1. Diabetes Mellitus and Cognitive Decline: Retrospective Analysis Using Clinical Data from a Repository System
The University of Kansas Medical Center
PRVM 868 – Medical Informatics Driven Clinical Research
Eber A. S. Beck Jr PT, Marcio Santos PT MS PhD, Russ Waitman PhD
Dec. 1st, 2016

2. DIABETES MELLITUS 29.1 million of people have diabetes in the U.S.A.
Centers for Disease Control and Prevention, 2014
29.1 million of people have diabetes in the U.S.A.
People who have diabetes are at higher risk of serious health complications:
That’s about 1 out of every 11 people
Recommendation: “Consider assessing for and addressing common comorbid conditions (…) that may complicate diabetes management.”
(Evidence Level B - Supportive evidence from well-conducted cohort/case-control studies)
Lipid Control
Blood Pressure
Glycaemic Control
Medication Adjustment
Depression
Obstructive Sleep Apnea
Fatty Liver Disease
Cancer
Fractures
Cognitive Impairment

3. COGNITIVE FUNCTION Includes: Knowledge acquisition Comprehension
Thinking
Knowing
Remembering
Judgment
Problem Solving
Imagination
Planning

4. DIABETES AND COGNITIVE FUNCTION
Diabetes is associated with:
Significantly increased risk rate of cognitive decline (Cukierman et al., 2005)
Increased risk of dementia (Biessels et al., 2006)
Accelerated progression of total brain atrophy (Van Elderen et al. 2010)
Accelerated decline in cognitive performance (Van Elderen et al. 2010)
Altered brain network measures (Van Bussel et al., 2016)
CHECK REFERENCES:
Significantly increased risk rate of cognitive decline (Cukierman et al., 2005)
Increased risk of dementia (Biessels et al., 2006)
Van Bussel et al. (2016) Functional Brain Networks Are Altered in Type 2 Diabetes and Prediabetes: Signs for Compensation of Cognitive Decrements? The Maastricht Study.
Van Elderen et al. (2010) Progression of brain atrophy and cognitive decline in diabetes mellitus.

5. Recommendation – Psychosocial Issues:
“Routinely screen for psychosocial problems such as depression, diabetes-related distress, anxiety, eating disorders, and cognitive impairment.” B
“Older adults (aged $ 65 years) with diabetes should be considered for evaluation of cognitive function and depression screening and treatment.” B

6. RESEARCH QUESTIONS:
Are the diabetic patients seen at KUH and KU clinics being screened for cognitive impairment?
Do diabetic patients seen at KUH and clinics have cognitive decline?

7. The Healthcare Enterprise Repository for Ontological Narration (HERON)
Method to integrate clinical and biomedical data for translational research.
Distributed as an open-source framework to collaborators through an “Informatics for Integrating Biology and the Bedside” (i2b2) software.
Cohort discovery queries on HERON can span electronic medial records (EMR) from the University of Kansas Hospital (KUH) and other sources.

8. Cognitive Dysfunction
Defining Variables DM
Cognitive Dysfunction
Few longitudinal studies have investigated DM as possible risk factor for MRI-assessed brain atrophy and WMH’s, reporting conflicting results.
ICD Diabetes mellitus =1,613,880 facts; 80,448 patients
ICD 10 E08-E13 Diabetes mellitus = 956,760 facts; 66,468 patients
ICD 9 and 10 diagnose codes
Neuropsychological Tests

9. Neuropsychological Tests on HERON
Number of Patients who Performed the Test (as of Oct. 2016)
Rey Osterrieth Complex Figure Test
Digit Span Test
Stroop Test
Cognitive Timed Up and Go (cTUG)
AD8 Dementia Score 19
Saint Louis University Mental Status Exam (SLUMS)
221
Trail Making Test A
1,333
Trail Making Test B
1,272
Word Fluency Test
656
Verbal Fluency Test
2,222
Mini-Mental State Examination (MMSE)
1,973
Montreal Cognitive Assessment (MoCA)
2,256
Verbal Fluency Test
Word Fluency Test
MMSE:
CODE: KUH|FLO_MEAS_ID:
CODE_LABEL: 003- # Mini-Mental Status Examination
VARIABLE: 003- # Mini-Mental Status Examination
MOCA:
CODE: KUH|FLO_MEAS_ID:15319
VARIABLE: 008- #15319 MOCA Score (out of 30)
CODE_LABEL: 008- #15319 MOCA Score (out of 30)

