Clinical characteristics and healthcare utilisation associated with undiagnosed cognitive impairment in elderly patients with diabetes in a primary care setting: a population-based cohort study.

OBJECTIVES: The objective of this study is to report the prevalence, clinical characteristics and healthcare utilisation of patients with type 2 diabetes (T2DM) and previously undiagnosed cognitive impairment who were identified as having a low Montreal Cognitive Assessment (MoCA) score. DESIGN: A population-based cohort study comparing clinical characteristics, medications, outpatient and inpatient care of patients with a MoCA score <19 to MoCA >26 using descriptive statistics, linear regression and multivariate logistic regression. SETTING: Electronic medical records of a large health maintenance organisation in Israel. PARTICIPANTS: 350 patients, age >65 with T2DM who participated in a cognitive function screening initiative using MoCA, and had a follow-up visit during the 12 months after screening. RESULTS: 130 (37.1%) had a MoCA score >26 and 68 (19.4%) <19. Patients with MoCA<19 had more diabetes-related complications, poorer glycaemic and lipid control, fewer visits to their main primary care physician (PCP; 3.9±3.2 vs 7.3±4.2 visits/year p=0.008), shorter duration of PCP visits (8.3±4.5 vs 4.0±3.5 min, p=0.007), fewer nutritionist and endocrinologist visits, and lower participation in diabetes or smoking cessation workshops. They were less likely to be treated with glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 inhibitor (DPP-4), or sodium-glucose transport protein 2 (SGLT-2) inhibitors and more likely to receive insulin or sulfonylurea. Moreover, they had more emergency room visits (ER; 15 (11.5%) vs 16 (23.5%), p=0.019), hospitalisations (8 (6.2%) vs 22 (32.4%), p=0.001), and longer hospital stays (4.3±3.2 vs 14.5±9.8, p=0.001). Using statistical models, MoCA<19 was identified as a risk factor for fewer and shorter PCP visits and more ER visits and hospitalisations. CONCLUSIONS: This study highlights the high prevalence of undiagnosed severe cognitive impairment in elderly patients with T2DM and its association with poor outpatient care. Appropriate interventions are needed to improve outcomes and prevent hospitalisation in this high-risk population.

The Association between Glucose Control and Functional Indices in Older People with Diabetes.

Diabetes may be viewed as a disease of accelerated aging as it is a risk factor for physical disability and impairment in simple and complex activities, and is a higher risk for falls and fractures. Data from the last several years suggests that this increased risk is due not only to recognized diabetes complications but also to an accelerated decline in physical capacity due to lower muscle quality and a more rapid decline in muscle mass and lower extremity strength over time. Aim. To find the association between glucose control and functional indices. Methods. A cross-sectional study conducted at the Center for Successful Aging with Diabetes at the Sheba Medical Center. Individuals with a diagnosis of type 2 diabetes over the age of 60 were included. Functional status was assessed using tools that assess aerobic, strength, and balance capacities. Medical assessment was conducted through interview, physical examination, and collection of information from medical records. The association between functional indices and A1C was assessed using linear regression. Results. 153 consecutive individuals were evaluated. There was an inverse association between A1C and score achieved on the 6-minute walk; with increasing meters walked on the 6-minute walk test, there was a reduction in A1C (p = 0.003). There was also an inverse association with the 10-meter walk (p = 0.007), BERG balance test (p = 0.0006), and timed up and go (p = 0.01). Conclusion. In this cohort of older people with diabetes, there was an association between A1C and measures of functional indices. Future studies of glucose-lowering medication should include physical and functional assessment.