Sage Journals: Discover world-class research

Abstract

Background:

Type 2 diabetes mellitus (T2DM) and dementia are two of the leading chronic diseases in aging and are known to influence each other’s disease progression. There is well-established evidence that T2DM increases the risk for cognitive decline and dementia. At the same time, people with cognitive changes or dementia can find it difficult to manage their diabetes, resulting in hyper- or hypoglycemic events which can exacerbate the dementia disease progression further. Monitoring of glucose variability is, therefore, of critical importance during aging and when people with T2DM develop dementia. The advent of continuous glucose monitoring (CGM) has allowed the monitoring of glucose variability in T2DM more closely. The CGM seems to be highly feasible and acceptable to use in older people with T2DM and has been shown to significantly reduce their hypoglycemic events, often resulting in falls. Less is known as to whether CGM can have a similar beneficial effect on people with T2DM who have cognitive impairment or dementia in community or hospital settings.

Aims:

The current perspective will explore how CGM has made an impact on T2DM management in older people and those with comorbid cognitive impairment or dementia. We will further explore opportunities and challenges of using CGM in comorbid T2DM and dementia in community and hospital settings.

Keywords

Alzheimer’s diseases CGM device continuous glucose monitoring dementia type 2 diabetes mellitus

Introduction

Diabetes—Background, Pathophysiology, Dementia Linkage

Type 2 diabetes mellitus (T2DM) and dementia are aging-associated chronic and progressive conditions.^1,2 The T2DM is a complex metabolic disorder affecting 483 million adults worldwide³ with high mortality and morbidity rates.⁴ The pathophysiology of T2DM is attributed to insulin resistance as a subset of the metabolic syndrome,⁵ including obesity and dyslipidaemia,⁶ due to an imbalance between energy intake and expenditure to affect the metabolism of nutrient-storage. Not surprisingly, lifestyle factors (eg, obesity, low physical activity, unhealthy diet) are a major contributor to the risk of insulin resistance and T2DM.⁷ Furthermore, T2DM has significant short-term and long-term health effects.⁸

Key short-term effects of T2DM in aging are hypoglycemia and hyperglycemia. Hypoglycemia, defined as plasma glucose levels below 70 mg/dL or 3.9 mmol/L, is highly prevalent in aging. In the United Kingdom, the prevalence of both mild, moderate, and severe hypoglycemia is 20%.⁹ Hypoglycemia often results in changes to cognition, confusion, falls, fractures,^10,11 and anxiety, and in severe cases delirium, comas, cardiovascular complications, and even death.¹² Similarly, hyperglycemia can also result in life-threatening acute consequences such as diabetic ketoacidosis (DKA), hyperglycaemic hyperosmolar syndrome (HHS), coma, and death.¹³ Long-term T2DM effects are related to microvascular and macrovascular conditions,⁸ such as myocardial infarction, stroke, retinopathy, nephropathy, and neuropathy.^14,15 Of particular interest in terms of long-term risk of T2DM, dementia has emerged as a key factor in recent years. It is now well established that T2DM can increase the risk of cognitive impairment and dementia significantly in the long-term.^16,17

Dementia—Background, Pathophysiology, and Type 2 Diabetes Mellitus Linkage

Dementia is a clinical syndrome associated with changes to the cognition, including memory, which affects everyday activities,^18,19 with Alzheimer’s disease (AD) the most common form. An estimated 55 million people worldwide have dementia, which is predicted to increase to ~130 million by 2050.²⁰ Dementia is thought to be caused by the accumulation of amyloid-β proteins and phosphorylated tau, which can be exacerbated by insulin, cardiovascular, and inflammatory risk factors.²¹ The largest risk factors for dementia are age, high blood pressure, diabetes, cerebrovascular disease, and obesity.¹ Lifestyle factors such as nutrition and physical activity status are now regarded as some of the biggest risk factors for future AD, with interventions targeted toward reducing cardiovascular and metabolic risk factors. Of particular interest in this regard is that people with T2DM receiving healthy lifestyle advice including a balanced diet and physically active lifestyle show a 30% lower risk for cognitive decline,²² even just by adhering for six months to a multimodal lifestyle intervention that targeted improved dietary habits and regular physical activity behaviors.²³

