|Year : 2016 | Volume
| Issue : 1 | Page : 48-55
|Appraisal of cognitive function of diabetics in a rural healthcare teaching institute
Arup Bandyopadhyay1, Pradip Kumar Mohanta2, Gautam Sarker3, Kamakhya Kumar1, Debabrata Sarbapalli4, Ranabir Pal5
1 Department of Physiology, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
2 Department of Surgery, College of Medicine and JNM Hospital, Kalyani, West Bengal, India
3 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
4 Department of Anaesthesiology, Bankura Sammilani Medical College, Bankura, West Bengal, India
5 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
Click here for correspondence address and email
|Date of Web Publication||22-Jan-2016|
| Abstract|| |
Context (Background): Cognitive dysfunctions as the unexplored complications in diabetics need to be systematically studied. Aims: To assess the correlation between type 2 diabetes mellitus (DM) and associated cognitive dysfunctions with varying age groups and duration. Settings and Design: A hospital-based cross-sectional study was conducted in a tertiary care teaching institute in eastern India. Materials and Methods: In this study the participants were allocated into five groups according to duration of diabetes, for example, less than 3 months, 3 months-5 years, 6-10 years, 11-20 years, and more than 20 years. Each of these groups was then classified into following six subgroups according to age: group A (20 years or less), group B (21-30 years), group C (31-40 years), group D (41-50 years), group E (51-60 years), and group F (more than 60 years). A predesigned, pretested, semi-structured questionnaire was used to find the cognitive functions based on the Global Deterioration Scale (GDS) in diabetics and age-matched nondiabetic participants. Statistical Analysis Used: Statistical analysis using Statistical Package for the Social Sciences (SPSS) version 11.0 to calculate proportions and significance test were done in this study. Results: There was noticeable attenuation of cognitive functions in diabetics in all age groups irrespective of duration of the morbidity. Further, a distinct pattern of incremental cognitive dysfunctions was also noticed as the age progressed in diabetics and in healthy controls. Conclusion: Diabetics are more at risk of cognitive dysfunctions than age-matched controls, which needs more elaborative studies.
Cognitive dysfunctions, duration of disease, type 2 diabetes mellitus (DM)
|How to cite this article:|
Bandyopadhyay A, Mohanta PK, Sarker G, Kumar K, Sarbapalli D, Pal R. Appraisal of cognitive function of diabetics in a rural healthcare teaching institute. Ann Trop Med Public Health 2016;9:48-55
|How to cite this URL:|
Bandyopadhyay A, Mohanta PK, Sarker G, Kumar K, Sarbapalli D, Pal R. Appraisal of cognitive function of diabetics in a rural healthcare teaching institute. Ann Trop Med Public Health [serial online] 2016 [cited 2017 Jun 29];9:48-55. Available from: http://www.atmph.org/text.asp?2016/9/1/48/168686
| Introduction|| |
Diabetes mellitus (DM) affects all systems of the body and the cognitive dysfunctions resulting due to this is a global public health problem, particularly for the elderly population. Yet not many studies have been reported in the literature on the psychological effects of this morbid condition under varying state of affairs. 
Diabetes is a major and specific risk factor for cerebral microangiopathy with varying incidences as reported in several studies [between 5% and 25%] including subclinical cognitive impairment in middle-aged patients amidst well-known and widely accepted cerebrovascular complications along with risk correlates of arterial hypertension, smoking, and dyslipidemia. It is plausible that the main consequence of small cerebral vessels disease might be a cause of decrease in individual cognitive capability. ,,,
"Brain at risk" is a term recently introduced in the medical literature referring to the state of cognitive impairment that occurs in a patient who in or after "middle life" was diagnosed with DM or essential hypertension, dyslipidemia, obesity, or atherosclerotic diseases. 
