The risk of dementia in patients with type 2 diabetes increases rapidly with age, and patients aged 60-64 years It is 83/10,000 person-years in China, and it has exceeded 10 million/10,000-year-olds in patients over 85 years old. The existing guidelines for the diagnosis and treatment of diabetes in my country do not emphasize the management of cognitive impairment in patients with type 2 diabetes. The “Chinese Expert Consensus on the Prevention and Treatment of Cognitive Dysfunction in Patients with Type 2 Diabetes” aims to improve the ability of endocrinologists in my country to screen, diagnose and manage cognitive dysfunction in patients with type 2 diabetes.
Clinical features of type 2 diabetes-related cognitive impairment
《 According to the consensus, type 2 diabetes-related cognitive impairment is divided into cognitive decline, mild cognitive impairment (MCI) and dementia according to the severity. 1. Cognitive decline only involves a single cognitive domain. The symptoms are mild and patients are often unaware, but the brain structure and function have changed. 2. The scores of one or more cognitive domains in MCI patients were 1-2 standard deviations lower than those in normal subjects, while the scores of multiple cognitive domains in dementia patients were lower than those in normal subjects by more than 2 standard deviations Difference. 3. The most prominent symptom of dementia patients in the early stage is episodic memory impairment. As the disease progresses, other cognitive domain functions decline gradually, and symptoms such as abnormal mental behavior and delirium may appear in the later stage of the disease. .
The process of screening and diagnosis of cognitive dysfunction in patients with type 2 diabetes
When the patient has any of the following conditions, The screening and diagnosis process of cognitive dysfunction in patients with type 2 diabetes can be initiated: those older than 65 years old complain of cognitive decline, unexplained falls, repeated hypoglycemia episodes, difficulties in self-management of blood sugar, or symptoms of depression and anxiety. The specific screening and diagnosis process (see Figure 1). Figure 1 Screening and diagnosis process of cognitive impairment in patients with type 2 diabetesNote: MMSE: simple and intelligent mental state examination; MoCA : Montreal Cognitive Assessment Scale; a: Impaired cognitive function; MMSE score ≤17 (no education), ≤20 (1-6 years of education), ≤24 (more than 7 years of education), MoCA score ≤13 ( No education), ≤19 (1 to 6 years of education), ≤24 (more than 7 years of education).
Type 2 Diabetes Patient Cognitive Dysfunction Screening and Diagnosis Tool
Type 2 Diabetes Patient Has Multiple Cognitions Commonly used screening and diagnostic tools include neuropsychological assessment scales, biological markers and brain imaging tests. The “Consensus” recommends the following:
➤ Patients with type 2 diabetes over the age of 65 should be screened for cognitive dysfunction regularly.
➤ Patients with type 2 diabetes who have risk factors such as anxiety and depression, recurrent hypoglycemia, unexplained falls, and difficulty in self-management of blood glucose should be screened for cognitive impairment.
➤ The neuropsychological assessment scale is the most commonly used cognitive function assessment tool. Commonly used cognitive dysfunction screening scales include the Mini-Mental State Examination (MMSE). and the Montreal Cognitive Assessment Scale (MoCA).
➤ Cerebrospinal fluid examination is a routine examination for dementia patients. When making differential diagnosis and judging the pathological process of AD, total tau and tau protein test are recommended for patients who are to be diagnosed with AD. Phosphorylation levels at site 181 and Aβ42/Aβ40 detection.
➤ Brain magnetic resonance imaging (MRI) examination is a routine examination for the diagnosis and differential diagnosis of dementia, and can also be used for follow-up of dementia patients and judgment of drug efficacy.
