes type 2 (T2DM) in both AD and VaD. Based on the clinical and experimental work of scientists from 18 countries participating in the International Congress on Vascular Disorders and on literature search using PUBMED, it can be concluded that T2DM is a risk factor for both, AD and VaD, based on a pathology of glucose utilization. This pathology is the consequence of a disturbance of insulin-related mechanisms leading to brain insulin resistance. Although the underlying pathological mechanisms for AD and VaD are different in many aspects, the contribution of T2DM and insulin resistant brain state (IRBS) to cerebrovascular disturbances in both disorders cannot be neglected. Therefore, early diagnosis of metabolic parameters including those relevant for T2DM is required. Moreover, it is possible that therapeutic options utilized today for diabetes treatment may also have an effect on the risk for dementia. T2DM/IRBS contribute to pathological processes in AD and VaD.

Relationship between cognitive function in individuals with diabetic foot ulcer and mortality.

BACKGROUND: Diabetic foot ulcer (DFU) is a common diabetes mellitus (DM) complication. Individuals with DM and a DFU achieved significantly lower scores in cognitive tests than those without a DFU. We investigated whether baseline cognitive function in individuals with a DFU is a determinant of mortality. METHODS: A prospective study using data collected during a case-control study conducted in 2010-2012 whereby 90 participants with a DFU (mean age at baseline 58.28 ± 6.95 years, 75.6% male) took the paper and pencil and the NeuroTrax battery of cognitive tests. Depression was assessed, and the DFU status was evaluated. In 2020, information pertaining to participants' vital status (dead/alive) was collected and the relationship between baseline cognitive status and vital status was assessed. RESULTS: During a median follow-up of 6.8 years (range 0.2-9.5), 39 participants died (43.3%). Individuals alive vs. those who had died during follow-up had a higher global cognitive score at baseline (92.16 ± 10.95 vs. 87.18 ± 12.24, p = 0.045), but increased risk was not found. Individuals who were alive vs. those who had died during follow-up had statistically significantly higher baseline executive function, reaction time and digit symbol substitution test results. However, after adjustment for glycosylated hemoglobin (HbA1c), microvascular and macrovascular complications, no relationship between cognitive tests and mortality remained significant. CONCLUSIONS: The higher mortality rate among people with type 2 DM and a DFU was not significant after adjustment for HbA1c, micro- and macrovascular complications. There may be common pathophysiological pathways to both DM complications and cognitive impairment, which may contribute to increased mortality. Further studies are warranted.

Determining the Optimal Cognitive Screening Tool in Older People With Diabetes.

Background: Self-care is an important perspective to aging and transitional states in diabetes management. Population studies have shown that lower cognitive function is associated with worse self-care abilities. Several guidelines have emphasized the importance of assessing cognitive function in older people with diabetes and tailoring treatment plan accordingly. Those guidelines do not specify which tools are the most appropriate for this population. One approach to delineate which tools should be used is to assess which tools best correlate with self-care capacity. Objective: To assess which cognitive assessment tools best correlate with self-care capacity in older people with type 2 diabetes. Methods: Cross-sectional study, conducted amongst individuals with diabetes over the age of 60. The association between self-care capacity indices and different cognitive assessment tools was examined. Principal Component self-care constructs were determined and the association between these and the different cognitive assessment tools was examined. Results: A significant association was found between the Principal Component self-care construct and the Montreal Cognitive Assessment and MindstreamsTM scores. In a stepwise regression model including only the Montreal Cognitive Assessment score, a significant association was found between this score and the Principal Component self-care construct. The same was not found in a model that included only the MindstreamsTM scores. Conclusions: The Montreal Cognitive Assessment, previously validated as a brief cognitive screening tool, may be useful as an adjunct to assess the self-care capacity of older individuals with diabetes. Future studies in the clinic are needed to evaluate if using this tool may improve treatment plans.

A Comprehensive Intervention for Promoting Successful Aging Amongst Older People With Diabetes With Below-Normal Cognitive Function-A Feasibility Study.