Numerous community-based sociodemographic studies have shown that diabetes is a specific risk factor intimately related to cognitive impairments particularly occurring in middle and elderly persons. , Other research groups have reported their analysis focussing the cognitive impairment of elderly age groups (above 60 years) and by now, this fact has been substantially a well-established matter of concern in the healthcare arena. ,,
Our study was conducted in a tertiary-care teaching institute in eastern India among participants presenting with diabetes, who were from all age groups and with varying durations of the disease, to find out the downstream effects of DM on cognitive impairment.
| Materials and Methods|| |
A hospital-based cross-sectional study was conducted in a tertiary-care teaching institute in eastern India to find correlation between DM and cognitive functions across varying age groups and durations of the disease.
The study was conducted from July 2010 to June 2013.
All the consecutive diabetic patients presenting at the outpatients departments of general medicine, pediatric, and diabetic clinic were included as participants in this study; consecutive nondiabetic subjects were considered as controls. The participants were divided into the following age groups for the purposes of comparison: Group A (aged up to 20 years), group B (aged 21-30 years), group C (aged 31-40 years), group D (aged 41-50 years), group E (aged 51-60 years), and group F (aged above 60 years). Further comparisons were made between controls and diabetic patients with different durations of the disease (less than 3 months, 3 months-5 years, 6-10 years, 11-20 years, and above 20 years).  In all these groups, factors such as restrictions on gender, ethnicity, literacy, occupation, addiction, dietary patterns, nonpsychiatric comorbidities, and medications were set aside for participation requisites of inclusion or exclusion.
Data collection procedure
Ethical clearance was obtained from Institutional Ethics Committee. The data-collection tool used for this study was an interview schedule that was developed at the institute with the assistance from the faculty members and a statistician. A predesigned, pretested, and semi-structured questionnaire was used to collect the data relating to cognitive function based on the Global Deterioration Scale (GDS). By initial translation, back-translation, retranslation followed by a pilot study, the data were collected, and this collection module was custom-made for the study. The pilot study was carried out at the outpatient department among comparable subjects, following which some of the questions from the interview schedule were modified. Informed consent was obtained from each of the participants and in the case of minor from his or her caregivers wherever necessary. Persons who were severely ill and those with known psychiatric morbidity, pregnant women, and nonconsenting individuals were excluded from the study.
Operational definitions used
GDS: The GDS was used for the evaluation of cognitive function in our study. Initially the participants were assessed on overall characteristics on the GDS for a preliminary diagnosis of mild cognitive impairment (MCI).  These characteristics were as follows: (a) mild decline in cognitive function reported by the patient or caregiver and confirmed objectively, which is more than typical for age, but less severe than dementia; (b) mild impairment, primarily involving memory; and (c) a subtle impairment in complex, instrumental activities of daily living (keeping the common activities of daily living intact). The GDS thus provided an overview of the stages of cognitive function that can be classified into seven different levels: levels 1-4 (predementia stages) and levels 5-7 (dementia stages where individual cannot survive without assistance) - each level was numbered (1-7) with short title (i.e., forgetfulness, early confusional, and others followed by a brief characteristics for that stage). The levels are as follows: 
Level 1: No cognitive disorder - clinically normal.
Level 2: Very mild cognitive disorder - time of amnesia.
Level 3: Mild cognitive disorder - the earliest stage with clear disorder.
Level 4: Moderate cognitive disorder - late stage of confusion.
Level 5: Early severe cognitive disorder - early-phase
Level 6: Severe cognitive disorder - intermediate-phase dementia.
Level 7: Late severe cognitive disorder-late-phase dementia.
Type 2 DM [formerly known as noninsulin-dependent DM (NIDDM) or adult-onset diabetes] is a metabolic disorder that is characterized by hyperglycemia (high blood sugar) in the context of insulin resistance and relative lack of insulin. 
Only those participants were included in the study who presented with DM with no accompanying disease or condition that requires certain medications that affects the mental status.
