A few weeks ago, we had a patient in her forties ask us for help because she felt it was becoming difficult remembering simple things. She had been a diabetic for about ten years and her previous HbA1c levels were 7 and 8.8 percent (normal values 4-6 percent). She noticed that she often lost things and forgot her appointments. Checking through her records—we immediately sent her to a neurologist for evaluation at our memory clinic in the hospital. Was this dementia? A stroke? Or was our patient just under stress?

Among the complications of diabetes—those affecting our eyes, kidneys, nerves and heart are regularly screened for. Dementia is emerging as a complication needing equal evaluation due to its debilitating and life-changing effects on the patient and their family.

What is dementia?
Dementia is an aging process of the brain where there is loss of function over a period of time. Patients will often complain of forgetting common things—turning off the stove or iron, losing the keys and as it gets worse—not being able to remember where they are or how to get home. Aside from difficulty remembering things, relatives may begin to note changes in personality and behavior in a patient. A patient may struggle with common everyday words.

Dementia is usually irreversible, progressive and worsens with time—caring for this patient becomes challenging and difficult for even the most loving of spouses or children. A previously independent and responsible parent may slowly become irritable and paranoid—begin to refuse to change, eat or bathe—often can no longer handle their finances and in some cases, accuse their children of misplacing their money.

Causes of dementia
Parkinson’s disease, multiple strokes, multiple sclerosis, hydrocephalus, alcoholism, brain tumors and metabolic disorders like diabetes are just a few causes of dementia.

The good news for diabetics is that early prevention, detection and intervention can slow or reverse the aging of the brain.

Diabetes causes changes in the brain which lead to its gradual loss of function. There are several possible causes for dementia in diabetics. As with other complications of diabetes, elevated glucose levels increase the risk of macrovascular and microvascular disease (large vessel and small vessel disease). The buildup of atherosclerotic plaques, the constriction in the caliber of the vessels, the production of inflammatory substances and deposition of protein deposits in the brain—all contribute to the change in the architecture of the brain and the slow deterioration of neurons—these all lead to loss of memory and function.

Just as with the other complications of diabetes, the risk of dementia increases with increasing HbA1c levels—as in our patient, her HbA1c levels were above 7. Increase in HbA1c levels indicates worsening of glucose control.

Another significant factor leading to dementia is repeated hypoglycemia. The immediate effect of low glucose levels—usually below 60 mg/ dl—manifests as confusion, loss of memory, inability to speak clearly and even loss of consciousness. Correcting hypoglycemia by ingesting or injecting glucose rapidly reverses these symptoms. Prolonged hypoglycemia of about thirty or more minutes can cause neuronal necrosis leading to cell loss. Frequent hypoglycemia is more commonly seen in patients on insulin, elderly patients on oral hypoglycemic medications, patients with renal insufficiency or failure and patients with poor appetite due to chronic disease.

The most common form of dementia is Alzheimer’s disease. Diabetics have a 1.2-1.7 fold increase in the risk of developing Alzheimer’s disease. Aside from a gradual loss of memory, they have in addition one or more changes in their social, behavioral or cognitive function (the ability to calculate, make judgments, or do abstract thinking).

Studies of patients with Alzheimer’s disease show an increase in cerebral insulin resistance and a reduction in glucose transport in the brain. A common pathologic finding is the deposition of plaques composed of amyloid in brain tissue. These amyloid plaques are similar to those found in the pancreas of diabetic patients. This common finding in the brain and pancreas has stimulated research to find a common pathway or link which may be targeted for treatment in the future.

Evaluation and diagnosis
At present, guidelines are still being developed for the proper screening for dementia in diabetics. In the clinic, routine clinical evaluation and examination may unmask this. Asking simple questions regarding everyday tasks, names of close relatives, or important data pertinent to the patient can give us a clue on their mental state.

Relatives may be on the watch for early signs of dementia such as difficulty performing simple tasks, confusion in familiar places, misplacing items, inability to learn new data or tasks, difficulty in remembering simple everyday words. As dementia is progressive, many patients will eventually become incontinent or be unable to swallow.

What can be done if you notice any of these signs and symptoms? We usually advise patients to come to the clinic for a medical evaluation which may include:

• A neurologic and medical evaluation
• Evaluation at the memory clinic
• Blood chemistries—preferably a complete blood panel
• Imaging studies of the brain such as an MRI or CT scan
• Evaluation of the cerebral circulation—CT angiogram or an MRI-MRA
• EEG
• CSF fluid analysis
• Thyroid function tests
• And other tests deemed necessary for evaluation. Included above are tests needed to be able to evaluate for other possible causes of dementia such as liver cirrhosis, hypothyroidism, hyponatremia, vitamin deficiencies—these are sometimes possible to correct or reverse.

Management
Treatment is aimed at controlling symptoms or slowing down the progression of the disease. For patients with behavioral problems, they may be given drugs such as antipsychotics, mood stabilizers or stimulants. Medications to slow down the progression of dementia include Donepezil (Aricept), Rivastigmine (Exelon) and Memantine (Namenda). Oftentimes, despite intervention, there is little improvement and patients continue to deteriorate.

Poor diabetes control essentially accelerates the aging of our body. We can slow or prevent the onset of complications due to diabetes with tighter glycemic control.

Impaired glucose tolerance and diabetes can be controlled with strict diet, regular exercise and proper medication. Good glycemic control, as evidenced with HbA1 c levels targeting 6.5 percent.

Home glucose monitoring is another way to achieve good glycemic control and for the patient to watch out for hypoglycemia. If you are aware of how your blood glucose swings throughout the day and the effect of food and medications on it, then the proper adjustment to treatment may be made.

We counsel our patients to think that the control of diabetes is just the practice of wellness. Hitting our targets for our glucose, lipid levels,uric acid, liver and kidney function, blood pressure levels and keeping our weight within the right BMI will keep us fit and active for years to come. A well patient reduces his risk of dementia and can remain productive even into his eighties.

Going back to our patient in her forties, work up revealed multiple ischemic infarcts on her CT scan. An adjustment in her medications was made and her diet enforced. She has been advised to monitor her glucose levels closely and to follow up regularly.

Related terms:

• HBA1C demented patient
• diabetics and demntia

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