Ind Psychiatry J. 2012 Jan-Jun; 21(1): 4448.

doi: 10.4103/0972-6748.110950
PMCID: PMC3678178

Diabetes mellitus: A risk factor for cognitive

impairment amongst urban older adults
S. C. Tiwari, Rakesh Kumar Tripathi, Siddiq Ahmad Farooqi, Rajesh Kumar,1 Garima
Srivastava,2 and Aditya Kumar
Department of Geriatric, BPK Institute of Health Sciences, Dharan, Nepal
1
BPK Institute of Health Sciences, Dharan, Nepal
2
Departmentof Psychology, Allahabad University, Uttar Pradesh, India
Address for correspondence: Dr. Rakesh Kumar Tripathi, Department of Geriatric Mental
Health, King George's Medical University, Lucknow, Uttar Pradesh, India. E-mail:
moc.liamg@ihtapirtsar
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Abstract
Background:
Studies reported in relation to diabetes mellitus and cognitive impairment are inconclusive.
Diabetes mellitus is a wide spread physical illness amongst older adults. The study explores
whether, it leads to cognitive impairment amongst older adults in comparison to those
without diabetes mellitus.

Materials and Methods:

Study sample consisted of 900 subjects fulfilling the inclusion/exclusion criteria out of 1067
elderlies aged 55 years and above residing in a randomly selected ward of urban Lucknow.
Pathological investigation was done on all elderlies to rule out diabetes mellitus. Out of 900
subjects 145 were found to have Diabetes Mellitus and rests 755 were without diabetes
mellitus. These subjects were further divided into two groups: (i) with and (ii) without
cognitive impairment based on detailed assessment of Mini Mental State Examination
positive subjects by Cambridge Examination for Mental Disorders of the Elderly- Revised
(CAMDEX-R). International Classification of Diseases-10th revision criteria were used to
make diagnosis. Data analysis was done calculating odds ratio, Chi square, and percentages.

Results:

Diabetes mellitus was found to be prevalent is 13.7% and 16.9% amongst older adults aged
55-59 years and 60 years and above respectively. Odds ratio 1.3 with CI 95% indicates that
subjects with diabetes mellitus is 1.3 times at more risk to develop cognitive impairment
amongst urban older adults than non-cognitively impaired subjects. But differences on Chi
square test were found to be insignificant.

Conclusion:
There is a weak association between diabetes mellitus and cognitive impairment amongst
urban older adults.
Keywords: Cambridge examination for mental disorders of the elderly-revised, cognitive
impairment, diabetes mellitus, mini mental state examination, prevalence
Diabetes mellitus is a common medical condition known to have adverse effects on all
system of human body. Normally, insulin and glucagons are produced by the Islets of
Langerhans in the pancreas. Insulin regulates the conversion of glucose to glycogen for
storage in various cells. Elevated blood glucose levels can result in brain malfunction and it
promotes the synthesis of sorbitol, which damages blood vessels and causes degeneration of
the nerves, resulting in neuropathology which can lead to dementia or cognitive impairment.
[1]
With increase in the world population and average life span of the individuals; the prevalence
of diabetes mellitus is steadily increasing with other physical and mental health problems.
Diabetes mellitus and its complications are important health care problems in the older adults.
For mental health problems, it was hypothesized that diabetes mellitus leads to cognitive
impairment. Studies available in literature are both in favor,[2,3] as well as against[46] this
hypothesis.[712]
A national survey of diabetes conducted in six major cities in India in the year 2000 has
shown that the prevalence of diabetes in urban Indian adults is 12.1%.[13] The prevalence of
diabetes increases with age and it peaks at 60-69 years of age. With the demographic
transition and population aging, diabetes mellitus will be a major public health problem in
India. The increased frequency of depression, anxiety and forgetfulness has also been
reported in older patients with diabetes mellitus.[14]
In India alone, diabetic patients are expected to increase from 40.6 million in 2006 to 79.4
million by 2030. Studies have shown that the prevalence of diabetes in urban Indian adults is
about 12.1%, the onset of which is about a decade earlier than their western counterparts and
the prevalence is higher in urban than in rural areas.[15] The prevalence rates of diabetes
varied from 103 per thousand to 124 per thousand in different studies. In a meta analysis, 118
per thousand prevalence was reported of studies between year 1996 and 2002 for urban adult
population.[16]
From the state of Uttar Pradesh, the current overall prevalence of cognitive disorders is
reported 7.6%[17] in urban older adults aged 60 years and above using stringent
methodology. A prevalence of 3.9% was found in rural areas[18] and in Jaipur[19] amongst
elderlies. In year 2005 Shaji and associates[20] found prevalence of dementia to be 3.36% in
urban population of Kerela aged 65 years and above. In a study by Das and associates[8] an
overall prevalence of 14.89% of mild cognitive impairment (MCI) was found amongst