- Sudden onset of cognitive decline other than having DM;
- Patients with history of neurological diseases (e.g., large vessel stroke, Parkinson's disease, severe brain injury, seizure, multiple sclerosis, brain infection, meningitis, transient ischemic attack, cerebrovascular disease or epilepsy, any sensory or motor disorder that would preclude psychological testing including blindness) or any condition that may impair cognitive function (hypothyroidism, vitamin B 12 deficiency, electrolyte disturbance, hepatic diseases);
- History of psychiatric illness (e.g., schizophrenia, bipolar disorder);
- Patients who were taking medication known to have psychoactive effects such as benzodiazepines, β-adrenoceptor antagonists, steroids, major tranquillizers, antidepressants; and
- The participant and whose caregivers did not give consent.
The collected data were thoroughly screened and entered into Excel spreadsheets and were analyzed for interpretation. Statistical Package for the Social Sciences (SPSS) version 11.0 (SPSS-Inc., Chicago, US) was used to calculate proportions. Significance test was also used in this study.
| Results|| |
Overall minimum cognitive dysfunction was in 21.33% among those detected less than three months in less than 20 years age group. In this group, the cognitive dysfunction were noted highest in 60 years and above in control (27.27%) and in diabetic (46.96%) followed by 51-60 years age group controls (12.28%) and diabetics (41.93%), respectively [Table 1].
Minimum cognitive dysfunction was in 34.37% among diabetics detected between 3 months and 5 years in less than 20 years age group. In this group, cognitive dysfunction was maximum above 60 years of age in controls (34.16%) and in diabetics (51.61%) followed by controls (32.00%) and diabetics (48.48%) from the 31-40 years age group [Table 2].
Under 20 years of age, cognitive dysfunction were noted minimum (39.21%) among those cases who are suffering for the 6-10 years. Cognitive dysfunction were 56.31% in diabetics in more than 60 years age groups followed by 54.90% in 51 to 60 years age groups [Table 3].
Similarly, minimum cognitive dysfunction was noted in diabetic cases (48.57%) from the less than 20 years age groups for whom diabetes was detected within last 11-20 years of age. In this group, the maximum cognitive dysfunction was 67.34% in 51-60 years age groups followed by 59.45% in 41-50 years age groups [Table 4].
Again minimum cognitive dysfunction was noted in diabetic cases (42.85%) from less than 20 years age groups who were suffering from diabetes for more than 20 years. In this group, the maximum cognitive dysfunction was 70.58% in 51-60 years age groups followed by 66.66% in 41-50 years age groups [Table 5].
As per the overall data across all age groups irrespective of the duration of diabetes, normal cognitive function (level 1) was noted among 73.57% in the nondiabetic control groups and 53.55% in diabetic groups. Cognitive dysfunction in diabetic groups was 46.45% and it was only 26.43% in control groups [Table 6].
| Discussion|| |
Cognitive dysfunctions in diabetics and age-matched nondiabetic participants were studied by using the GDS, and it was noted that there was noticeable diminution of cognitive functions in diabetics from all age groups irrespective of the duration of the morbidity that uniformly increased with age.
Life expectancy is increasing as a result of advances in medical science and the availability of better healthcare services. The proportion of elderly persons in the general population is therefore rising along with the spectrum of cognitive dysfunctions. As the risk of dementia increases with increasing age, the number of persons with dementia in the general population is also rising.  Related study in the United States demonstrated that the incidence of dementia increased among the elderly population over time. 
The prevalence of MCI was 5.3% in Japan; the yearly rate of progression of MCI to dementia was about 4%.  The rate of amnestic MCI in the USA, in a cohort of 1,248 individuals with the mean age of 74.6 (±5.3) years, was about 3-4%.  In a Swedish cohort, among those aged 75-95 years, the rates of amnestic MCI, single domain non-memory MCI, and multi-domain MCI were found to 2.1%, 7.2%, and 1.8%, respectively, using standard definitions; these rates were almost doubled when the criterion for normal cognitive functioning was removed in the modified definitions.  The rate of MCI in India among those aged 50 years or more was 14.9%; amnestic MCI accounted for 6.0% and multi-domain MCI accounted for 8.9%. 