It is well established that T2DM increased the risk for dementia, even though the exact pathophysiology links are still being established. Still, T2DM is associated with 1.5- to 2.5-fold higher risk of dementia.^24,25 Similarly, higher HbA_1c levels are attributed with higher risk of dementia incidence among patients with T2DM.²⁶ It is estimated that 13% to 20% of people with dementia have comorbid diabetes,²⁷ although an exact prevalence has not been established, due to many people with dementia having undiagnosed T2DM. At the same time, people with cognitive impairment or dementia are at higher risk for hypoglycemia,²⁸ since it is often not clear whether cognitive or behavior changes are due to the dementia or hypoglycemia¹¹ with older people with T2DM most vulnerable for severe hypoglycemia.²⁴ Furthermore, hypoglycemia increases the risk of falls and fractures in older people with T2DM,²⁹ which can further exacerbate cognitive decline due to potential delirium.^10,11 Finally, people with both T2DM and dementia experienced more hypoglycemic events with coma and used insulin more often than those without dementia.³⁰ Similarly, people who attended hospital by ambulance due to severe hypoglycemia were significantly older adults.³¹ From the above, it emerges that diabetes management is critical not only for T2DM and its complications but also that people with cognitive impairment or dementia who are particularly vulnerable to significant changes in glucose variability (GV) resulting in hyperglycemic or hypoglycemic complications.^32-34 Although annual neurocognitive tests such as Montreal Cognitive Assessment (MoCA) is suggested to older people having type 2 diabetes,³⁵ Mini Mental State Examination (MMSE), Abbreviate Mental Test (AMT), Addenbrookes Cognitive Examination (ACE) could be also recommended to the same population who are at relatively higher risk for dementia.

Glucose Variability

Glucose variability refers to fluctuations in plasma glucose levels throughout the day.^36,37 Although HbA_1c has been widely accepted as a gold standard biochemical parameter for glycemic control, it is now accepted that it mostly reflects average glycemia over the last three months.^38,39 Based on this, HbA_1c is now more commonly regarded as indicative of long-term dysglycemia, whereas GV is indicative of more short-term fluctuations in blood glucose.^37,40 The GV has, therefore, has emerged as a key factor in managing short-term dysglycemia, and its measurement has become increasingly crucial. The current gold standard is still to measure blood glucose via finger pricks. However, finger pricks are only conducted a few times a day which might miss GV and potential adverse events in between those measurements. Instead, continuous glucose measurements became increasingly popular to monitor GV (Figure 1).^36,41

Figure 1.

The blood glucose fluctuations with the time both captured by finger pricks and for CGM alarms/alerts. Diagram illustrating differences in glucose fluctuations via finger prick measurements or CGM. The red shaded area shows the dysglycemia. The red “x” refers the finger prick measurements., TIR = time in range, time spent in targeted blood glucose (70-180 mg/dL). The blue-shaded area shows the time that CGM receiver or smartphone sends alarms/alerts when it detects the interstitial glucose is upgoing/descending trend in a short time. The CGM can send notifications when the interstitial glucose of the user is increasing or decreasing rapidly (it also provides the speed with two modes) even if they are in euglycemia.

Continuous Glucose Monitoring

Continuous Glucose Monitoring (CGM) devices allow real-time monitoring of interstitial glucose. Even though CGM sensors are now widely used by people with type 1 diabetes, they are only more recently being adopted for T2DM, with 70% of people with type 1 diabetes using them in the United States, whereas only 13% of people with T2DM used CGM.^42,43 Relatively higher costs including initial set up and specially maintenance costs without financial support from government emerge as one of the main obstacles of increased frequency of using CGM sensors.⁴⁴ According to a recent research, older adults with type 1 diabetes using CGM were more likely to report impaired awareness of hypoglycemia and less likely to have cognitive impairment who benefit from diabetes technologies including insulin pumps,⁴⁵ and reduced nocturnal hypoglycemia may improve the cognition in adults with type 1 diabetes.⁴⁶

Despite the low uptake in T2DM, it is now well established that CGM is highly feasible and acceptable to people diagnosed with T2DM over 65 years, while simultaneously improving glycemic control and the detection of hypoglycemic episodes.^27,47,48 There are now numerous studies that have recommended the use of CGM sensors in the management of T2DM,^37,49 in particular as they are more effective than finger prick results in capturing asymptomatic hypoglycemia events,⁵⁰ and can support reducing HbA_1c in the long-term.⁴ For instance, people with T2DM using CGM for 16 weeks showed lower HbA_1c levels compared to those using only finger pricks.⁵¹ Furthermore, the use of CGM sensor reduced overall hospitalization, including due to DKA, diabetes-related coma.^52-54 Finally, since older age is one of the highest risk factors for dementia, it has been suggested to use CGM for T2DM management in older people might not only improve glucose control but also future dementia risk.⁵⁵ Unfortunately, due to the paucity of CGM data in older people with T2DM, it is yet to be established whether CGM might reduce future dementia risk, compared to existing finger prick glucose measurement methods.

Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus and Dementia

Monitoring glycemic levels in people with diabetes and cognitive impairment/dementia is becoming increasingly important. Specifically, conducting finger prick testing and remembering to conduct those tests while also remembering whether medication has been administered, clearly poses a challenge to people with dementia, since their memory is commonly affected from the early stage of the diseases. In addition, both people with dementia and their carers might not recognize or mistake dysglycemia symptoms with changes to their cognition. The CGM emerges, therefore, as an ideal method to monitor and mitigate GV changes in people with T2DM and dementia.⁴⁷ There is also now evidence that using CGM is feasible and acceptable for people with comorbid diabetes-dementia, as well as their carers.²⁷

Carers are playing a significant role in the management of diabetes among people having cognitive impairment as well as providing an environment to interact and understand the cognitive needs of people with dementia. Hence, cognitive support by carers becomes crucial.⁵⁶ In the research including person-centered interventions on persons with dementia, educational support to carers and internal care team is found key in enhancing and maintaining quality of life.⁵⁷

Most of the existing CGM studies in this aspect have been conducted in the prodromal forms of dementia (eg, Mild Cognitive Impairment) or early stage dementia, at which stage people might still be able to monitor and respond to hyperglycemic and hypoglycemic level CGM alerts. Less clear is whether people with moderate or severe cognitive dysfunction or dementia might still benefit from CGM. This is of particular interest, as people in the moderate or severe stages of dementia might benefit most from using CGM which can then inform their carer on whether glycemic levels need to be optimized.⁵⁸ In the interest of safety, Diabetes UK recommends that glucose reading less than 4 mmol/L should be treated in the frail population.⁵⁹ In addition to this, the suggested HbA_1c target for people with comorbidities, cognitive impairment, and who are living in a care home is 59 to 69 mmol/mol, whereas glycemic target is addressed 4.9 to 7.2 mmol/L (90-130 mg/dL).^60,61

In this regard, there is, to our knowledge, also no evidence yet whether carers of people with comorbid T2DM-dementia might play a role in monitoring CGM alerts—similar to parents for children with type 1 diabetes. In the following section, we highlight briefly, existing studies in patients comorbid T2DM-dementia in community and in-hospital settings.

Community-Based Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus Dementia

In the community, CGM has shown that large glycemic fluctuations just after a 72-hours’ period can contribute to poorer cognitive outcomes.⁶² Fasting glucose levels, postprandial peak glucose, and 24-hour area under the glucose curve obtained from CGM sensors have also been found to relate to cognitive function.⁶³ Importantly, glucose metrics as measured via CGM sensors were more closely associated with cognitive impairment than HbA_1c or other GV factors.⁶⁴ Moreover, GV and glycemic excursions were strongly linked with cognitive impairment.⁶⁵

Time in range (TIR; accepted glycemic target: 70-180 mg/dL or 3.9-10 mmol/l) and time above range (TAR; time spent in hyperglycemia) obtained from CGM sensors are associated with cognitive performance; especially in executive function and working memory tests.⁶⁶ Higher time below range (TBR; time spent in hypoglycemia) and TAR (>13.9 mmol/L) were related to worse cognition in terms of memory, visuospatial ability, and executive functioning.⁶⁷ Hypoglycemia captured by CGM was very common in older people, even though the clinical relevance of such low glucose readings remains still unclear.⁶⁸ Nearly half of the hypoglycemic episodes in older adults are asymptomatic and emerging during the night, between dinner and breakfast.^69,70 Similarly, community-based studies in older people, some diagnosed with dementia, using CGM sensors showed that most hypoglycemic episodes were missed during the night via finger pricks. Recently provided smart insulin pen, as another diabetes technology product, also supports CGM with improving diabetes management and providing less risk for hypoglycemia via its memory recording missed or extra doses, in particular people with cognitive impairment.⁷¹

The CGM allows to capture those episodes and potentially mitigate adverse outcomes at night, such as falls.^27,50,72 Furthermore, the failure to capture night-time hypoglycemia might be particularly exacerbated in older people who experience delirium, which is common in dementia, and in turn can lead to significant progression of the dementia or even death.^73,74

Although there was no direct causality between TIR and cognitive impairment, there is evidence that well-managed TIR can improve cognition and other chronic complications via frequent glucose monitoring using CGM sensors.⁷⁵ A community-based CGM feasibility study involving older adults with cognitive impairment and diabetes, resulted in the high acceptability and feasibility of sensors perceived by the study population and carers according to their experiences. Despite the short study duration of two weeks, the study highlights the potential benefits of CGM usage for comorbid diabetes-dementia in the community.²⁷ Less clear is whether such benefits can also be seen in hospital settings, where a high percentage of in-patients are diagnosed with either diabetes, dementia, or both.