10. Mini-Mental State Examination (MMSE)
Purpose: to provide a quantitative assessment of cognitive impairment.
Description: 11 questions grouped into 7 cognitive domains:
Orientation to time, orientation to place, registration of three words, attention and calculation, recall of three words, language, visual construction
Total possible score = 30; A score ≥ 24 is considered normal (Dick et al, 1984; Lopez et al, 2005)
Purpose: to detect mild cognitive dysfunction
Description: 16 items and 11 categories to assess multiple cognitive domains:
Visuo-spatial and executive functions, naming, memory, attention, language, abstraction, orientation.
Total possible score = 30; A score ≥ 26 is considered normal (Nasreddine et al, 2005)
Montreal Cognitive Assessment (MoCA)

11. DM (n=81,248 on HERON as of Sept. 2016)
Diabetic Group
n=281
Non-diabetic Group
n=1,203
DM (n=81,248 on HERON as of Sept. 2016)
MMSE or MoCA (Occurs >1x; n=1,484 on HERON as of Sept. 2016)
Oct. 2016:
MMSE and MoCA = 77
MMSE or MoCA = 4,152
Demographics:
Age, Gender, Race, Ethnicity, Marital Status, BMI, HbA1c

12. Queries on HERON (as of Sept. 2016):
EXCLUDING DM
CREATE A FOURTH GROUP; ADD ALZHEIMER’S DISEASE INTO IT.
ALL PATIENTS WERE SEEN BY A NEUROLOGIST

13. How many diabetic patients are being screened for cognitive impairments?
DATA FROM FLOWSHEET

14. 213 patients took the MMSE more than 1x
How many patients took their first MMSE before receiving diagnosis of Diabetes?
213 patients took the MMSE more than 1x
n=135 (63.38%)
n=78 (36.62%)
Yes, but only with 135 (63.38%) patients.
DM_1st_DX
1st_MMSE
1st_MMSE
DM_1st_DX

15. These 22 patients will not be excluded from the cohort
1st_MMSE
DM_1st_DX
n=22 (10.3%)
Last_MMSE
DM_1st_DX
Yes, but only with 135 (63.38%) patients.
Largest period = 3.16 years
These 22 patients will not be excluded from the cohort

16. 70 patients took the MoCA more than 1x
How many patients took their first MoCA before receiving diagnosis of Diabetes?
70 patients took the MoCA more than 1x
n=44 (62.85%)
n=26 (37.14%)
DM_1st_DX
1st_MoCA
1st_MoCA
DM_1st_DX

17. These 11 patients will not be excluded from the cohort
1st_MoCA
DM_1st_DX
n=11 (15.71%)
Last_MoCA
DM_1st_DX
Largest period = 3.12 years
These 11 patients will not be excluded from the cohort

18. Age differences between DM and NDM groups

19. BMI differences between DM and NDM groups

20. Cognitive Decline in Patients with Diabetes
MMSE mostly taken by patients at the Alzheimer’s clinic
TALK TO A STATISTICIAN
COMPARE: MOCA vs. MMSE
COMPARE: DM vs. NDM

21. MMSE and MoCA in Diabetic and Neurologic Patients
Queries on HERON (as of Nov. 2016):
MMSE and MoCA (n=4,152)
MMSE (n=1,973)
MoCA (n=2,256)
MMSE and MoCA occurring >1x (n=1,536)
MMSE occurring >1x (n=1,086)
MoCA occurring >1x (n=457)
Total DM
NDM
Parkinson's Disease – ICD9 332; ICD10 G20 (n=7,990) 77 54 23
383 18
365
Dementia with Lewy Bodies – ICD ; ICD10 G31.83 (n=586) 72 21 51 4 14
Alzheimer's Disease – ICD9 331; ICD10 G30 (n=5,659)
674
124
550 28 6 22
Mild Cognitive Impairment – ICD ; ICD10 G31.84 (n=2,651)
418 94
324 26 9 17
Vascular Dementia – ICD ; ICD10 F01 (n=1,211) 66 31 35 2
Frontotemporal Dementia – ICD ; ICD10 G31.0 (n=423) 87 69
All conditions above (n=16,209)
1015
204
811
406 61
345
DM - ICD9 250; ICD10 E08-E13 (n=82,733)
271
815 71
386
HERON: BILLING DIAGNOSIS – PRINCIPAL PROBLEM
TALK TO DRS WHO WORK WITH AD AND PD
Few patients with diabetes were screened with MMSE or MoCA MMSE is mostly taken by patients with Alzheimer’s disease (Alzheimer’s Clinic) MoCA is mostly taken by patients with Parkinson’s disease (Neurology, Landon Center)

22. FUTURE DIRECTIONS Abstract submission:
Kansas Physical Therapy Association (KPTA); 2017 Spring Conference – (April 7-9 – Wichita, KS); Research Session; Poster Presentation.
American Diabetes Association 77th Scientific Sessions (June 9-13 – San Diego, CA).
Further analysis on demographics:
Set characteristics of patients to be recruited in prospective study.
HbA1C Vs Cognitive Decline
3 months