Nowadays, diabetes is considered as an epidemic disease, with about 173 million diabetic people all over the world. Diabetes is a chronic disease that leads to long-term complications, which include the risk of cognitive changes. A preserved cognitive status is essential for the understanding of the outcome. ,
Cognitive performance of diabetic patients is lower compared to that of subjects that do not suffer from this kind of metabolic impairment. Considering the results, the "brain at risk" stage (risk of dementia) is not asymptomatic, manifests subclinically as cognitive impairment. 
Cognitive ability of diabetic patients was poor when compared to subjects with no metabolic impairment. Executive function was the most affected. The risk factors for cognitive impairment determine not only an increased risk for dementia in "late life" but also a cognitive ability impairment during "middle life". 
Forty two percent cognitive dysfunction found in a study conducted by Priyam et al.  In a study conducted by Solanki et al., 48% of the diabetic patients below 60 years of age showed cognitive impairment.  Another study conducted by Shuba et al.  revealed that 63.33% of the diabetics had a decreased cognition.
Patients with type 2 DM are at higher risk of developing dementia  for reasons of neurodegeneration and/ or microvascular changes,  where both conditions may lower the threshold for more severe cognitive impairment. Diabetes substantially accelerates progression from MCI to dementia in older patients. Earlier onset, longer duration, and poor glycemia control are all associated with cognitive dysfunction in diabetics. ,
In our study, the GDS was used to find cognitive dysfunction in diabetics.  Other research groups had used the GDS with stage 3 to define MCI. 
Both type 2 DM and dementia that are common in elderly individuals are often progressive and disabling conditions. Ten percent of people over the age of 65 years develop dementia, rising to more than 50% of people over the age of 85 years. ,
More than 10% of the elderly population in the United States suffer from type 2 DM, the prevalence of which rises with the increase of age, and a global pandemic of this condition is evident. ,
Cognitive function (particularly of memory) declines with age, although the rate of decline is not distributed uniformly within the population. For a minority, this progress in severity to cause disability until dementia is diagnosed. A possible relationship between cognitive decline and diabetes has been hypothesized since the discovery of insulin by Miles and Root. 
Type 2 DM increases the risk of cognitive dysfunction,  with resultant worse performance on neuropsychological screening tests, irrespective of the patient's age and the DM type. ,,
The underlying mechanisms of cognitive impairment in patients with DM remain under investigation, but it seems clear that vascular endothelial disease, glucose and insulin abnormalities, dyslipidemia, metabolic syndrome, hypertension, and obesity and amyloid metabolism are all involved, both separately and in association. 
Microscopically, cognitive dysfunction may be the result of hippocampal injury, reduction in gray matter density, or microvascular changes in white matter. 
Several research groups had reported that type 2 DM was associated with cognitive impairment. ,,
The association between DM and cognitive performance is difficult to understand due to the fact that other complications typically observed with type 2 DM including cardiovascular disease; hypertension, and depression are also associated with cognitive deficit. Yet, the specific mechanism linking type 2 DM with cognitive deficits has yet to be clearly identified. However, extraneuronal hyperglycemia, disturbed brain glucose metabolism, and altered brain insulin signaling have been hypothesized. 
Identification and effective treatment of comorbid depression is increasingly considered as an essential component of the high-quality clinical care of patients with chronic illness, especially the geriatric population, in special medical settings. Diabetes is considered as one of the most psychological and behaviorally demanding chronic illness. Because 95% of diabetic management is conducted by patient; comorbid depression in diabetes that may lead to poorer outcomes and increased risk of complication by lowering adherence to glucose monitoring, exercise, diet, and medication regimens. 
Type 2 DM has been related to an accelerated cognitive decline in elderly people, the development of MCI and an increased risk of dementia, which include both Alzheimer's disease and vascular dementia. 
Even a modest effect of diabetes on the cognitive function has significant public health implications. 
Ruis et al. had shown that diabetes duration was associated with the effect size (cognitive decline) of the study: The longer the duration of known diabetes, the bigger the effect size was substantiated by other studies that clearly showed that the age of diabetes onset was inversely related with performance of tasks for memory and information-processing speed in diabetic patients. Abovementioned findings were in concurrence with the findings of the present study.
