Denise Feil

Risk of Hypoglycemia in Older Veterans with Dementia and Cognitive Impairment:: Implications for Practice and Policy

To examine the relationship between management of diabetes mellitus and hypoglycemia in older adults with and without dementia and cognitive impairment.

Frontal Lobe Hypometabolism and Impaired Insight in Alzheimer Disease

OBJECTIVE The authors examined the relationship between impaired insight regarding cognitive and functional deficits and frontal cortex hypometabolism in 41 patients with Alzheimer disease (AD). METHODS Regional cerebral glucose metabolism was determined with (18F)fluorodeoxyglucose and positron emission tomography. Level of insight was measured with the clinician-rated Neurobehavioral Rating Scale, and severity of global cognitive impairment was determined with the Mini-Mental State Exam. RESULTS Inaccurate insight was correlated with glucose metabolic rate in the right lateral frontal cortex (Brodmann areas 6 and 45, and the lateral aspect of Brodmann areas 8 and 9) after controlling for global cognitive dysfunction. CONCLUSIONS The findings from this study help to further elucidate the neurobiological mechanisms underlying impaired insight in AD, indicating a link between this important clinical phenomenon and dysmetabolism in a focal region of the right prefrontal cortex.

Cognitive Impairment, Chronic Medical Illness, and Risk of Mortality in an Elderly Cohort

OBJECTIVE The mortality risk for older persons with chronic medical illness and cognitive impairment is relatively unknown. The authors assessed 6-year mortality risks for cognitive impairment and six chronic diseases in 7,482 subjects from the East Boston, Massachusetts, and rural Iowa cohorts of the Established Populations for Epidemiologic Studies in the Elderly (EPESE). METHODS Cognitive impairment was identified with a modified form of Pfeiffers Short Portable Mental Status Questionnaire. Chronic medical illnesses included diabetes, stroke, myocardial infarction, hypertension, hip fracture, and cancer. The authors examined the association of cognitive impairment and each of the six chronic illnesses with mortality by means of Cox proportional-hazards regression models, and determined the interaction of cognitive impairment and chronic medical illness on mortality. RESULTS Participants who were cognitively impaired at baseline were found to have a 68% increased relative risk of mortality. The relative risks of mortality from diabetes, heart attack, stroke, and hip fracture were similar to the risk from cognitive impairment. Interactions between cognitive impairment and each chronic medical illness on mortality were not statistically significant. CONCLUSION Survival curves demonstrate that the effects of cognitive impairment and chronic medical illness on mortality are mostly additive, resulting in very poor survival for those with both medical illness and cognitive impairment. Further research should examine the healthcare behaviors and needs of older adults with cognitive impairment.

Quality Indicators for the Care of Dementia in Vulnerable Elders

The literature summaries that support each of the indicators judged to be valid in the expert panel process are described.

The role of cognitive impairment and caregiver support in diabetes management of older outpatients.

Objectives: To examine the role of cognitive impairment and caregiver support in diabetes care adherence and glycemic control. Methods: Fifty-one veteran male outpatients (27 with caregivers) aged 60 years and older with type 2 diabetes were evaluated for cognitive impairment with the Cognitive Abilities Screening Instrument. Patients or caregivers completed diabetes self-care and depression scales. Medical morbidity information and HbA1c plasma levels at baseline and 1 year later were obtained from electronic medical records. Results: Greater cognitive impairment (F = 5.1, p < .05), and presence of a caregiver (F = 5.3, p < .05), were independently associated with worse diabetes care adherence (adjusting for age, education, medical comorbidity, and depression). In addition, Mean HbA1c levels were worse in the cognitively impaired group with caregivers relative to the three other groups (F = 4.10, p < .05, η2 =.09). One year later, mean HbA1c levels rose from 7.7 to 8.2% in the cognitively impaired group with caregivers. Conclusion: Cognitive impairment is associated with worse diabetes care management. Surprisingly, the presence of a caregiver is not protective. Further research is necessary to examine the healthcare needs of cognitively impaired, diabetic patients and their caregivers.

Valproate-induced hyperammonemia as a cause of altered mental status.

The authors describe valproate-induced hyperammonemia and mental status changes in an 88-year-old man, the first known reported case in an elderly patient. They discuss this underrecognized complication of valproate use and the implications for treating elderly patients, in whom valproate use is increasing.

Impact of dementia on caring for patients’ diabetes

Objective: To explore caregivers’ challenges and quality-of-life issues managing diabetes in patients with dementia. Method: We conducted six focus groups with 21 caregivers of patients with dementia and type 2 diabetes. Focus groups were digitally recorded, transcribed, and translated using a software coding system. Emergent themes were identified and confirmed. Results: Three themes emerged. (1) Memory loss was the first identified cause of self-care neglect leading to caregiver intervention. (2) Behavioral and psychological symptoms of dementia (BPSD) disrupted the daily diabetes care routine, with ‘denial’ of having diabetes or memory loss (anosognosia) being the most disruptive. (3) Caregivers reported that caring for both diabetes and dementia was highly burdensome, felt overwhelmed with BPSD, and wanted more support from family and patients’ healthcare providers. Conclusion: Caregivers of patients with dementia and diabetes face extraordinary challenges managing both conditions and the accompanying BPSD. Their identified need for a greater response from the healthcare system should be tested in quality improvement programs for this overlooked yet rapidly growing population.

Cognitive impairment is a major risk factor for serious hypoglycaemia; public health intervention is warranted

Commentary on: Yaffe K, Falvey CM, Hamilton N, et al. Association between hypoglycemia and dementia in a biracial cohort of older adults with diabetes mellitus. JAMA Intern Med 2013;173:1300–6.[OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] Severe hypoglycaemia in persons with diabetes mellitus (DM) has received recognition as a major public health problem in recent years.1 Recently the US Department of Health and Human Services proposed a National Action Plan2 for hypoglycaemic safety that emphasises known risk factors for severe hypoglycaemia, including cognitive impairment (CogI) and dementia (D). Yaffe and colleagues add to the epidemiological evidence defining this at-risk population. The authors used a 12-year longitudinal population-based study of 783 older, multiracial, multiethnic adults with DM to evaluate whether CogI or D increases the risk of developing a severe hypoglycaemic event and whether prior hypoglycaemia … [1]: {openurl}?query=rft.jtitle%253DJAMA%2BIntern%2BMed%26rft.volume%253D173%26rft.spage%253D1300%26rft_id%253Dinfo%253Adoi%252F10.1001%252Fjamainternmed.2013.6176%26rft_id%253Dinfo%253Apmid%252F23753199%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1001/jamainternmed.2013.6176&link_type=DOI [3]: /lookup/external-ref?access_num=23753199&link_type=MED&atom=%2Febmed%2F19%2F2%2F77.atom [4]: /lookup/external-ref?access_num=000324160100007&link_type=ISI