In-Patient Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus-Dementia

Studies to date using CGM in comorbid T2DM-dementia have been exclusively conducted in the community, with hospital-based studies virtually non-existent. Current hospital guidelines on T2DM management are all based on finger prick GV monitoring, whereas CGM usage has been little explored. This is not trivial, as dysglycemia in this population might be even more difficult to detect and treat within hospitals.^47,76 Not surprisingly, in-patient hypoglycemia has been associated with increased adverse in-patient outcomes,⁷⁷ such as prolonged length of stay, mortality, and readmission.

A recent study, using CGM in a hospital setting, indicated those with frailty managed with insulin or sulfonylurea showed the highest risk of delirium (4.8%), hypoglycemia (3.5%), cardiovascular disease (CVD) (20.2%), and hospitalization (49%).⁷⁸ The use of CGM might allow the detection of potential dysglycemic events in comorbid T2DM-dementia patients much earlier and alert the patient or health care professionals of such events in case of hypoglycemia particularly during the night. Despite the advantages, there are also challenges in using CGM within hospital settings, which we outline in Table 1.

Table 1.

Benefits and Challenges of Using Continuous Glucose Monitoring Sensors Among Individuals With Cognitive Impairment in Hospital Setting and After Hospitalization.

Opportunities	Possible outcomes
Benefits	• Captures dysglycemia, including nocturnal hypoglycemia. • Improves CGM-derived glucose metrics including time in range. • Provides real-time insight into glycemic levels to health care professionals. • May mitigate adverse hospital outcomes, such as length of stay, readmission, or mortality.
Challenges	• Additional training for patients and health care staff required on how to use, manage, and monitor CGM. • Frequent alarms/alerts can lead “alarm/alert fatigue,” and patients may remove CGM sensors. • Cost for the health care system, if CGM is not covered and no current training exists.

This table defines some benefits, opportunities, and challenges of CGM use in individuals with cognitive impairment in hospital setting.^44,58,78,79

Abbreviation: CGM, continuous glucose monitoring.

The CGM sensors as a part of diabetes management have key benefits for people with cognitive dysfunction in hospital settings.^80,81 In particular, it may not only improve cognitive outcomes in hospitalized people with cognitive impairment⁸¹ but also hospital outcomes in terms of length of stay, readmissions, or even mortality. Therefore, using CGM should be considered as a part of usual care in order to improve functional and mental abilities and as a support system for each patient.⁸² Future research in this direction is, therefore, urgently needed to establish the evidence base for CGM in hospital settings.

Conclusion

In summary, management of T2DM in older adults with cognitive impairment is critical for providing better clinical outcomes including less diabetes-related complications and improved cognitive function. Such management requires close, real-time monitoring of GV, for which CGM is the ideal candidate. This is particularly pertinent for people with dementia who have more moderate or severe cognitive impairment, which makes it more challenging to identify symptoms of hypoglycemia. Existing community-based studies in T2DM-dementia using CGM show promising potential for better management of T2DM in those people. By contrast, there are virtually no studies on CGM in hospitalized people diagnosed with comorbid T2DM-dementia despite its potential benefits.

The CGM has a significant potential impact to reduce cognitive impairment and dementia risk via improving diabetes management and increasing glycemic awareness. It also has key opportunities to improve glucose management for health care professionals and carers during hospitalization and after discharge. Importantly, CGM sensors have been found feasible, useful, and significantly effective in capturing hypoglycemic events, allowing health professionals to manage the T2DM more closely and mitigate any adverse health or hospital outcomes. However, if usage of CGM in hospitals would be adopted, it would require a significant education program for health care professionals, which currently does not exist.

For the future, there is an urgent need to establish additional evidence for the benefits and challenges of CGM usage in the community and in-hospital settings for comorbid T2DM-dementia. Specifically, CGM usage in those populations and their long-term feasibility are needed and should be complemented by randomized controlled trials in this area. The potential benefits of using CGM in comorbid T2DM-dementia are, therefore, highly promising but underexplored.

