Type 2 diabetes is a multisystemic disease. Besides the widely recognized micro- and macro-vascular complications of heart attack, stroke, neuropathy, retinopathy, kidney failure, diabetes is also known to be a risk factor for the development of dementia. When diabetes and dementia coexist, they pose a challenge to the treating clinician. Self-management is an integral part of management of diabetes and dementia impairs the ability to carry out self-care activities. Together the two conditions create a vicious cycle, which further makes diabetes management an arduous task.

The features of dementia are worsening memory, thinking and impaired ability to perform everyday activities. In an earlier published article, my coauthors and I have used the term “memoryporosis” in place of dementia, likening it to osteoporosis, when counseling family members about the diagnosis. Using a more innocuous term may help them accept the condition better as it sounds less threatening and less judgmental.¹

Dementia is more common in people with diabetes and studies have established a link between the two. Younger age at onset of diabetes is associated with higher risk of subsequent dementia as shown in a recent JAMA study, with a median follow-up of 31.7 years.² Several factors such as vascular damage, hypoglycemic episodes due to tight glycemic control, inflammatory state may contribute to the development of dementia in diabetes. Persons with Alzheimer’s disease have an increased risk of developing type  2 diabetes and persons with type 2 diabetes are at greater risk of developing Alzheimer’s disease, which has been termed type 3 diabetes.

The remarkable increase in the life expectancy has led to an aging population. This is an outcome of the shift in the pattern of diseases, from communicable to noncommunicable diseases. This also means that the number of people living with NCDs like diabetes and its attendant complications is rising and will continue to increase further. Most dementia patients will in due course of time need constant medical attention and assistance in carrying out basic activities of daily living resulting in heavy economic and social burden. Hence, prevention is of utmost importance for an active and healthy life.

Prevention should begin early and continue throughout life.¹ Five levels of prevention of diabetes dementia have been described: primary, secondary, tertiary, quaternary and quinary. ³

The objective of primary prevention is to prevent a disease from ever occurring. Strategies to prevent dementia from occurring in diabetic individuals include optimization of glycemic control, avoidance of hypoglycemia, optimal management of high BP/obesity/depression, lifestyle changes such as regular physical activity, cessation of tobacco use. A higher educational level may also be helpful. ³

Secondary prevention calls for early detection of subclinical disease and its management. All persons with diabetes older than 60 years should be screened for cognitive impairment. All those with cognitive impairment should be regularly monitored for any alteration in status. Also, screen for reversible causes of dementia such as hypothyroidism, hyperthyroidism, B12 and estrogen deficiency. In all this, the caregivers should not be left out; focus should be to prevent compassion fatigue, physical and financial fatigue. ³

Tertiary prevention of dementia in diabetes involves selection of less stringent treatment goals, choosing treatments that cause less hypoglycemia; opting for parsimonious regimens with minimum pill/injection burden, maximum flexibility in time of administration. ³

Quaternary prevention is “action taken to identify patients at risk of overmedicalization, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable.” ⁴ Quarternary prevention of dementia in diabetes involves avoiding use of nonspecific diagnostic tools, unnecessary labeling of mild cognitive insufficiency as dementia, treatment with irrational therapy. ³

Today, when people look to social media for information, it is important to prevent the spread of false health information. This is the premise of the fifth level of prevention called quinary prevention, which is a mode of preventing the spread of hearsay and false health information. It overlaps and includes all the above levels of prevention.⁵ Enhancing awareness about diabetes dementia among all healthcare professionals, members of the public and healthcare policy makers is quinary prevention of dementia in diabetes. ³

Treating diabetes is not just about keeping the blood glucose under control. Since, diabetes is a chronic illness, treatment also includes measures to prevent complications and to check any disability and rehabilitation. All of this calls for a multidisciplinary approach across several specialties to deliver high quality diabetes care. Strategies to manage diabetes therefore must also take into consideration the social and economic impact of the disease, including its effect on the caregivers.

References

1. Kalra S, et al. Memoryporosis: Dementia in primary care diabetology. J Pak Med Assoc. 2021 Feb;71(2(B)):772-774.
2. Barbiellini Amidei C, et al. Association between age at diabetes onset and subsequent risk of dementia. JAMA. 2021 Apr 27;325(16):1640-1649.
3. Kalra S, et al. Prevention of diabetes dementia. March 2020. https://www.touchendocrinology.com/insight/prevention-of-diabetes-dementia/
4. Kisling LA, M Das J. Prevention Strategies. [Updated 2021 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537222/
5. Dutta D, et al. Quinary prevention in diabetes care: Need for multidisciplinary approach. Clinical Epidemiology and Global Health. 2021;11:100757.