Cognitive impairment in diabetes oft overlooked

Cognitive decline is a growing concern in people living with diabetes. Dr Wong Ping Foo, a family medicine specialist with the Ministry of Health (MOH), outlines the connection between diabetes and cognitive impairment.

People with diabetes are at higher risk of cognitive decline. These cognitive changes may affect self-care, medication use, and daily function. It falls upon the frontliners, i.e., the primary care teams to help detect early signs and take action, Wong said.

The link between diabetes and cognitive decline
Studies show that diabetes increases the risk of both vascular dementia and Alzheimer’s disease. It is thought that chronic hyperglycaemia, insulin resistance, and inflammation may affect brain function. Key factors that increase the risk are duration of diabetes (longer equals higher risk), poor glycaemic control, and frequent hypoglycaemic episodes.

It is also possible that microvascular damage can impair cognitive performance over time. Diabetes-related complications such as stroke and kidney disease also increase the risk.

What to look for
Cognitive decline can be subtle and often, patients may not complain directly. Caretakers and HCPs should be on the lookout for:

·        Missed appointments

·        Poor medication adherence

·        Repeatedly asking the same questions during consults

·        Difficulty understanding instructions

·        Forgetting daily tasks

·        Reduced social interaction

For confirmation, always ask family members or caregivers if they have noticed any changes.

Most cognitive issues seen in clinical practice are those categorised as mild cognitive impairment, which is not considered as dementia, as their daily function remains mostly intact. Dementia usually involves significant cognitive decline that affects the patient’s independence. Common forms of dementia are Alzheimer’s disease, vascular dementia, and mixed dementia.

Early detection can come in the form of targeted screening, especially in the primary care setting.  Screening is warranted when a family member or patient raises concerns, in cases of poor glycaemic control, among older patients, and in patients presenting with multiple vascular risk factors, said Wong.

Several quick cognitive screening tools are suitable for use in primary care. The Mini-Cog is brief, easy to administer, particularly for older adults. The Montreal Cognitive Assessment (MoCA) provides more detailed screening in about 10-15 minutes. The Mini-Mental State Examination (MMSE), which is widely used, tests five cognitive areas: orientation, registration, attention and calculation, recall, and language, but may miss early cases. Wong said it was always good to consider the patients’ language and education level when choosing these tools.

Management
Once diagnosed, management needs to be practical and patient specific. HCPs should focus on simplifying treatment regimens, supporting caregivers and planning ahead for decline.

Increased risk of hypoglycaemia among older patients calls for safer, individualised target HbA_1c based on the patient’s comorbidities and functional status. Wong suggested avoiding sulfonylureas and insulin, and considering medications with once-daily dosage. Caregivers have an important role in monitoring intake of meals and medication as well as behaviour changes. Thus, caregivers should be involved in decision making and provided clear, written instructions. Caregivers should be referred to community support services when needed, as caregiving can take a heavy toll on their wellbeing.