Die Diabetesprävalenz liegt in der Altersgruppe ab 80 Jahren bei über 30 %. Bei der Diagnostik und Therapie älterer Menschen mit Typ-1- und Typ-2 Diabetes müssen altersspezifische Besonderheiten wie funktionelle und kognitive Einschränkungen sowie Komorbiditäten und Aspekte der Polypharmazie in besonderem Maße berücksichtigt werden. Die S2k-Leitlinie der Deutschen Diabetes Gesellschaft wurde mit 6 weiteren Fachgesellschaften (Deutsche Gesellschaft für Kardiologie, Deutsche Gesellschaft für Allgemeinmedizin und Familienmedizin, Deutsche Gesellschaft für Geriatrie, Deutsche Gesellschaft für Ernährungsmedizin, Deutsche Gesellschaft für Pflegewissenschaft, Deutsche Gesellschaft für Palliativmedizin) und der Patientenvertretung (DBW) erarbeitet. Therapieziele wie Erhalt der Lebensqualität und strikte Vermeidung von Akutkomplikationen wie schwere Hypoglykämien treten in den Vordergrund. HbA1c-Ziele sollten gemeinsam mit den Patienten in Abhängigkeit der individuellen Wünsche und Fähigkeiten festgelegt werden. Altersspezifische Besonderheiten einzelner Medikamente müssen insbesondere im Kontext der Multimorbidität beachtet werden. In der Leitlinie werden pflegerische Aspekte, Schnittstellenmanagement, Schmerztherapie sowie häufige Komorbiditäten bei Diabetes wie Hypertonie, Frailty, Sarkopenie, Demenz, Depression, End-of-Life Situationen ausführlich dargestellt.

Diagnostik, Therapie und Verlaufskontrolle des Diabetes mellitus im Alter

Objective
The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

Methods
This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study.

Results
Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions.

Conclusions
This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

/pdf/dementia-and-co-occurring-chronic-conditions-a-systematic-4eted4pnrn.pdf

Dementia and co-occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

We aimed to evaluate the link between severe hypoglycaemia and domain-specific cognitive decline, smaller brain volumes and dementia in adults with type 2 diabetes, which so far has been relatively poorly characterised. We included participants with diagnosed diabetes from the community-based Atherosclerosis Risk in Communities (ARIC) study. At the participants’ fifth study visit (2011–2013), we examined the cross-sectional associations of severe hypoglycaemia with cognitive status, brain volumes and prior 15 year cognitive decline. We also conducted a prospective survival analysis of incident dementia from baseline, visit 4 (1996–1998), to 31 December 2013. Severe hypoglycaemia was identified, using ICD-9 codes, from hospitalisations, emergency department visits and ambulance records. Prior cognitive decline was defined as change in neuropsychological test scores from visit 4 (1996–1998) to visit 5 (2011–2013). At visit 5, a subset of participants underwent brain MRIs. Analyses were adjusted for demographics, APOE genotype, use of diabetes medication, duration of diabetes and glycaemic control. Among 2001 participants with diabetes at visit 5 (mean age 76 years), a history of severe hypoglycaemia (3.1% of participants) was associated with dementia (vs normal cognitive status): OR 2.34 (95% CI 1.04, 5.27). In the subset of participants who had undergone brain MRI (n = 580), hypoglycaemia was associated with smaller total brain volume (−0.308 SD, 95% CI −0.612, −0.004). Hypoglycaemia was nominally associated with a 15 year cognitive change (−0.14 SD, 95% CI −0.34, 0.06). In prospective analysis (n = 1263), hypoglycaemia was strongly associated with incident dementia (HR 2.54, 95% CI 1.78, 3.63). Our results demonstrate a strong link between severe hypoglycaemia and poor cognitive outcomes, suggesting a need for discussion of appropriate diabetes treatments for high-risk older adults.

/pdf/severe-hypoglycaemia-mild-cognitive-impairment-dementia-and-dbjs35d5em.pdf

Severe hypoglycaemia, mild cognitive impairment, dementia and brain volumes in older adults with type 2 diabetes: the Atherosclerosis Risk in Communities (ARIC) cohort study.

BACKGROUND: Postoperative cognitive dysfunction (POCD) occurs frequently after surgery, particularly among older people. Diabetes, chronic hyperglycemia, and a history of hypoglycemia are related to cognitive impairment, but little is known about their roles in POCD. Here, we estimated their associations with risk of POCD on the basis of published epidemiological research. METHODS: The PubMed and Cochrane databases were searched for longitudinal studies of adults undergoing surgery with reporting of associations of diabetes status, glycemic levels, and/or a history of hypoglycemia with risk of POCD as relative risks or odds ratios. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. RESULTS: The search identified 246 publications of which 14 met inclusion criteria, reporting on a total of 2642 patients (mean age 64 y). Follow-up periods spanned 1 day to 5 years. Overall, patients with diabetes had a 1.26-fold higher risk of POCD compared with diabetes-free patients (95% CI, 1.12-1.42). A single study assessed glycemic control in patients with diabetes and identified a higher hemoglobin A1c (HbA1c) level as associated with higher POCD risk (relative risk per percent higher HbA1c, 2.0; 95% CI, 1.4-2.6). We did not find studies on glycemic levels in the nondiabetic range or on hypoglycemia as potential predictors of POCD. CONCLUSION: Patients with diabetes appear to have a higher risk of POCD compared with diabetes-free persons. Among patients with diabetes, POCD risk may further increase with poorer glycemic control as indexed by higher HbA1c. The roles of HbA1c levels among nondiabetic persons in POCD risk warrant further research.