Background: Older people with diabetes have an increased risk for disability and cognitive dysfunction, which may impede self-care capacity. These are not evaluated routinely in current health systems. In the Center for Successful Aging with Diabetes, patients over the age of 60 undergo multi-disciplinary evaluation days and are provided with an integrated (cognitive, physical, nutritional, and medical) treatment plan. Among individuals with below-normal cognitive function, self-adherence to these recommendations poses a challenge. Thus, the aim of this study was to test the feasibility of a multidisciplinary intervention amongst older people with diabetes with below-normal cognitive function and sub-optimal glucose control. Methods: Patients with a MoCA score under 26 and A1C >= 7.5% participated in a two-arm intervention: (A) a medical intervention: monthly meetings with a diabetes nurse-educator, supervised by a diabetes specialist and study psychologist during which changes in their pharmacological regimen of glucose, blood pressure, and lipid control were made and (B) a cognitive/physical rehabilitation intervention. This arm consisted of (1) an intensive phase-group meetings which included computerized cognitive training, aerobic, balance, and strength exercise, and group discussions and (2) a monthly consolidation phase. Outcomes included change in A1C, change in strength, balance, and aerobic exercise capacity as well as change in quality of life. Results: After 12 months there was a 0.7% reduction in A1C. After 3 months there was a statistically significant improvement in physical indices, including aerobic capacity (6-min walk), balance (FSST) and indices assessing the risk of fall (10-meter walk, time up and go). There was no additional improvement in physical indices between the 3 and 12 month visits. For some of the physical measures, the improvement observed after 3 months persisted partially to the 12-month visit. Conclusions: This feasibility study provides preliminary data that support the efficacy of the complex interventions described. The findings suggest that this older population would require an ongoing "intensive phase" intervention. Larger prospective randomized trials are needed.

Cognitive Dysfunction: Part and Parcel of the Diabetic Foot.

OBJECTIVE: The presence of a foot ulcer increases the self-treatment burden imposed on the individual with diabetes. Additionally, this condition increases the cognitive demands needed for adherence to medical recommendations. A potential gap could exist between medical recommendations and the individual's ability to implement them. Hence, the goal of this study was to examine whether the cognitive profile of people with diabetic foot ulcers differs from that of people with diabetes without this complication. RESEARCH DESIGN AND METHODS: This was a case-control study. Ninety-nine individuals with diabetic foot ulcers (case patients) and 95 individuals with type 2 diabetes (control subjects) (age range 45-75 years), who were matched for diabetes duration and sex, underwent extensive neuropsychological evaluation using a NeuroTrax computerized battery, digit symbol, and verbal fluency tests. A global cognitive score after standardization for age and education was computed as well as scores in the following six cognitive domains: memory, executive function, reaction time, attention, psychomotor abilities, and estimated premorbid cognition. RESULTS: Individuals with diabetic foot ulcers had significantly (P < 0.001) lower cognitive scores than individuals with diabetes without this complication, in all tested cognitive domains, excluding estimated premorbid cognition. Individuals with diabetic foot ulcers demonstrated a significant difference between precognitive and current cognitive abilities, as opposed to the nonsignificant difference among control subjects. The differences persisted in multivariable analysis after adjusting for depression and smoking. CONCLUSIONS: Individuals with diabetic foot ulcers were found to possess fewer cognitive resources than individuals with diabetes without this complication. Thus, they appear to face more self-treatment challenges, while possessing significantly fewer cognitive resources.

The Delis-Kaplan Executive Function System Sorting Test as an evaluative tool for executive functions after severe traumatic brain injury: a comparative study.

Neuropsychological tests are often used to evaluate executive function (EF) deficits in patients suffering traumatic brain injuries (TBIs). This study compared the sensitivity of three such tests--namely, the Delis-Kaplan Executive Function System Sorting Test (D-KEFS ST), the Wisconsin Card Sorting Test (WCST), and the Trail Making Test (TMT)--in differentiating between severe TBI patients and healthy controls. The differences between the two groups were significant for 5/5 variables evaluated through the D-KEFS ST, for 4/6 variables evaluated through the WCST, and for 2/2 variables evaluated through the TMT. Receiver operating characteristic analysis revealed that the variables "attempted sorts" in the D-KEFS ST and completion time in Part B of the TMT were the most powerful predictors of group assignment, with cutoff points of 9.5 sorts and 84.5 seconds, respectively. Our results highlight the possible value of the D-KEFS ST in the evaluation of postinjury EF deficits in TBI patients.