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Running head: GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY POPULATION Glycemic Control and Dementia in Elderly Population Farzaneh Raoufi Samuel Merritt University Epidemiology and Population Health N703 Karen Wolf, Ph.D. April 13, 2013 1 GLYCEMIC CONTROL IN ELDERLY POPULATION 2 Abstract Management of diabetes and glycemic control in general population, particularly in elderly adults is costly and difficult due to complexity and comorbidity associated with diabetes. People with diabetes are twice at risk for death in comparison to adults without diabetes (Centers for Disease Control and Prevention [CDC]). Glycemic control in elderly adult aged 65 years or older is crucial, as incidences of hypoglycemia may result in vision impairment, altered mental status and other health related issues. Diabetes type 2 is associated with “1.5-2.5 fold increased risk of dementia” (Strachan, Reynolds, Marioni, & Price, 2011). The purpose of this paper is to establish whether or not hypoglycemia is associated with the development of dementia in elderly population, aged 65 years or older with diabetes type 2. Introduction Diabetes is considered to be the “seventh leading cause of death” in the United States. Approximately, 10.9 million of U.S. adult population aged 65 years or older had diabetes in 2010 (CDC, 2011). From 2006 through 2009, the number of Emergency Department (ED) visits related to diabetes was increased by about 10,528,000. From 2005 through 2008, results of fasting blood glucose and hemoglobin A1c indicated that 50 percent of adults aged 65 years or older were considered to be pre-diabetes (CDC, 2011). In the United States, diabetes is the leading cause of renal insufficiency, below knee amputation and blindness. In addition, diabetes is the “major cause” of cardiovascular disease and stroke. Cost of medical care related to diabetes is high and will continue to rise. In 2007, the estimated “direct medical cost” related to diabetes was $116 billion (CDC, 2011). GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 3 It is estimated that about half of elderly adults with diabetes do not know that they have the disease. Due to “physiological changes associated with aging”, the signs and symptoms of diabetes are masked in the elderly population. Often, elderly adults with diabetes present with altered mental status, disorientation and incontinence. Due to an “enhanced epinephrine response”, elderly adults have severe hypoglycemia (Chau, & Edelman, 2001). In 2011, 28.5 percent of adults aged 65 years or older reported “poor mental health at least one day in the past thirty days” (CDC, 2011). Therefore, glycemic control in elderly adult is highly desirable and would reduce the incidences of confusion, dehydration and other symptoms or diagnoses associated with diabetes. Literature Review One of the potential complications associated with diabetes is hypoglycemia. Hypoglycemia is defined as “all episodes of an abnormally low plasma glucose concentration that expose the individual to harm” (Services, et.al, 2012, para. 1). In a “longitudinal cohort study from 1980-2007”, 16,667 elderly patients with the following criteria were screened for hypoglycemia: a. diagnosis of diabetes type 2 and b. were a member of Northern California Kaiser Permanente (Whitmer, et.al, 2009, p. 1565). Participants’ mean age was 65 years old. About 66 percent of the participants were white and 55 percent were male. From 1980 through 2002, hospital discharges and ED diagnoses were utilized to collect and analyze the hypoglycemia episodes. “Cohort members”, who had no history of dementia, or memory and cognitive impairments “as of January 1st, 2003, were followed up for a dementia diagnosis through January 15th, 2007” (Whitmer, et al., 2009, p. 1565). During follow up: a. 1465 of the participants had one episode of hypoglycemia, b. 1822 patients had dementia, and c. 250 patients had both one episode of hypoglycemia and dementia. Adjusted “hazard ratio” (HR) and “95 GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 4 percent confidence interval” (CI) for participants with” a. one hypoglycemic event were 1.26 and 1.10-1.49 (HR: 1.26, and CI: 1.10-1.49), b. two hypoglycemic events were 1.80 and 1.37- 2.36 (HR: 1.80 and CI: 1.37-2.36), and c. three or more hypoglycemic events were 1.94, and 1.422.64 (HR: 1.94 and CI: 1.42-2.64) (Whitmer et al., 2009, figure 3). The results of this study indicated that elderly population with diabetes type 2 and hypoglycemic events were linked to being at a great risk for dementia. The strengths of this research study were: a. inclusion of a large cohort of participants of elderly adults of aged 65 years or older with diabetes type 2, and b. participants had no prior history of dementia. The weaknesses of this study are: a. dementia diagnosis was obtained from retrospective medical chart review and neurological assessments were not utilized to validate the diagnosis, and b. majority of the subjects were women and white. Glycemic control in elderly population is complicated due to the presence of comorbidities and other aged related risk factors. In a study conducted in Taiwan, one million participants were randomly chosen from the “National Health Insurance Research Database” (Lin & Sheu, 2013, p. 103). Total of 15,404 participants; “more likely women”, with the following criteria were included in the study: a. diabetes type 2 diagnosis and b. no prior history of dementia. The mean age was 64.2 years. The participants were followed up for a period of seven years. Approximately, 289 participants had at least one episode of hypoglycemia in a three year period of time. 1106 of the subjects were diagnosed with dementia. The incidence rate of dementia for those with hypoglycemic events was 29.9 “per 1000 person-years” in comparison to those without hypoglycemic episodes with “11.1 per 1000 “per 1000 personyears.” The results of this study indicated that elderly population with diabetic type 2 and episodes of hypoglycemia were at higher risk for developing dementia (Lin & Sheu, 2013, GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 5 p.104). The strength of this study was inclusion of a large number of participants. The weaknesses and limitations of the study were: a. majority of the participant were likely women, and b. the episodes of hypoglycemia were only followed for a period of three years. In the “developed country”, the number of elderly adults with diabetes will increase from 25 million to 48 million. This increase can be due to lack of physical activity, obesity and fast food and poor nutrition (Strachan, et al., 2008). In a study conducted in China, 8,213 subjects aged 65 years or older participated. 1,109 participants with diabetes type 2 were selected via interview and glucose testing. All participants were “screened with the DSM-IV criteria for dementia” (Fei, et.al, 2013, para. 2). Cognitive and neurological assessments were completed for all participants. 132 were diagnosed with “all cause dementia” with a prevalence rate of 1.61%. The results of the study supports the fact that hypoglycemia was linked with dementia in Chinese elderly population, aged 65 years or older with diabetes type 2 (Fei, et al, 2013). The strengths of this study were: a. inclusion of a large number of participants, and b. comprehensive neurological and cognitive assessments were utilized for screening dementia. The weakness of the study is that age and gender of the participants were not included in the study. Barriers to change Monitoring of blood glucose is the ideal method for “achieving glycemic goal.” “Physiological changes associated with aging”, the signs and symptoms of diabetes are masked in the elderly population (Chau, & Edelman, 2001). Generally, hemoglobin A1c is monitored: a. two times per year for elderly adults with “stable glycemic control,” and b. every three months for elderly with fluctuating and unstable glycemic control (McCulloch, et al., 2013). Blood glucose can be easily monitored by patients or caregivers at home. “Self-monitoring of blood glucose” (SMBG) is beneficial in elderly patients with diabetes type 2 in order to avoid GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 6 occurrences of hypoglycemic events (McCulloch, et al., 2013). However, compliance and adherence to monitoring, treatment and follow-up may be a challenge in elderly population due to cognitive impairment. Gaps Elderly population with diabetes type 2 may benefit from “health management support system”, in which the results of blood glucose are either manually entered in a “personal digital assistant” (PDA) or the results are digitally recorded and send to the primary care provider. The physician may access and monitor patients’ results and provide instructions to the patients (Tani et al., 2010). To evaluate use of a PDA, twenty volunteers from a corporation, “whose age’s ranged from twenty to sixty,” responded to a survey questionnaire utilizing a PDA. The evaluation of the results indicated that feedback from participants (Tani et al., 2010). Although, advances have been made in this field, much improvement is needed, particularly for patients with vision impairment or language barrier. Diabetes in the United States Diabetes is considered to be the “seventh leading cause of death” in the United States. In the United States, diabetes among people aged 18-79 has been on rise from 1980 through 2010. About 63 percent of U.S. adults aged 18-79 were diagnosed with diabetes in 2011. Approximately, 21 percent of diabetes diagnosis in 2011 was among elderly adults aged 65-79. In 2011, “the median duration of diabetes” among