Footnotes

Abbreviations

AD, Alzheimer’s disease; ADA, American Diabetes Association; BG, blood glucose; CGM, continuous glucose monitoring; DKA, diabetic ketoacidosis; GV, glucose variability; HbA_1c, hemoglobin A_1c; HHS, hyperglycemic hyperosmolar syndrome; SMBG, self-monitoring of blood glucose; T2DM, type 2 diabetes; TAR, time above range; TBR, time below range; TIR, time in range.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Busra Donat Ergin

Ketan Dhatariya

References

WHO. Dementia [Online]. January 21, 2024.https://www.who.int/news-room/fact-sheets/detail/dementia#:~:text=Key%20facts,nearly%2010%20million%20new%20cases. Accessed December 10, 2024.

Edridge

Dunkley

Bodicoat

, et al. Prevalence and incidence of hypoglycaemia in 532,542 people with type 2 diabetes on oral therapies and insulin: a systematic review and meta-analysis of population based studies. PLoS ONE. 2015;10(6):e0126427.

International Diabetes Federation. IDF Diabetes Atlas 2021: Diabetes Atlas. Brussels: International Diabetes Federation; 2021.

Kieu

King

Govender

Östlundh

. The benefits of utilizing continuous glucose monitoring of diabetes mellitus in primary care: a systematic review. J Diabetes Sci Technol. 2023;17(3):762-774.

Roberts

Hevener

Barnard

. Metabolic syndrome and insulin resistance: underlying causes and modification by exercise training. Compr Physiol. 2013;3(1):1-58.

Fahed

Aoun

Zerdan

, et al. Metabolic syndrome: updates on pathophysiology and management in 2021. Int J Mol Sci. 2021;23(2):786.

CDC. National diabetes statistics report. [Online]. September 5, 2023. https://www.cdc.gov/diabetes/basics/diabetes.html. Accessed December 10, 2024.

Kim

Sims-Robinson

Sakowski

S. A.

Feldman

E. L.

Diabetes and cognitive dysfunction. In: Zigmond

Michael J.

Rowland

Lewis P.

Coyle

Joseph T.

, eds. Neurobiology of Brain Disorders. New York: Academic Press; 2023:185-201.

National Diabetes Inpatient Audit Report. [Online]. Prevalence of hypoglycaemic episodes declines in hospitals, according to diabetes inpatients. 2017. https://digital.nhs.uk/data-and-information/clinical-audits-and-registries/national-diabetes-inpatient-audit. Accessed December 10, 2024.

10.

Huang

Zhu

. Association between hypoglycemia and dementia in patients with diabetes: a systematic review and meta-analysis of 1.4 million patients. Diabetol Metab Syndr. 2022;14(1):31.

11.

Zheng

Price

Tzoulaki

Ahmadi-Abhari

Middleton

. Glycemic control, diabetic complications, and risk of dementia in patients with diabetes: results from a large UK. Diab Care. 2021;44(7):1556-1563.

12.

Amiel

. The consequences of hypoglycaemia. Diabetologia. 2021;64(5):963-970.

13.

Umpierrez

Davis

ElSayed

, et al. Hyperglycemic crises in adults with diabetes: a consensus report. Diab Car. 2024: 47(8):1257-1275.

14.

Goldstein

Janson

Skeie

Ling

Greiner

. The effects of diabetes mellitus on the corneal endothelium: a review. Surv Ophthalmol. 2020;65(4):438-450.

15.

Zheng

Ley

. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature Reviews Endocrinology. 2017;14(2):88-98.

16.

O’Brien

Sakowski

Feldman

. Mouse models of diabetic neuropathy. ILAR J. 2014;54(3):259-272.

17.

Savelieff

Chen

Elzinga

Feldman

. Diabetes and dementia: clinical perspective, innovation, knowledge gaps. J Diabetes Complications. 2022;36(11):108333.

18.

Ghowsi

Qalekhani

Farzaei

Mahmudii

Yousofvand

Joshi

. Inflammation, oxidative stress, insulin resistance, and hypertension as mediators for adverse effects of obesity on the brain: a review. Biomedicine (Taipei). 2021;11(4):13-22.

19.

Dubois

Feldman

Jacova

, et al. Revising the definition of Alzheimer’s disease: a new lexicon. Lancet Neurol. 2010;9(11):1118-1127.

20.

Tadokoro

Sasaki

Wakutani

Takao

Abe

. Clinical characteristics of patients with dementia in a local emergency clinic in Japan. Geriatr Gerontol Int. 2018;18(9):1383-1387.

21.

Chin

. Pathophysiology of dementia. Royal Aust Colle Gen Pract. 2023;52(8):516-521.

22.