1. Neuropsychological Assessment ScaleThe Neuropsychological Assessment Scale is currently the most commonly used Cognitive function assessment tools (see Table 1), commonly used cognitive impairment screening scales include MMSE and MoCA. Table 1 Cognitive domains and recommended cognitive function assessment scales2.biology logo Biomarkers reflecting brain changes in patients with type 2 diabetesmainly include the following categories : Markers reflecting the main causes of dementia [Alzheimer’s disease (AD) and vascular disease]; markers reflecting changes in brain parenchyma; markers reflecting changes in brain blood supply and metabolism. 3. Imaging Features
Prevention of cognitive impairment in patients with type 2 diabetes
➤Cognition There is a lack of obvious and effective treatment drugs and interventions for functional impairment. Early identification of risk factors for cognitive impairment should be carried out, and interventions should be carried out for the risk factors that can be modified.
➤Regulating blood sugar management, reducing blood sugar fluctuations, and improving insulin resistance can all help prevent cognitive impairment in patients with type 2 diabetes.
➤The risk assessment model can be used to predict the risk of cognitive impairment in patients with type 2 diabetes early.
1. General risk factors for cognitive impairmentCurrently , the more definite risk factors for cognitive impairment can be divided into early adult risk factors (low education level), middle age risk factors (hypertension, obesity, hearing loss, head trauma and alcohol consumption), Risk factors in old age (smoking, depression, physical inactivity, lack of social interaction, diabetes, and air pollution), where depression is both a risk factor and a prodrome of dementia. 2. Diabetes-related risk factors for cognitive impairmentRisk factors for cognitive impairment in patients with diabetes include disease duration, Hyperglycemia, hypoglycemia, insulin resistance, vascular damage, inflammation, etc. 3. Early prediction and warning and risk assessment modelBased on the discovered AD-related risk factors and biomarkers, The researchers tried to establish a scoring model for the occurrence of cognitive impairment, including elderly dementia risk score, late-onset AD risk score, and primary medical unit risk score. Age was the strongest predictor in these scoring models, followed by low education and vascular risk factors.
Management of patients with cognitive impairment and type 2 diabetes mellitus
➤For older adults 2 The blood sugar management of patients with type 2 diabetes should fully consider the patient’s overall health status and treatment risks, and reduce blood sugar fluctuations and hypoglycemia events. ➤ The HbA1C control target of elderly patients with type 2 diabetes with mild to moderate cognitive impairment is less than 8.0%, and the HbA1C in patients with type 2 diabetes with moderate to severe cognitive impairment The control target can be relaxed to below 8.5%.
The “Consensus” pointed out that for the elderly, infirm and patients with cognitive impairment, blood glucose management should be based on the premise of ensuring the quality of life and daily living ability of patients, and the treatment plan should be simplified as much as possible. Choose simple, highly compliant medications and “de-intensive therapy.”
➤The drug treatment of cognitive impairment in diabetic patients is similar to that in non-diabetic patients, and there is no effective treatment drug recommendation yet. Cognitive training therapy for MCI patients can be used for cognitive impairment in dementia patients. Knowledge training can be used as a supplement to drug therapy.
Cognitive intervention refers to the direct or indirect treatment of cognitive dysfunction through non-drug treatments, including cognitive stimulation, cognitive rehabilitation and cognitive training.
➤Cholinesterase inhibitors can be used for definite diagnosis of AD patients, and high-dose cholinesterase inhibitors can be used for moderate-to-severe AD patients, but the dose should be gradually increased from a low dose. amount, and pay attention to possible adverse drug reactions.
The drug treatment of cognitive impairment in diabetic patients is similar to that in non-diabetic patients, and there is no new drug with obvious curative effect.
Summary
The current epidemic situation of diabetes in my country is severe, and the prevalence of cognitive dysfunction is inevitable. It will bring a huge burden to society and families. Type 2 diabetes-related cognitive dysfunction is affected by many factors, the specific pathogenesis is not yet clear, and there is a lack of effective treatment drugs, early screening is extremely important. Early intervention should be carried out in patients with high risk of cognitive impairment, strict control of blood glucose levels, and delay of disease progression. The above content is excerpted from: Endocrinology Branch of Chinese Medical Association, Chinese Adult Type 2 Diabetes Antihypertensive Treatment Target Research Working Group. Chinese Expert Consensus[J] . Chinese Journal of Endocrinology and Metabolism, 2022,38(6):453-464.
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