Cognitive deterioration in elderly diabetic patients

Arch. Gerontol. 0167-4943/98/$19.00 COGNITIVE

Geriatr.

suppl. 6 (1998) 347-354 0 1998 Elsevier Science Ireland

DETERIORATION

M.

MOTTA,

C.

D.

ROSSO,

G.

Institute Hospital,

of Via

ELIA,

IN

F.

Internal Messina,

ELDERLY

SALOMONE,

SALERNO,

D.

Ltd. All right DIABETIC

A.

and

L.

Medicine and Geriatrics, 629, l-95126 Catania.

347

PATIENTS

ZOCCOLO,

MAUCERI

reserved

L.

FERLITO,

MOTTA

Catania

University,

Cannizzaro

Italy

SUMMARY This study was aimed at evaluating the cerebral alterations occurring in diabetic subjects. The total study population consisted of 29 males (mean age: 76.2 + 6.3 years) and 40 females (mean age: 74.2 + 8.6 years). The patients were divided in 3 groups: (i) Late onset elderly diaetics (15 patients of mean age 76.9 + 7.6 years, onset of diabetes at 70 years of age) ; (ii) Early onset elderly diabeacs (15 patients of mean age 74.4 + 0.3 years, onset of diabetes at 46 years of age); (iii) Non-d’ la b e t ic elderly c&trols (39 patients of mean age 74.5 + 7.7 years). The patients underwent psychometric testings by using the following methods : mini mental state examination (MMSE), geriatric depression scale activity of daily living (ADL), instrumental activity of daily living (CDS), (IADL); attentional matrix test (AMT), visuo-spatial span test (VSST) and verbal span test (VST). The results indicate that diabetes is apparently not influencing the cognitive performance. As regards the affective disorders, the late onset elderly diabetics display more depressive disorders than the other 2 groups of patients studied. Keywords orders

: in

diabetes diabetes,

mellitus, psychometric

cognitive tests

impairments

in

diabetes,

affective

dis-

INTRODUCTION Diabetes

mellitus

insufficiency with

of

vascular

central all

vascular

areas

(McCall,

in

characterized

various

including

only

from

the

have

treated

the

mechanisms above

the in

problem

of

et

of

sugar

the

glycemic

peaks

are

alterations netic

a relative

or

hyperglycemia

and

Diabetes

the

the

risk

cerebral

a matter

oral of

mechanisms.

blood necessary of

of acute

or

fact,

diabetics, One

al.,

the

1984;

absolute glycosuria

influences

of

arteriosclerosis

blood

flow

are

down

the in

and

of

both

responsible

in

spite

of

can

list

the

the

to for

lack

following

an the

of

and

1990;

Ryan

meta-

of

or

exact

knowledge

vascular

disorders

1993).

with

severe of

camp charac-

treatment less

of

vascular

hypoglycemic

inadequate more

al.,

im-

stabilization

development and

derive authors

cognitive et

a relative

hyper-

due

clearly

numerous

diabetes

with the

cannot years,

Richardson, together

to slow

duration,

decline recent

between

levels

episodes

chronic

antidiabetics,

cognitive

interrelationships

(Lawson

As

in During

control

or

to

1970).

alters

involved

considerations.

elderly

sulin

al.,

increases

brain,

adequate

either

by et

ways,

An

lications.

due

1992).

specific

ter,

syndrome

(Signorelli

system

The

pairments

a dysmetabolic action,

complications

nervous

bolism

is

insulin

the

involved

in-

cerebral pathogein

the

348

pathogenesis (due

to

thelial

of

chronic

a loss

of

diabetic

pericytes,

proliferation).

cular

(ii)

reactivity

(due

Alterat’

response,

modification

cits,

decreased

sensitivity

(iii)

which

have

Endocrine

been

vels;

reduced level;

neuronal

tion

between

scribed the

reaction In

lar

(Reaven

the

after

and

the

fact

During

the

19911,

(Draelos

et

al.,

Diabetes valence has al.,

in

%, while

in

The

the

other

appearance by

the

teriosclerotic This cases,

situation around

no correla-

others

also

le-

hypogly-

observed while

and may

be

depends

on

the

cerebral

generally

have

de-

a deterioration

as

range of

and

of

actual

level

of

transitory

phenomena.

returns

of

glycemia

the

intellectual

to

of

its

et

arteriothe based

et

level

al.,

capacity

1993).