persons aged 50 years and above in Kolkata. Studies,[8,21] also reported that diabetes
mellitus is the major risk factor for the MCI.
Furthermore, vascular risk factors e.g., hypertension and diabetes also contribute to vascular
dementia and mixed Alzheimer's plus cerebro-vascular disease.[22]
Studies reported in relation to cognitive impairment and diabetes mellitus is inconclusive
because of inconsistent reports. The inconsistency in findings may be due to differences in
study design, sources of study subjects, and variations in criteria for the diagnosis of diabetes
mellitus or cognitive impairment. However, it may also be due to differences in the duration
or severity of diabetes mellitus among study subjects. For this study, much precautions were
taken care of in inclusion of the subjects from the community, using definite case criteria for
diabetes mellitus (fasting and post prandial investigations) and cognitive impairment,
assessment by trained clinical psychologists and physicians for diagnostic formulation.
Randomly selected 10% of the sample was reassessed to control false positive and negative
diagnoses of the subjects. An Indian Council of Medical Research, New Delhi sponsored
study, An epidemiological study of prevalence of neuro-psychiatric disorders with special
reference to cognitive disorders amongst urban elderlies[23] provided an unique opportunity
to explore the prevalence of diabetes mellitus and its impact on cognitive functioning of
urban older adults. It was hypothesized that diabetes mellitus is a risk factor of cognitive
impairment.

Aim
To study the prevalence of diabetes mellitus amongst urban older adults and to study the
relationship between diabetes mellitus and cognitive impairment.

MATERIALS AND METHODS

Study sample consisted of 900 subjects fulfilling the inclusion/exclusion criteria, recruited
out of 1067 elderlies aged 55 years and above residing permanently in a randomly selected
ward of urban Lucknow. Out of total 1067 subjects 167 (15.65%) subjects refused to
participate in the study because their family members refused to give blood of the subjects for
pathological investigations such as blood sugar (fasting and PP), hemoglobin %, Total
Leucocyte Count (TLC), Differential Leucocyte Count (DLC), Liver Function Test (LFT),
serum urea/createnin and lipid profile.
Mean age of the study sample was found to be 67.17 years. Pathological investigation was
done on all 900 study subjects to see the status of diabetes mellitus. Out of 900 subjects 145
were found to have diabetes mellitus and rest 755 subjects were without diabetes mellitus.
These subjects were further divided into two groups: (i) with and (ii) without cognitive
impairment based on detailed assessment of Mini Mental State Examination (MMSE)[24]
positive subjects by Cambridge Examination for Mental Disorders of the Elderly-Revised
(CAMDEX-R).[25] Age and education specific cut off criteria[26] was used to determine the
MMSE positive and negative subjects to control education bias. International Classification
of Diseases-10th revision (ICD-10)[27] criteria were used to make diagnosis of cognitive
(organic) disorders. Subjects with a definite diagnosis of dementia or subjects having
objective cognitive impairment but no dementia (other than dementia) as per ICD-10 criteria
(F00-F09 only) were called as cognitively impaired group.

Statistical analysis
Data was analyzed using statistical test of odds ratio Chi square and percentages.