Kulmala

Rosenberg

Ngandu

, et al. Facilitators and barriers to implementing lifestyle intervention programme to prevent cognitive decline. Eur J Public Health. 2021:816-822.

23.

Sandison

Callan

NGL

Rao

Phipps

Bradley

. Observed improvement in cognition during a personalized lifestyle intervention in people with cognitive decline. J Alzheimers Dis. 2023;94(3):993-1004.

24.

Strachan

Reynolds

Marioni

Price

. Cognitive function, dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol. 2011;7(2):108-114.

25.

Chatterjee

Peters

Woodward

, et al. Type 2 diabetes as a risk factor for dementia in women compared with men: a pooled analysis of 2.3 million people comprising more than 100,000 cases of dementia. Diabetes Care. 2016;39(2):300-307.

26.

Wang

Zhao

Kam-Pui Lee

, et al. Risk of dementia among patients with diabetes in a multidisciplinary, primary care management program. JAMA Netw. 2024;7(2):e2355733.

27.

Mattishent

Lane

Salter

, et al. Continuous glucose monitoring in older people with diabetes and memory problems: a mixed-methods feasibility study in the UK. BMJ Open. 2019;9(11):e032037.

28.

Mattishent

Loke

. Bi-directional interaction between hypoglycaemia and cognitive impairment in elderly patients treated with glucose-lowering agents: a systematic review and meta-analysis. Diabetes, Obes Metab. 2015;18(2):135-141.

29.

Mattishent

Richardson

Dhatariya

Savva

Fox

Loke

. The effects of hypoglycaemia and dementia on cardiovascular events, falls and fractures and all-cause mortality in older individuals: a retrospective cohort study. Diabetes Obes Metab. 2019;21(9):2076-2085.

30.

Prinz

Stingl

Dapp

, et al. 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. Diabetes Res Clin Pract. 2016;112:73-81.

31.

Sampson

Bailey

Clark

, et al. A new integrated care pathway for ambulance attended severe hypoglycaemia in the East of England: the Eastern Academic Health Science Network (EAHSN) model. Diabetes Res Clin Pract. 2017;133:50-59.

32.

Jackson

Ahmann

Shah

. Type 2 diabetes and the use of real-time continuous glucose monitoring. Diabetes Technol Therap. 2021;23(1):27-34.

33.

American Diabetes Association (ADA). Standards of Care in Diabetes. Arlington, VA: ADA; 2024.

34.

NICE. Type 2 diabetes in adults. March 2, 2023 [Online]. https://www.nice.org.uk/guidance/qs209/chapter/Quality-statement-5-Treatment-with-an-SGLT2-inhibitor. Accessed December 10, 2024.

35.

Dong

Kua

Hao Khoo

Merchant

. The utility of brief cognitive tests for patients with type 2 diabetes mellitus: a systematic review. J Ame Med Direc Assoc. 2016;17(10):889-895.

36.

Gorst

Kwok

Aslam

, et al. Long-term glycemic variability and risk of adverse outcomes: a systematic review and meta-analysis. Diabetes Care. 2015;38(12):2354-2369.

37.

Belli

Bellia

Sergi

Barone

Lauro

Barillà

. Glucose variability: a new risk factor for cardiovascular disease. Acta Diabetol. 2023;60(10):1291-1299.

38.

Mattishent

Loke

. Is avoidance of hypoglycaemia a better target than HbA1C in older people with diabetes? Br J Clin Pharmacol. 2020;87(1):9-11.

39.

Chen

. Mean HbA1c and HbA1c variability are associated with differing diabetes-related complications in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract. 2022;192:110069.

40.

Wang

, et al. Impact of short-term glycemic variability on risk of all-cause mortality in type 2 diabetes patients with well-controlled glucose profile by continuous glucose monitoring: a prospective cohort study. Diabetes Res Clin Pract. 2022;189:109940.

41.

Sartore

Ragazzi

Caprino

Lapolla

. Long-term HbA1c variability and macro-/micro-vascular complications in type 2 diabetes mellitus: a meta-analysis update. Acta Diabetol. 2023;60(6):721-738.

42.

DeSalvo

Noor

Xie

, et al. Patient demographics and clinical outcomes among type 1 diabetes patients using continuous glucose monitors: data from T1D exchange real-world observational study. J Diabetes Sci Technol. 2023;17(2):322-328.

43.

Mayberry

Guy

Hendrickson

McCoy

Elasy

. Rates and correlates of uptake of continuous glucose monitors among adults with type 2 diabetes in primary care and endocrinology settings. J Gen Intern Med. 2023;38(11):2546-2552.