(Langan

al.,

speech

vascu-

original

(Ryan

(Gold

fluency

for

accompanying

attention

and

responsible

alterations

performance normal

to

1985; al.,

1994).

occurrence

of

the

1994),

have

been

with

aging:

increase diabetic

of

justifies 70 years

the of

of

distinction age)

et

1986;

al., wide

et

as

well

observed

from

in older

of the

the aged

an

life ages

the

senile diabetes

(Zimmet

Blazy

also

found

to

and

been

ob-

be

13.6

1995). is due,

on

adequate

span

of

one

the

and

(Carnazzo

diabetes (i.e.,

hand,

therapy, total

(i.e., the

to

and

on

population.

70 years)

ages,

itself

prethis

far

1989; has

(above

older

pancreas

so

was

ages

of

older for

the

al.,

its

observed,

Fedele,

diabetes

et

medium in

be

variability

of

a result

the

cases

can

epidemiologically

diabetes

typical

damage

variability

The

as

correlated

studied

% (Amaducci

diabetics

insulin-resistance vascular

wide

prevalence

22.3

of new

a

Wilson

national

reached

of

if

populations

al., et

it

is strongly

Even all

mean

survival hand,

authors

crisis

The

diabetes

age. et

the

increasing

The

The

Hiltunen

Catania

increased

action

memory

in

Verillo

Italy:

an

partly

aging.

verified

1993;

Nguyen, served

this

concentration

with

been

1981;

decreased myoinositol

acidosis;

hyperglycemy,

a reduction

verbal

pyruvate

barrier, normal

hyperglycemic

re-

metabolism,

(decreased

with

Some

TxA2

1992). and

increases

trend

the

vasdefi-

the

glucose

blood-brain

acquisition,

brain.

episodes, of

the

vas-

altered

1989).

the

of

diabetes

1996).

neuro-behavioral

decrease

of

and

considered

reestablished

a deterioration

models

hypoglycemic

the

are

hypoglycemic

al.,

et al.,

of

of

that

altered

in

memory

extent

episodes

having

damage

the

to an

of

the

activity

endo-

and

catecholamine

by

in

and

(CBF)

connected

homeostasis,

transport

et al.,

flow

hyperstimulation

animal

impairment

alterations

membranes,

blood

CBF

circulatory

in

short-term

vasculopathy

hypoglycemic

et

cognitive

diabetics,

accidents

as

(Sass0

elderly

sclerotic

on

damages)

times

of

Na+/K+-ATP-ase ischemic

a disturbed

cerebral

caused

glucose

hypoxic the

the

least

decreased

increased

cemic

at

the

Microcirculatory

basement

beta-receptors,

disorders

found

dehydrogenase; glutathione

of

the

reduction

of of

(i)

of

ion

to a regional

cular ceptors).

encephalopathy:

a thickening

is explained

also

by

et

al.,

the early

the

ar-

1996).

late onset

onset ca-

349 585,

starting

during

during

the

vascular

whole

lesions

while

in

mena

of

which

are

evidently

The

study

total

97

they

itself

accompanying

diabetes,

precede

disease

or

the

patient

arteriosclerotic

induce

with

by

the

the

even

induces

aggravated

late

onset

time

the

diabetes,

the

vascular

processes

and

pheno-

diabetics of

(mean

age:

were

divided

(15

70 years

of

age).

(ii)

mean

age

74.4

(15

patients (iii)

types

purpose,

of Non-d’

of

29

74.2

diabetics

age).

the

this

consisted

patients

about

revealing For

population

The

at

at

of the

cognitive

mental

and

affec-

performance

wa

patients.

40 females

elderly

diabetes

aimed patients.

of

study and

years.

was

diabetic

3 groups

(SD)

and

in

patients

of

mean

+

(mean [i)

age

76.9

(39

3 groups

of

years,

55 or

onset

early

onset

of

diabetes

onset

6.3

diabetics,

+ 7.6

patients

+

between

Senile

or

years,

controls

76.2

ranging

diabetics,

8.3

age:

years),

3 groups:

Aged

Ia b e t ic elderly

males

+ 8.6

of mean

of

elderly at

age

46

74.5

+

years). The

the

psychometric

following

1975);

tial

(ADL)

(Lawton span

test

(Vlechsler,

ance

et

state (CDS)

al.,

(Spinnler

[Brink

1963).

