Clinical Geriatrics
Recent studies have suggested that certain psychiatric disorders occur with increased frequency among older adults with type 2 diabetes mellitus for several reasons.1,2 First, diabetes is considered to be one of the most psychologically and behaviorally demanding of the chronic medical illnesses. Multiple coping strategies are necessary to deal with the losses that can occur with aging. Because 95% of the management of diabetes is conducted by the patient, a diagnosis of diabetes can lead to increased levels of anxiety, depressive symptoms, and lowered self-esteem. This is often true in individuals who are predisposed to psychiatric disorders or those with limited social supports.
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DIABETES AND DEPRESSION
The association between diabetes and depression dates back to 1674, when Dr. Thomas Willis believed that depression caused diabetes. Persons with depression are twice as likely as the general population to develop diabetes.3 The lifetime prevalence of depression among adults with diabetes is estimated to be 28.5%,1 which is almost three times the prevalence rate for the general adult population in the United States1,7 and 14 times the rate for older adults.
Depressive symptoms include sad mood, anhedonia, insomnia with early morning awakening, anorexia, helplessness, hopelessness, excessive guilt, and/or death wishes or suicidal ideas. Depressive symptoms have been significantly and consistently associated with hyperglycemia.5,8 Hypercortisolemia, often associated with depression, is known to increase blood sugar levels, and this may in part explain this finding. Alternatively, due to the degree of self-management needed, comorbid depression in diabetes may lead to poorer outcomes and increased risk of complications because of lower adherence to glucose monitoring, exercise, diet, and medication regimens.9 Depressive symptoms have been associated with decreased quality of life, and higher serum cholesterol and triglycerides10 in elderly persons with diabetes, as well as an increased risk of stroke, particularly in black men with diabetes. In fact, the lowest adherence to dietary and exercise recommendations is among older adults with the highest levels of depressive symptom severity.11,12
Diabetes is also a risk factor for cerebrovascular disease. The associated vascular cerebrocortical abnormalities preferentially occur in the frontal lobes and have been linked with a subtype of depression seen in older adults that presents with psychomotor retardation, loss of interest, paranoia at times, and executive dysfunction.13 This executive dysfunction can further interfere with adherence to diabetes self-management, because planning, sequencing, and organizing are all adversely affected.14
[...]
DIABETES AND DEMENTIA
Several prospective studies have found that obesity in middle age, as well as diabetes in later life, can increase the risk for developing dementia in at least two different ways.21-23 First, animal studies have suggested that depletion of the neuronal insulin receptor mimics some aspects of the neurodegeneration seen in Alzheimer’s disease.24 This provides support for the idea that Alzheimer’s disease may be caused in part by neuronal insulin resistance. Type 2 diabetes is a risk factor for Alzheimer’s disease, particularly among carriers of the ApoE-4 gene.25 Second, the presence of multiple cardiovascular risk factors at midlife substantially increases the risk of late-life dementia in a dose-dependent manner,26 and type 2 diabetes is associated with a twofold increased risk of vascular dementia.27
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Any identified reversible causes of cognitive impairment, such as medications, nutritional deficiencies, and metabolic disturbances, should be addressed. Neuropsychological testing should be considered if the etiology of cognitive impairment is unclear.
Although Alzheimer’s disease is the most common cause of dementia, in the older person with diabetes the prevalence of vascular dementia or a mixed dementia is high. Additionally, cholinergic deficits do occur in vascular dementia due to ischemia of basal forebrain nuclei and of cholinergic pathways, and do respond modestly to the cholinesterase inhibitors used to treat Alzheimer’s disease.
[...]
Risk reduction for dementia in diabetes, especially control of glucose hypertension and dyslipidemias, are likely to be a more effective way to prevent cognitive deterioration in vascular dementia. Additional education should be provided regarding the importance of weight control, exercise, and nutrition in disease self-management.
[...]
DIABETES, SCHIZOPHRENIA, AND ATYPICAL ANTIPSYCHOTIC MEDICATIONS
Studies have consistently found that rates of diagnosed diabetes in patients with schizophrenia exceed general population figures,33,34 even before the widespread use of the newer second-generation (or atypical) antipsychotics. Among older psychiatrically hospitalized patients, increased prevalence rates of diabetes were also found in patients with schizoaffective and bipolar disorder.35 Although most risk factors for diabetes are similar to those seen in the general population, the prevalence of those risk factors is much higher among patients with serious mental illness. For example, patients with schizophrenia are more likely than age-matched controls to be overweight, consume fewer fruits and vegetables, be sedentary,36,37 and have other cardiovascular risk factors, especially tobacco use.38 As a result, patients with schizophrenia have higher mortality rates, at younger ages, than the general population.38
More recently, the use of the newer atypical antipsychotic medications appears to increase the risk of acquiring or exacerbating type 2 diabetes,39 rarely causing diabetic ketoacidosis.
[...]
CONCLUSION
For a variety of reasons, several psychiatric disorders frequently co-occur with diabetes mellitus. Diabetes risk reduction, including nutritional/physical activity counseling, control of blood pressure, lowering cholesterol and triglyceride levels, weight loss, and increased physical activity can have a positive impact on both the diabetes and the psychiatric illness. Screening for cardiovascular and metabolic risk factors is particularly important when atypical antipsychotics are to be prescribed. Desired benefits of these medications must be weighed against the potential adverse effects, especially the possibility of cerebrovascular events, in older adults with dementia and behavioral disturbances. The identification and treatment of the psychiatric illness can often improve diabetes outcomes.