In the study of osteoporotic fractures by Gregg et al.,  there was a trend of increasing risk of cognitive decline with increasing duration of diabetes, and in the Framingham study, Elias et al.,  each 5-year increment between diabetes diagnosis and cognitive assessment was associated with lower scores on tests of logical memory, word fluency, and similarities. Grodstein et al. showed beneficial effect of sugar control on cognitive dysfunction. But more study is needed to find adequate data demonstrating the same.
Strength of the study
Our study comprised a heterogeneous group of participants. Number of study participants was 1,629 and in control groups there were 1,650 patients from different age groups (from less than 20 years to 60 years and above) with varying duration of diabetes. Similar types of other studies had taken older age groups like around 50 years. The GDS was used in this study to assess cognitive function of diabetic patients but in similar type of other studies the mini-mental state examination (MMSE) was used.
Limitations of the study
Fewer studies were available using the GDS for comparison. Further, due to the resource-poor settings of diabetic care other variables like gender, literacy, and occupation could not be taken into account in our study.
Future directions of the study
In the next phase of our cognitive dysfunction study with other variable like demographic information such as age, sex, literacy level, years of schooling, occupation held during their work life, and addictions especially tobacco use will be included. Further, we wish to extend our study to find relation between cognitive dysfunction and other comorbidities like hypertension, dyslipidemia, obesity, type of antidiabetic medications, hemoglobin A 1 C (HbA 1 C) levels.
| Conclusion|| |
Diabetics suffer from more cognitive dysfunctions compared to nondiabetics that increases with the increase of age. There is also a significantly higher incidence of cognitive dysfunction in newly developed diabetics than age-matched controls, showing that cognitive dysfunction may not altogether be a result of long-standing diabetes but may also be a cause of comorbidity for which more elaborative studies are needed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Allen KV, Frier BM. Strachan MW. The relationship between type 2 DM and cognitive dysfunction: Longitudinal studies and their methodological limitations. Eur J Pharmacol 2004;490:169-75.
Nicolae H, Panea C, Gurgu R, Banjenaru O. Subclinical cognitive impairment in middle aged patients with Type II diabetes mellitus. Romanian J Neurol 2012;11:184-8.
Gouw AA, van der Flier WM, Fazekas F, van Straaten EC, Pantoni L, Poggesi A, et al
.; LADIS Study Group. Progression of white matter hyperintensities and incidence of new lacunes over a 3-year period: The Leukoaraiosis and disability study. Stroke 2008:39:1414-20.
Pantoni L, Garcia JH. Pathogenesis of Leukoaraiosis: A review. Stroke 1997:28:652-9.
Goldstein LB, Adams R, Alberts MJ, Appel LJ, Brass LM, Bushnell CD, et al.
; American Heart Association/American Stroke Association Stroke Council; Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; Quality of Care and Outcomes Research Interdisciplinary Working Group, et al
. Primary prevention of ischemic stroke: A guideline from the American Heart Association/American Stroke Association Stroke Council: Cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: The American Academy of Neurology affirms the value of this guideline. Stroke 2006;37:1583-633.
Kivipelto M, Ngandu T, Laatikinen T, Winbland B, Soininen H, Tuomilehto J. Risk score for the prediction of dementia risk in 20 years among middle-aged people: A longitudinal, population- based study. Lancet Neurol 2006;5:735-41.
Kivipelto M, Solomon A. Preventive neurology: On the way from knowledge to action. Neurology 2009;73:168-9.
Xu WL, Qiu CX, Wahlin A, Winbland B, Fratiglioni L. Diabetes mellitus and risk of dementia in the Kungholmen project: A 6-years follow-up study. Neurology 2004;63:1181-6.
Biessels GJ, Staekenborg S, Brunner E, Brayne C, Scheltens P. Risk of dementia in diabetes mellitus; a systemic review. Lancet Neurol 2006:5:64-74.
Cukierman T, Gerstein HC, Williamson JD. Cognitive decline and dementia in diabetes - Systematic overview of prospective studies. Diabetologia 2005;48:2460-9.
