Study Suggests Diabetes Managed More Intensively in Older Veterans with Dementia and Cognitive Impairment
Individuals with diabetes have nearly twice the risk of developing dementia and cognitive impairment as those without diabetes. Individuals are at additional risk for dementia if they have had diabetes for a long duration, have advanced complications, or take insulin. Moreover, cognitive impairment interferes with diabetes self-care management, yet is widely unrecognized in the clinical care setting. This study sought to examine and compare anti-glycemic medication use, glycemic control, and risk of hypoglycemia in older Veterans with and without dementia or cognitive impairment. Other variables assessed included comorbid conditions, extended care and nursing home stays, demographics, and HbA1c levels. For this study cohort, investigators used VA data, in addition to Medicare and Medicaid data, to identify 497,900 Veterans ages 65 and older with diabetes who used VA healthcare services in FY02 and FY03.
- Diabetes was managed more intensively in older Veterans with dementia or cognitive impairment than in those with no impairment, with more patients on insulin (30% vs. 24%) among those with cognitive problems. These conditions were independently associated with a greater risk of hypoglycemia.
- Of all Veterans taking insulin, the incidence of hypoglycemia was higher among those with dementia (27%) or cognitive impairment (20%) than among those with neither condition (14%). Veterans with dementia or cognitive impairment also had a greater decline in HbA1c over the 2-year study period. These findings suggest that providers were less likely to pursue individualized glycemic goals, as recommended by VA-DoD clinical practice guidelines (updated in 2010), when patients had cognitive problems.
- In this cohort of patients with diabetes, the prevalence of combined dementia and cognitive impairment was 13% for Veterans ages 65 to 74 and 24% for Veterans ages 75 and older. Prevalence of dementia in Veterans with extended care or nursing home stays (6% of the study population) was markedly higher (45%).
- This study relied on administrative data rather than clinical examinations. In addition, data were from 2002 and 2003, therefore may not reflect current practices.
- Although some chronic comorbid illnesses were controlled for, it was not possible to assess severity of illness. Also, it is possible that unmeasured participant-level and social support factors account for the relationship found between hypoglycemia and dementia or impaired cognitive function.
- Harms to Veterans were not evaluated.
This study was partly funded by HSR&D. Dr. Feil also was supported by an HSR&D Career Development Award and is part of HSR&D’s Center for the Study of Healthcare Provider Behavior, Sepulveda, CA. Drs. Rajan, Tseng, and Pogach are part of HSR&D’s Center for Healthcare Knowledge Management for Chronic Complex Illnesses, East Orange, NJ. Dr. Pogach is also Clinical Coordinator of VA/HSR&D’s Diabetes Mellitus Quality Enhancement Research Initiative (DM-QUERI). Dr. Miller is part of HSRD’s Center for Health Quality, Outcomes, and Economic Research, Bedford MA.
Feil D, Rajan M, Soroka O, Tseng C, Miller D, and Pogach L. Risk of Hypoglycemia in Older Veterans with Dementia and Cognitive Impairment: Implications for Practice and Policy. Journal of the American Geriatrics Society December 8, 2011;E-pub ahead of print.