elderly adults aged 65-79 was 9.8 years. In 2011, Diabetes was 25 percent higher among African American males and females and Asian males, who were 65 years or older (CDC). Age, Gender and Race The table below presents the prevalence of diabetes among U.S. population (CDC, 2011). GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS Category 7 Number of people with diabetes People aged 20 years or older 25.6 million People aged 65 years or older 10.9 million Men 13.0 million Women 12.6 million “Non-Hispanic White” 15.7 million “Non-Hispanic White” 4.9 million Trends Population of elderly is on rise and it is expected that population of people aged 65 or older will increase by about 134 percent over the next thirty years ((Strachan, et.al, 2008). It is estimated that about 2.8 percent of the “global population” (171 million people) have diabetes. It is expected that about 4.4 percent (366 million people) of the world’s population will have diabetes by 2030 (Strachan, et.al, 2008, para. 1). Future Directions and Limitation Glycemic control in patients with diabetes is the gold standard and would minimize the risks associated with hypoglycemia. Elderly adults with diabetes type 2 are particularly sensitive to low blood glucose level and may suffer from cognitive impairment and dementia. Cognitive assessment along with blood glucose monitoring can be achieved via PDA. In a study done by Onoda, et.al, 2013, use of PDA was found to be helpful in screening of dementia in Japanese population. However, much advancement in the electronic medical record and PDA are needed to ensure that: a. patient privacy is safe-guarded and b. PDA features are user friendly. GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 8 Summary and Conclusion The “prevalence of diabetes type 2” continues to rise, particularly among age group 6074 years old (McCulloch, et al., 2013). Achieving optimal glucose is crucial in the elderly population as they are at risk for developing dementia. Based on the literature review of several studies in this paper, there is a link between hypoglycemia and development of dementia in elderly population aged 65 years or older, who have diabetes type 2. Most of the studies included in this literature review, failed to include and demonstrate the effect of age, gender and race. SMBG is beneficial in elderly patients with diabetes type 2 in order to avoid occurrences of hypoglycemic events (McCulloch, et al., 2013). Advancement in the electronic medical record and PDA will improve SMBG monitoring in patients with diabetes. Advance practice nurses (APN) with informatics background can be instrumental in reaching out and educating the elderly population with diabetes, who are vulnerable and at risk for cognitive impairment. Future research studies are needed to examine the effect of PDA and role of APNs in educating and assessing elderly patients with diabetes. GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS References CDC. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/diabetes/statistics/incidence/fig1.htm CDC. Retrieved from Centers for Disease Control and Prevention: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf Chau, D., & Edelman, S. V. (2001). Clinical management of diabetes in the elderly. Clinical Diabetes, 19(4), 172-175. http://dx.doi.org/doi.10.2337/diaclin.19.4.172 Fei, M., Ping, Z. Y., Juan, M. R., Ning, L. N., & Lin, G. (2013, ). 1/7. Age Ageing. http://dx.doi.org/doi: 10.1093/aging/afs188 Lin, C. H., & Sheu, W. H. (2013). Hypoglycaemic episodes and risk of dementia in diabetes mellitus: 7 year follow-up study. Journal of Internal Medicine, 273(1), 102-110. http://dx.doi.org/doi: 10.111/joim.12000 McCulloch, D. K., Munshi, M., Nathan, D. M., Schmader, K. E., & Mulder, J. E. (2013). Treatment of type 2 diabetes mellitus in the elderly patient. Retrieved from http://www.uptodate.com Onoda, K., Hamano, T., Nabika, Y., Aoyama, A., Takayoshi, H., Nakagawa, T., Yamaguchi, S. (2013, 3/26). Validation of a new mass screening tool for cognitive impairment: Cognitive assessment for dementia, iPad version. Journal of Clinical Interventions in Aging, 8, 353-360. http://dx.doi.org/doi: 10.2147/CIA.S42342 Service, F. J., Cryer, P. E., Hirsch, I. B., & Mulder, J. E. (2012). Hypoglycemia in adults: Clinical manifestations, definition, and causes. Retrieved from http://www.uptodate.com 9 GLYCEMIC CONTROL AND DEMENTIA IN ELDERLY ADULTS 10 Strachan, M. W., Reynolds, R. M., Frier, B. M., Mitchell, R. J., & Price, J. F. (2008, 10/18). The relationship between type 2 diabetes and dementia. British Medical Bulletin, 88(1), 131146. http://dx.doi.org/doi: 10.1093/bmb/dn042 Strachan, M. W., Reynolds, R. M., Marioni, R. E., & Price, J. F. (2011). Cognitive function, dementia and type 2 diabetes mellitus in the elderly. 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