Shuba N, Karan. Assessment of cognitive status in Diabetes Mellitus. J Clin Diagn Res 2014;6:1658-62.
Reisberg B, Ferris SH, de Leon MJ, Crook T. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 1982;139:1136-9.
Kim JS, Won CW, Kim BS, Choi HR. Predictability of various serial subtractions on global deterioration scale according to education level. Korean J Fam Med 2013;34:327-33.
Kumar Vinay, Fausto N, Abbas AK, Cotran RS, Robbins SL. Robbins and Cotran Pathologic Basis of Disease. 7 th
ed. Philadelphia, Pa: Saunders; 2005. p. 1194-5.
Andrade C, Radhakrishnan R. The prevention and treatment of cognitive decline and dementia: An overview of recent research on experimental treatments. Indian J Psychiatry 2009;51:12-25.
Kokmen E, Beard CM, O'Brien PC, Offord KP, Kurland LT. Is the incidence of dementing illness changing? A 25-year time trend study in Rochester, Minnesota (1960-1984). Neurology 1993;43:1887-92.
Ikeda M. Nippon Ronen Igakkai Zasshi. Epidemiology of mild cognitive impairment (MCI) among the community-dwelling elderly-findings from the Nakayama study. Nihon Ronen Igakkai Zasshi 2004;41:186-8.
Ganguli M, Dodge HH, Shen C, DeKosky ST. Mild cognitive impairment, amnestic type: An epidemiologic study. Neurology 2004;63:115-21.
Palmer K, Bäckman L, Winblad B, Fratiglioni L. Mild cognitive impairment in the general population: Occurrence and progression to Alzheimer disease. Am J Geriatr Psychiatry 2008;16:603-11.
Das SK, Bose P, Biswas A, Dutt A, Banerjee TK, Hazra AM, et al
. An epidemiologic study of mild cognitive impairment in Kolkata, India. Neurology 2007;68:2019-26.
Alencar RC, Cobas RA, Gomes MB. Assessment of the cognitive status in patients with type 2 diabetes through the Mini-Mental Status Examination: A cross-sectional study. Diabetol Metab Syndr 2010;2:10.
Yamazaki Y, Miwa T, Sakurai H, Hanyu H, Iwamoto T, Odawara M. Clinical backgrounds and morbidity of cognitive impairment in elderly diabetic patients. Endocr J 2011;58:109-15.
Nicolae H, Panea C, Gurgu R, Bajenaru O. Subclinical cognitive impairment in middle-aged patients with type II diabetes mellitus. Romanian J Neurol 2012;11:184-8.
Mukherjee P, Mazumdar S, Goswami S, Bhowmik J, Chakroborty S, Mukhopadhyay S. Cognitive dysfunction in diabetic patients with special reference to age of onset, duration and control of diabetes. Activitas Nervosa Superior 2012;54:67-75.
Solanki RK, Dubey V, Munshi D. Neurocognitive impairment and comorbid depression in patients of diabetes mellitus. Int J Diabetes Dev Ctries 2009;29:133-8.
Velayudhan L, Poppe M, Archer N, Proitsi P, Brown RG, Lovestone S. Risk of developing dementia in people with diabetes and mild cognitive impairment. Br J Psychiatry 2010;196:36-40.
Umegaki H. Pathophysiology of cognitive dysfunction in older people with type 2 diabetes: Vascular changes or neurodegeneration? Age Ageing 2010;39:8-10.
Xu W, Caracciolo B, Wang HX, Winblad B, Bäckman L, Qiu C, et al
. Accelerated progression from mild cognitive impairment to dementia in people with diabetes. Diabetes 2010;59:2928-35.
Roberts RO, Geda YE, Knopman DS, Christianson TJ, Pankratz VS, Boeve BF, et al
. Association of duration and severity of diabetes mellitus with mild cognitive impairment. Arch Neurol 2008;65:1066-73.