1969);

carried

test

1987),

and

daily

and

verbal

al.,

activity

of

[AMT)

by

et

1982).

activity

matrix

out

[Folstein

Yesavage,

instrumental

Tognoli,

was

(MMSE)

and

attentional

and

patients

examination

of living

visuo-spa-

span

test

[VST)

1945).

All

data

or

x2

are test

correlations ran,

scale

Brody,

[VSST)

the

mental

(Katz and

of

mini

depression

living

(IADL)

analysis

methods:

geriatric

daily

expressed were

were

as

utilized

analyzed

mean

+ SD,

when by

or

prevalence

comparing

the

the

method

of

least

groups

and

the

in

various

%. Analysis

group

squares

of

averages.

(Snedecor

variLinear

and

Ccch-

1980).

RESULTS

AND

The Tables

DISCUSSION

composition I and

of

no the

group

if

is to

study

the

differences

groups

displaying

depression

the

significant

study

Nevertheless,

or

of

main

results

are

summarized

in

II.

Basically scores

trols,

then

and

senile

METHODS

in

in

years)

I).

ages, in

i.e., the

present

evaluated

each

age-related, diabetes,

AND

The

7.7

medium

aged

alterations

years

or

Therefore,

aging.

PATIENTS

tive

are

the

complications

younger

senescence).

more aged

we

in are

either

going

pathological frequent diabetics

in

were of

to

(Table

senile II).

encountered

scores

analyze

levels the

the

of

the the

diabetic

of

between

psychometric

prevalence scores, group,

it

the tests

of turns compared

persons out

within

that to

mean (Table

the

major con-

350 Table

I

THE

COMPOSITION

AND

THE

Parameter

of patients total pool

76.2

Senile diabetes Number of oatlents Age (yearsj Clycemy (mg%) MMSE CDS IADL AMT VSST VST

means

The

absence better

deficits Table

performed

172.9 23.6 11.2 10.3 41.7 3.7 3.9

+ 34.2 7 1.9 7 5.2 7 4.0 T 15.3 + 1.0 T 0.9

103.8 23.5 12.8 9.9 39.4 3.3 3.7

also

deriving

the

15 + 7.6 ‘i: 1 1.9 5 6.3 T 7.3 7 3.3 r 1 3.8 7 0.7 7 1.0 .-

76.9 131.7 22.1 11.9 9.8 39.2 3.4 3.2

+ 10.9 T 7.9 T 8.2 T 3.6 T 16.2 7 0.4 5 0.9

+ 72.6 7 3.5 7 6.0 T 2.8 r 17.1 7 0.9 T 1.2

+ 35.4 7 4.9 7 5.3 T 3.3 T 16.0 T 1.4 T 1.1

the

total

results

the

brain

can III

of

patients.

pool

74.4 163.2 24.3 11.2 10.6 36.43 3.1 3.7

15 + 8.3 + 63.4 7 3.4 T 5.3 T 2.9 7 17.3 ir 1.3 T 1.1

74.5 108.6 23.8 11.9 10.0 32.8 3.4 3.5

39 + 7.7 T 34.7 7 3.5 + 5.2 T 3.3 7 16.0 T 1.2 7 0.9

cognitive the

higher

the

verbal

also

the is

scores This subjects

In span

addition test

to

the

for

such

type

or

autosufficiency,

to

that prevent

correlations the

note

presence

indicates helps

measuring

looking

to

the in

fact

of

interesting

from

elderly

by

results

It

skills.

deteriorations. of

analyzed lists

independently

displaying

of

be

Table

expectations,

autosufficiency

from the

patients

results.

subjects in

the

test

the

the

diabetes,

of

of

in

with

performed

III,

69 + 7.8

75.0

20

various

agreement

preservation

in

Total

11

scores

between

of

CROIJPS

+ SD

evaluation, in

125.6 21.0 13.9 10.1 47.9 3.1 3.3

19

psychometric

correlations

8.9 2.7 4.6 2.1 9.1 0.0 1.1

+ 22.5 7 2.4 T 3.0 T 0.0 T 20.1 T 1.3 7 0.6

114.0 24.1 10.9 9.9 33.9 3.8 4.0

STUDY

9

+ T 7 T + T 7

139.0 26.6 11.3 14.0 44.3 3.5 5.3

THE

40 + 8.6

74.2

4

Aged controls Number of patients Age (years) Glycemia (mg%) MMSE CDS IADL AMT VSST VST Notes:

29 + 6.3

139.0 23.8 8.0 8.5 39.4 4.0 4.0

OF

Females

6

jients Age (years) Glycemia (mg%) MMSE CDS IADL AMT VSST VST

of

RESULTS

Males

Number Age of

that,

MAIN

short

the also shown

term

me-

351 Table

II

EVALUATION

OF

THE

PSYCHOMETRIC

Parameter

RESULTS

Males

Senile diabetes Number ADL A subscale I3 subscale C subscale D subscale E subscale F subscale Pathological IADL Pathological MMSE Mild depression (CDS Major depression (CDS AMT < 50 percentile VSST < 50 percentile VST < 50 percentile

0 0 0 0

-

not

66.6 26.6 0 0 0

(1)

6.6 ( 1) 33.3 26.6 33.3 20.0 53.8 100.0 35.7

17) (3)

66.61:lo) 20.0 ( 3) 0 0 6.6 ( 1) 0 36.4 13.3 53.3 0

= 11-20) = 21-30)

significant

against

(10) ( 4)

0 0 0

11 63.6 27.3 0 0 0 0

57.1 78.5 21.4 ---__-----

Aged controls Number 19 ADL A subscale 63.2 (12) 6 subscale 21.0 ( 4) C subscale 10.5 ( 2) D subscale 5.3 ( 1) E subscale 0 0 F subscale Pathological IADL Pathological MMSE Mild depression (CDS = 11-20) Major depression (CDS = 21-30) AMT < SO percentile VSST < 50 percentile VST < 50 percentile NS

PC

15 (6) (2)

11.1

(n)

Total

9 66.6 22.2

(4) (2)

Aged diabetes number ADL A subscale 75.04(3) B subscale 0 C subscale 0 D subscale 0 E subscale 25.0 (1) F subscale 0 Pathological IADL Pathological MMSE Mild depression (CDS = 11-20) Major depression (CDS = 21-30) AMT < 50 percentile VSST < 50 percentile VST < 50 percentile

Notes:

PREVALENCES

Females

6 66.6 33.3

AS

20 75.0 20.0

39 (12) ( 4)

69.2 20.5 5.1 2.6 2.6

0 5.0°(

1) 0

either

of the

(27) ( 8) ( 2) ( 1) ( 1)

0 45.8 25.6 56.4 2.5 64.7 86.0 43.2 diabetic

groups

NS NS

NS NS NS 0.05 NS NS NS

352 Table

III

THE

RESULTS

OF

PSYCHOMETRIC Pairs

of

VST VST VST IADL IADL IADL

well

that

in

those

visual

type

levels vice

of

the

tasks.

mnemonic

higher and

memory

VARIOUS

STUDY

of

tests.

versa,

a

low

THE

0.004 0.033 0.013 0.130 0.000 0.004

has

matrix

a better

This

attention

OF

P=

attentional

Who

PAIRS

POOL

0.3687 0.2651 0.3125 0.3722 0.7784 0.4252

with

level

performance,

test,

observation

have

finds

a positive

attention

which

attention, its

is

more

explanation

influence

level

estimates

performs

on

the

cancelling

in memory

most

of

the

functions. It

rently

seems not

to

be

safe

influencing

those

of

the

other

Moradian

et

to conclude the

the

Baltimore

that

diabetes

hand,

our

demonstrating On

BETWEEN

TOTAL r

the

fact

with

THE

level

correlated attention

satisfactorily the

ANALYSES

WITHIN

parameters

- AMT - age - VSST - MMSE - AMT - educational

mory the

CORRELATION

SCORES

al.,

1988;

from

cognitive longitudinal per data

se

et

observations

is not

al.,

results

diabetes are

(Robertson-Tchabo

a risk

factor

those 19891

that

Our

study

contradict

Reaven

our

performance.

of who

for

others

et cerebral

the

is appaagreement al.,

1986),

deterioration.

(Permulter

suggested

in

et existence

al.,

1984; of

such

a risk. As more

regards

the

depressive

phenomenon,

affective

disorders most

probably,

disorders, than the

the aging

the other itself

late

onset

2 groups may

of play

elderly

diabetics

patients

studied.

the

main

display In

this

role.

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