44.

Prasad-Reddy

Godina

Chetty

Isaacs

. Use of continuous glucose monitoring in older adults: a review of benefits, challenges and future directions. Touchrev Endocrinol. 2022;18(2):116-121.

45.

Munshi

Slyne

Davis

, et al. Use of technology in older adults with type 1 diabetes: clinical characteristics and glycemic metrics. Diabetes Technol Ther. 2022;24(1):1–9.

46.

Zuniga-Kennedy

Wang

Fonseca

, et al. Nocturnal hypoglycemia is associated with next day cognitive performance in adults with type 1 diabetes: pilot data from the GluCog study. Clin Neuropsychol. 2024;38(7):1627-1646.

47.

Savoy

Holden

de Groot

, et al. Improving care for people living with dementia and diabetes: applying the human-centered design process to continuous glucose monitoring. J Diabetes Sci Technol. 2024;18(1):201-206.

48.

Chaytor

, et al. Clinically significant cognitive impairment in older adults with type 1 diabetes. J Diabetes Complic. 2018;33(1):91-97.

49.

Battelino

Danne

Bergenstal

, et al. Clinical targets for continuous glucose monitoring data interpretation: recommendations from the international consensus on time in range. Diabetes Care. 2019;42(8):1593-1603.

50.

Gomez

Umpierrez

Munoz

Herrera

Rubio

Aschner

. Continuous glucose monitoring versus capillary point-of-care testing for inpatient glycemic control in type 2 diabetes patients hospitalized in the general ward and treated with a basal bolus insulin regimen. J Diabetes Sci Technol/. 2015;10(2):325-329.

51.

Bergenstal

Mullen

Strock

Johnson

. Randomized comparison of self-monitored blood glucose (BGM) versus continuous glucose monitoring (CGM) data to optimize glucose control in type 2 diabetes. J Diabetes Complications. 2022;36(3):108106.

52.

Tsur

Cahn

Israel

Feldhamer

Hammerman

Rollack

. Impact of flash glucose monitoring on glucose control and hospitalization in type 1 diabetes: a nationwide cohort study. Diabetes Metab Res Rev. 2023;37(1):e3355.

53.

Riveline

Roussel

Vicaut

, et al. Reduced rate of acute diabetes events with flash glucose monitoring is sustained for 2 years after initiation: extended outcomes from the RELIEF study. Diabetes Technol Ther. 2022;24(9):611-618.

54.

Roussel

Riveline

Vicaut

, et al. Important drop in rate of acute diabetes complications in people with type 1 or type 2 diabetes after initiation of flash glucose monitoring in France: the RELIEF study. Diabetes Care. 2021;44(6):1368-1376.

55.

Ishikawa

Koshizaka

Maezawa

, et al. Continuous glucose monitoring reveals hypoglycemia risk in elderly patients with type 2 diabetes mellitus. J Diabetes Investig. 2018;9(1):69-74.

56.

Leung

Orgeta

Orrell

. The effects on carer well-being of carer involvement in cognition-based interventions for people with dementia: a systematic review and meta-analysis. Int J Geriatr Psychiatry. 2017;32(4):372-385.

57.

Kim

Park

. Effectiveness of person-centered care on people with dementia: a systematic review and meta-analysis. Clin Interv Aging. 2017;12:381-397.

58.

Munshi

. Continuous glucose monitoring use in older adults for optimal diabetes management. Diabetes Technol Ther. 2023;25(S3):S56-S64.

59.

Diabetes

. End of Life Guidance For Diabetes Care. London: Diabetes UK; 2021.

60.

Sinclair

Abdelhafiz

Dunning

, et al. An international position statement on the management of frailty in diabetes mellitus: summary of recommendations. J Frailty Aging. 2018;7(1):10-20.

61.

Bellastella

Maiorino

Meier

Esposito

Guigliano

. Diabetes and aging: from treatment goals to pharmacological therapy. Front. Endocrinol. 2019;10:45.

62.

Cui

Abduljalil

Manor

Peng

Novak

. Multi-scale glycemic variability: a Link to gray matter atrophy and cognitive decline in type 2 diabetes. PLoS ONE. 2014;9(1):e86284.

63.

Pearce

Noakes

Wilson

Clifton

. Continuous glucose monitoring and cognitive performance in type 2 diabetes. Diabetes Technol Therapeut. 2012;14(12):1126-1133.

64.

Cuevas

Muñoz

Nagireddy

Kim

Ganucheau

Alomoush

. The association of glucose variability and dementia incidence in Latinx adults with type 2 diabetes: a retrospective study. Clin Nurs Res. 2023;32(2):249-255.