RESULTS
The Table 1 shows the breakup of elderlies with and without diabetes mellitus by age and
status of cognitive functioning.
Table 1 shows that 13.7% pre-elderly (55-59 years) and 16.9% elderly (60 years and above)
were found to be suffering from diabetes mellitus amongst urban older adults. The prevalence
of cognitive impairment amongst the non-diabetic urban pre-elderlies aged 55-59 years was
found to be 1.5%. In pre-elderly group, none of the subjects with diabetes mellitus were
found to be having cognitive impairment. The prevalence of cognitive impairment amongst
the diabetic urban elderlies aged 60 years and above was found to be 9.6%. However, the
prevalence of cognitive impairment amongst the urban elderlies aged 60 years and above
without diabetes mellitus was found to be 7.5% which is slightly lower against the prevalence
rate of cognitive impairment amongst urban elderlies with diabetes mellitus (9.6%).
Odds ratio was calculated between the two groups i.e., urban elderlies aged 55-59 years and
60 years and above with and without diabetes mellitus with regard to evidence of cognitive
impairment in them and it was found to be statistically significant [Table 2]. More than 1 with
95% confidence interval (CI) for both the age ranges indicate that subjects with diabetes
mellitus is 1.3 times at more risk to develop cognitive impairment amongst urban older adults
than non-cognitively impaired subjects.
However, on Chi square test the differences between cognitively impaired and noncognitively impaired group on diabetes mellitus among pre-elderly and elderly age group was
not found.

DISCUSSION
In the study the prevalence of diabetes mellitus was 16.9% amongst older adults aged 60
years and above. This is quite high in comparison to other studies which have recorded a
prevalence of 12.1%[13] and 9%,[28] 10.3-12.4%[15] in Indian adults. However, the present
prevalence of diabetes may turn out to be similar to this study as in recent years the
prevalence of diabetes in on rapid rise in the Country. But in the light of escalating
population, increase of prevalence rate of diabetes is justified. It may be more than reported
in this study because in the study sample only those elderlies were included who were found
diabetic on blood sugar estimation without consideration to whether they were currently on
anti-diabetic medication or not. Many known diabetic elderlies whose blood sugar level may
have been within normal range due to intake of anti-diabetic drugs may have been missed
inclusion in the study sample.
Highest prevalence of cognitive impairment in the age group 70-79 (138 out of 186) suggests
that 8th decade in life is probably the most susceptible period for becoming the victim of
cognitive impairment, and probably those in this age suffering from diabetes mellitus are
maximally prone [Table 1].

The statistical analysis of odds ratio in the study has revealed that diabetes mellitus is risk
factor for cognitive impairment in urban older adults irrespective of the cut off age of either
55 years or 60 years [Table 2]. Although, the odds ratio was found to be significant on 95%
CI but Chi square is not. The range on odds ratio is also more wide (0.6532-2.5684) to predict
diabetes mellitus is a risk factor for cognitive impairment. Hence, the finding of the study is
not in strong support of the alternative hypothesis that diabetes mellitus is a risk factor of
cognitive impairment. It might be due to a small sample size of cognitive impairment based
on and cross sectional epidemiological study. Separate study with large sample size of
cognitive impairment would be more appropriate to establish the relation of cognitive
impairment with diabetes mellitus.
This is an important finding from a preliminary report of a large epidemiological study
employing stringent research criteria. The final report of the study will generate large sample
size to recheck the findings of the study.

CONCLUSION
Diabetes mellitus was found to be prevalent is 13.7% and 16.9% in urban older adults
amongst older adults aged 55-59 years and 60 years and above respectively. Diabetes mellitus
has been found to be a risk factor for cognitive impairment but, with weak significance level
amongst urban older adults.
Interventions aimed at diabetes that begins before age 60 might lessen the burden of cognitive
impairment in later life.

Strengths
It is a community based epidemiological study on large sample size using stringent research
methodology. Detailed psychological assessments of the subjects by trained clinical
psychologists, reliability exercises amongst research team for data collection, and
pathological investigations on all the study subjects are the major strengths of the study.

Limitations
An issue that emerges for more detailed investigations is whether the elderlies whose diabetes
is under control with drugs are more skip to non-diabetes or to diabetes in respect of their
vulnerability for cognitive impairment. It was also noticed that the sample of cognitive
impairment subjects is small to predict strong association. Urban population of north India is
different for their dietary habits from the other parts of the country hence; the findings cannot
be generalized.

Footnotes
Source of Support: Paper is based on an Indian Council of Medical Research (ICMR), New
Delhi, India funded research project entitled, An epidemiological study of prevalence of
neuro-psychiatric disorders with special reference to cognitive disorders amongst urban
elderly
Conflict of Interest: None declared

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Figures and Tables

Table 1

Status of diabetes mellitus and cognitive impairment by age

Table 2

Status of cognitive impairment and diabetes mellitus amongst older adults aged 55-59 years
and 60 years and above
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