/pdf/diabetes-is-associated-with-risk-of-postoperative-cognitive-4x05ki471k.pdf

Diabetes is associated with risk of postoperative cognitive dysfunction: A meta‐analysis

Objectives
Cerebral microvascular disease is considered to contribute to cognitive dysfunction. We opted to explore whether albuminuria, a marker of systemic microangiopathy, is associated with cognitive impairment, dementia, and cognitive function.

Design
Systematic review; independent reviewers screened 2359 articles, derived through the search strategy, for identification of observational studies quantifying an association of albuminuria with the outcomes of interest, abstracted data on study characteristics and results and evaluated studies on quality using the Newcastle-Ottawa scale.

Setting
Community.

Participants
Adults.

Mesurements
Cognitive impairment and dementia, defined by validated neuropsychological tests or clinical guidelines, respectively, and cognitive function, assessed by validated instruments.

Results
Thirty-two eligible studies were identified. Albuminuria was associated with cognitive impairment (Odds Ratio (OR): 1.35, 95% Confidence Interval (CI): 1.19–1.53; 7,852 cases), dementia (OR: 1.35, 95% CI: 1.10–1.65; 5,758 cases), clinical Alzheimer's disease (OR: 1.37, 95% CI: 1.11–1.69; 629 cases) and vascular dementia (OR: 1.96, 95% CI: 1.16–3.31; 186 cases); the effect remained significant among longitudinal, population-based and high quality studies. Time-to-event analysis on prospective studies of non-demented at baseline individuals also showed a significant association with incident dementia (Risk Ratio: 1.52, 95% CI: 1.16–1.99; 971 cases). Worse global cognitive performance (Hedge's g: −0.13, 95% CI: −0.18, −0.09; 68,348 subjects) and accelerated cognitive decline (g: −0.20, 95% CI: −0.34, −0.07; 31,792 subjects) were noted among subjects with albuminuria, who also scored lower in executive function, processing speed, verbal fluency, and verbal memory.

Conclusions
Albuminuria was independently associated with cognitive impairment, dementia and cognitive decline. The stronger effects for vascular dementia and cognitive performance in domains primarily affected by microvascular disease support that the association could be mediated by shared microvascular pathology in the kidney and the brain.

Albuminuria in Association with Cognitive Function and Dementia: A Systematic Review and Meta-Analysis.

High rate of hypoglycemia in 6770 type 2 diabetes patients with comorbid dementia: A multicenter cohort study on 215,932 patients from the German/Austrian diabetes registry.

Fracture risk in patients with type 2 diabetes aged ≥50 years related to HbA1c, acute complications, BMI and SGLT2i-use in the DPV registry.

Aims To examine the association of frozen shoulder (FS) with demographic
 and diabetes-related outcomes in individuals with type 1 (T1D) or type 2 (T2D)
 diabetes aged ≥30 years. Materials and methods Multivariable logistic regression models, adjusted
 for demographics were used to calculate the proportion of FS in association with
 age, gender, diabetes duration, body mass index (BMI), haemoglobin A1C (HbA1c)
 and diabetes treatment. Results The unadjusted percentage of FS was higher in T1D compared to T2D
 (0.22% vs. 0.06%). In T1D, adjusted regression models revealed
 higher prevalence of FS in women than men (0.26 [0.20–0.34] %
 vs. 0.15 [0.11–0.21] %, p=0.010). No significant
 relationship of age and BMI with FS was found in both diabetes types. Longer
 diabetes duration was associated with a higher proportion of FS in T1D
 (p<0.001) and T2D (p=0.004). In T1D, HbA1c
 >7% was related to a higher proportion of FS compared to HbA1c
 ≤7% (0.25 [0.19–0.32] vs. 0.12 [0.08–0.20]
 %, p=0.007), while an inverse relationship was found in
 T2D (HbA1c ≤7%: 0.08 [0.07–0.10] vs. HbA1c
 >7%: 0.05 [0.04–0.06] %,
 p=0.001). Conclusions Different associations of FS with gender and HbA1c were
 observed for T1D and T2D; however, longer diabetes duration increases the risk
 for FS independent of diabetes type. Musculoskeletal diseases are still
 underreported in individuals with diabetes and awareness should be raised for FS
 as a specific diabetes complication.

Idiopathic Frozen Shoulder in Individuals with Diabetes: Association with Metabolic Control, Obesity, Antidiabetic Treatment and Demographic Characteristics in Adults with Type 1 or 2 Diabetes from the DPV Registry.

Steffen Mühldorfer

Papers

High rate of hypoglycemia in 6770 type 2 diabetes patients with comorbid dementia: A multicenter cohort study on 215,932 patients from the German/Austrian diabetes registry.

Fracture risk in patients with type 2 diabetes aged ≥50 years related to HbA1c, acute complications, BMI and SGLT2i-use in the DPV registry.

Idiopathic Frozen Shoulder in Individuals with Diabetes: Association with Metabolic Control, Obesity, Antidiabetic Treatment and Demographic Characteristics in Adults with Type 1 or 2 Diabetes from the DPV Registry.