Recent studies have suggested that certain psychiatric disorders occur with increased frequency among older adults with type 2 diabetes mellitus for several reasons.1,2 First, diabetes is considered to be one of the most psychologically and behaviorally demanding of the chronic medical illnesses. Multiple coping strategies are necessary to deal with the losses that can occur with aging. Because 95% of the management of diabetes is conducted by the patient, a diagnosis of diabetes can lead to increased levels of anxiety, depressive symptoms, and lowered self-esteem. This is often true in individuals who are predisposed to psychiatric disorders or those with limited social supports.
[...]
DIABETES AND DEPRESSION
The association between diabetes and depression dates back to 1674, when Dr. Thomas Willis believed that depression caused diabetes. Persons with depression are twice as likely as the general population to develop diabetes.3 The lifetime prevalence of depression among adults with diabetes is estimated to be 28.5%,1 which is almost three times the prevalence rate for the general adult population in the United States1,7 and 14 times the rate for older adults.
Depressive symptoms include sad mood, anhedonia, insomnia with early morning awakening, anorexia, helplessness, hopelessness, excessive guilt, and/or death wishes or suicidal ideas. Depressive symptoms have been significantly and consistently associated with hyperglycemia.5,8 Hypercortisolemia, often associated with depression, is known to increase blood sugar levels, and this may in part explain this finding. Alternatively, due to the degree of self-management needed, comorbid depression in diabetes may lead to poorer outcomes and increased risk of complications because of lower adherence to glucose monitoring, exercise, diet, and medication regimens.9 Depressive symptoms have been associated with decreased quality of life, and higher serum cholesterol and triglycerides10 in elderly persons with diabetes, as well as an increased risk of stroke, particularly in black men with diabetes. In fact, the lowest adherence to dietary and exercise recommendations is among older adults with the highest levels of depressive symptom severity.11,12
Diabetes is also a risk factor for cerebrovascular disease. The associated vascular cerebrocortical abnormalities preferentially occur in the frontal lobes and have been linked with a subtype of depression seen in older adults that presents with psychomotor retardation, loss of interest, paranoia at times, and executive dysfunction.13 This executive dysfunction can further interfere with adherence to diabetes self-management, because planning, sequencing, and organizing are all adversely affected.14
[...]
DIABETES AND DEMENTIA
Several prospective studies have found that obesity in middle age, as well as diabetes in later life, can increase the risk for developing dementia in at least two different ways.21-23 First, animal studies have suggested that depletion of the neuronal insulin receptor mimics some aspects of the neurodegeneration seen in Alzheimer’s disease.24 This provides support for the idea that Alzheimer’s disease may be caused in part by neuronal insulin resistance. Type 2 diabetes is a risk factor for Alzheimer’s disease, particularly among carriers of the ApoE-4 gene.25 Second, the presence of multiple cardiovascular risk factors at midlife substantially increases the risk of late-life dementia in a dose-dependent manner,26 and type 2 diabetes is associated with a twofold increased risk of vascular dementia.27
[...]
Any identified reversible causes of cognitive impairment, such as medications, nutritional deficiencies, and metabolic disturbances, should be addressed. Neuropsychological testing should be considered if the etiology of cognitive impairment is unclear.
Although Alzheimer’s disease is the most common cause of dementia, in the older person with diabetes the prevalence of vascular dementia or a mixed dementia is high. Additionally, cholinergic deficits do occur in vascular dementia due to ischemia of basal forebrain nuclei and of cholinergic pathways, and do respond modestly to the cholinesterase inhibitors used to treat Alzheimer’s disease.
[...]
Risk reduction for dementia in diabetes, especially control of glucose hypertension and dyslipidemias, are likely to be a more effective way to prevent cognitive deterioration in vascular dementia. Additional education should be provided regarding the importance of weight control, exercise, and nutrition in disease self-management.
[...]
DIABETES, SCHIZOPHRENIA, AND ATYPICAL ANTIPSYCHOTIC MEDICATIONS
Studies have consistently found that rates of diagnosed diabetes in patients with schizophrenia exceed general population figures,33,34 even before the widespread use of the newer second-generation (or atypical) antipsychotics. Among older psychiatrically hospitalized patients, increased prevalence rates of diabetes were also found in patients with schizoaffective and bipolar disorder.35 Although most risk factors for diabetes are similar to those seen in the general population, the prevalence of those risk factors is much higher among patients with serious mental illness. For example, patients with schizophrenia are more likely than age-matched controls to be overweight, consume fewer fruits and vegetables, be sedentary,36,37 and have other cardiovascular risk factors, especially tobacco use.38 As a result, patients with schizophrenia have higher mortality rates, at younger ages, than the general population.38
More recently, the use of the newer atypical antipsychotic medications appears to increase the risk of acquiring or exacerbating type 2 diabetes,39 rarely causing diabetic ketoacidosis.
[...]
CONCLUSION
For a variety of reasons, several psychiatric disorders frequently co-occur with diabetes mellitus. Diabetes risk reduction, including nutritional/physical activity counseling, control of blood pressure, lowering cholesterol and triglyceride levels, weight loss, and increased physical activity can have a positive impact on both the diabetes and the psychiatric illness. Screening for cardiovascular and metabolic risk factors is particularly important when atypical antipsychotics are to be prescribed. Desired benefits of these medications must be weighed against the potential adverse effects, especially the possibility of cerebrovascular events, in older adults with dementia and behavioral disturbances. The identification and treatment of the psychiatric illness can often improve diabetes outcomes.
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