Cheng Y, Xiao S. Recent research about mild cognitive impairment in China. Shanghai Arch Psychiatry 2013;26:4-14.
Evans DA, Funkenstein HH, Albert MS, Scherr PA, Cook NR, Chown HJ, et al
. Prevalence of Alzheimer's disease in a community population of older persons. Higher than previously reported. JAMA 1989;262:2551-6.
Geldmacher DS, Whitehouse PJ. Evaluation of dementia. N Eng J Med 1996;335:330-6.
Harris MI. Diabetes in America: Epidemiology and scope of the problem. Diabetes Care 1998;21(Suppl 3):C11-4.
Harris MI, Flegal KM, Cowie CC, Eberhardt MS, Goldstein DE, Little RR, et al
. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults. The third National Health and Nutrition Examination Survey, 1988-1994. Diabetes Care 1998;21:518-24.
Miles WR, Root HF. Psychologic tests applied to diabetic patients. Arch Intern Med 1922;30:767-77.
Patiño-Fernández AM, Delamater AM, Applegate EB, Brady E, Eidson M, Nemery R, et al
. Neurocognitive functioning in preschool-age children with type 1 diabetes mellitus. Pediatr Diabetes 2010;11:424-30.
Nooyens AC, Baan CA, Spijkerman AM, Verschuren WM. Type 2 diabetes and cognitive decline in middle-aged men and women: The Doetinchem cohort study. Diabetes Care 2010;33:1964-9.
Ravona-Springer R, Schnaider-Beeri M. The association of diabetes and dementia and possible implications for nondiabetic populations. Expert Rev Neurother 2011;11:1609-17.
van den Berg E, Kloppenborg RP, Kessels RP, Kappelle LJ, Biessels GJ. Type 2 diabetes mellitus, hypertension, dyslipidemia and obesity: A systematic comparison of their impact on cognition. Biochim Biophys Acta 2009;1792:470-81.
Seaquist ER. The final frontier: How does diabetes affect the brain? Diabetes 2010;59:4-5.
Mooradian AD. Diabetic complication of central nervous system. Endocr Rev 1988;9:346-56.
Richardson JT. Cognitive function in diabetes mellitus. Neurosci Biobehav Rev 1990;14:385-8.
Biessels GJ, Kappelle AC, Bravenboer B, Erkelens DW, Gispen WH. Cerebral function in diabetes mellitus. Diabetologia 1994;37:643-50.
Stewart R, Liolitsa D. Type 2 diabetes, cognitive impairment and dementia. Diabet Med 1999;16:93-112.
Winokur A, Maislin G, Phillips JL, Amsterdam JD. Insulin resistance after oral glucose tolerance testing in patients with major depression. Am J Psychiatry 1988;145:325-30.
Whitmer RA. Type 2 diabetes and the risk of cognitive impairment and dementia. Curr Neurol Neurosci Rep 2007;7:373-80.
Ryan CM, Williams TM. Effects of insulin-dependent diabetes on learning and memory efficiency in adults. J Clin Exp Neuropsychol 1993;15;685-700.
Gregg EW, Yaffe K, Cauley JA, Rolka DB, Blackwell TL, Narayan KM, et al
. Is diabetes associated with cognitive impairment and cognitive decline among older women? Study of Osteoporotic Fractures Research Group. Arch Intern Med 2000;160:174-80.
Elias PK, Elias MF, D'Agostino RB, Cupples LA, Wilson PW, Silbershatz H, et al
. NIDDM and blood pressure as risk factors for poor cognitive performance. The Framingham study. Diabetes Care 1997;20:1388-95.
Grodstein F, Chen J, Wilson RS, Manson JE; Nurses' Health Study. Type 2 diabetes and cognitive function in community-dwelling elderly women. Diabetes Care 2001;24:1060-5.
483, Sahid Khudiram Bose Sarani, 3rd Floor, Kolkata - 700 030, West Bengal
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
| Article Access Statistics|
| Viewed||508 |
| Printed||24 |
| Emailed||0 |
| PDF Downloaded||10 |
| Comments ||[Add] |