65.

Rizzo

Marfella

Barbieri

, et al. Relationships between daily acute glucose fluctuations and cognitive performance among aged type 2 diabetic patients. Diabetes Care. 2010;33(10):2169-2174.

66.

Sugimoto

Tokuda

Miura

, et al. Cross-sectional association of metrics derived from continuous glucose monitoring with cognitive performance in older adults with type 2 diabetes. Diabetes Obes Metabol. 2022;25(1):222-228.

67.

Dong

Wang

Zhao

, et al. Relationship between key continuous glucose monitoring-derived metrics and specific cognitive domains in patients with type 2 diabetes mellitus. BMC Neurol. 2023;23(1):200.

68.

Selvin

Wang

Tang

Minotti

Echouffo-Tcheugui

Coresh

. Glucose patterns in very old adults: a pilot study in a community-based population. Diabetes Technol Ther. 2021;23(11):737-744.

69.

Cardona

Gomez

Vellanki

, et al. Clinical characteristics and outcomes of symptomatic and asymptomatic hypoglycemia in hospitalized patients with diabetes. BMJ Open Diabetes Res Care. 2018;6(1):e000607.

70.

Mattishent

Loke

. Detection of asymptomatic drug-induced hypoglycemia using continuous glucose monitoring in older people: systematic review. J Diabetes Complications. 2018;32(8):805-812.

71.

Ospelt

Noor

Sanchez

, et al. Facilitators and barriers to smart insulin pen use: a mixed-method study of multidisciplinary stakeholders from diabetes teams in the United States. Clin Diabetes. 2023;41(1):56-67.

72.

Grammes

Schmid

Bozkurt

Heinemann

Hess

Kubiak

. Continuous glucose monitoring in older adults with diabetes: data from the diabetes prospective follow-up (DPV) registry. Diabetic Med. 2023;41(3):e15261.

73.

Puttana

Padinjakara

. Management of diabetes and dementia. Brit J Diabetes. 2017;17(3):93-99.

74.

Grossi

Rocco

Stilo

, et al. Dysphagia in older patients admitted to a rehabilitation setting after an acute hospitalization: the role of delirium. Eur Geriatr Med. 2023;14(3):485-492.

75.

Husain

Sarhan

AlKhalifa

HKAA

Buhasan

Moin

ASM

Butler

. Dementia in diabetes: the role of hypoglycemia. Internat J Molecu Sci. 2024;24(12):9846.

76.

Moran

Than

Callisaya

Beare

. New horizons: cognitive dysfunction associated with type 2 diabetes. J Clin Endocrinol Metabol. 2022;107(4):929-942.

77.

Melson

Fazil

Lwin

, et al. Tertiary centre study highlights low inpatient deintensification and risks associated with adverse outcomes in frail people with diabetes. Clin Med (Lond). 2024;24(2):100029.

78.

Price

Callahan

Aloi

Usoh

. Continuous glucose monitoring in older adults: what we know and what we have yet to learn. J Diabetes Sci Technol. 2024;18(3):577-583.

79.

Rodbard

. Continuous glucose monitoring: a review of successes, challenges, and opportunities. Diabetes Technol Ther. 2016;18(suppl 2):S3-S13.

80.

Chinnappa-Quinn

Bennett

Makkar

Kochan

Crawford

Sachdev

. Is hospitalisation a risk factor for cognitive decline in the elderly? Curr Opin Psychiatry. 2020;33(2):170-177.

81.

Dasgupta

. Cognitive impairment in hospitalized seniors. Geriatrics (Basel). 2016;1(1):4.

82.

Wright

Mattacola

Burgess

Smith

Finlay

. The impact of flash glucose monitoring on the clinical practice of healthcare professionals working in diabetes care. Diabetes Res Clin Prac. 2021;183:109157.

Continuous Glucose Monitoring in Comorbid Dementia and Diabetes: The Evidence So Far

Abstract

Background:

Aims:

Keywords

Introduction

Diabetes—Background, Pathophysiology, Dementia Linkage

Dementia—Background, Pathophysiology, and Type 2 Diabetes Mellitus Linkage

Glucose Variability

Continuous Glucose Monitoring

Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus and Dementia

Community-Based Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus Dementia

In-Patient Continuous Glucose Monitoring in Comorbid Type 2 Diabetes Mellitus-Dementia

Conclusion

Footnotes

Abbreviations

Declaration of Conflicting Interests

Funding

ORCID iDs

References