Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus.
Hypoglycemic episodes and risk of dementia in older patients with type 2 diabetes mellitus.
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DOI：
10.1001/jama.2009.460
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发表时间：
2009-04-15
影响因子：
120.7
通讯作者：
Selby, Joseph V.
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文献类型：
--
作者：
Whitmer, Rachel A.;Karter, Andrew J.;Yaffe, Kristine;Quesenberry, Charles P., Jr.;Selby, Joseph V.
虽然急性低血糖可能与1型糖尿病儿童的认知功能障碍有关，但迄今为止还没有研究评估低血糖是否是老年2型糖尿病患者痴呆的危险因素。在随访27年的老年2型糖尿病患者中，确定严重到需要住院治疗的低血糖发作是否与痴呆风险增加相关。一项1980-2007年的纵向队列研究，纳入了北方加州综合医疗保健提供系统的16，667名平均年龄为65岁的2型糖尿病患者。收集1980-2002年的低血糖事件，并使用出院和急诊诊断进行审查。在2003年1月1日之前没有痴呆、轻度认知障碍或一般记忆投诉的队列成员被随访至2007年1月15日，以确定痴呆诊断。采用考克斯比例风险回归模型，对年龄、性别、人种/种族、教育、体重指数、糖尿病病程、7年平均糖化血红蛋白、糖尿病治疗、胰岛素使用时间、高脂血症、高血压、心血管疾病、卒中、短暂性脑缺血和终末期肾病进行校正，检查痴呆风险。在随访期间，1465例患者（8.8%）被诊断为至少1次低血糖发作，1822例患者（11%）被诊断为痴呆; 250例患者同时患有痴呆和至少1次低血糖发作（16.95%）。与无低血糖的患者相比，单次或多次发作的患者风险分级增加，完全校正的风险比（HR）为：1次发作（HR，1.26; 95%置信区间[CI]，1.10-1.49）; 2次发作（HR，1.80; 95% CI，1.37-2.36）; 3次或3次以上发作（HR，1.94; 95% CI，1.42-2.64）。有和无低血糖史的个体之间痴呆的归因风险为每年2.39%（95%CI，1.72%-3.01%）。当将医疗利用率、健康计划成员资格的长度或自首次糖尿病诊断以来的时间添加到模型中时，结果并没有减弱。当检查因低血糖入院急诊与痴呆风险的相关性时（535次发作），结果相似（与0次发作的患者相比），完全校正的HR为：1次发作（HR，1.42; 95% CI，1.12-1.78）和2次或2次以上发作（HR，2.36; 95% CI，1.57-3.55）。在老年2型糖尿病患者中，严重低血糖发作史与痴呆风险增加相关。轻微的低血糖发作是否会增加痴呆症的风险尚不清楚。
Although acute hypoglycemia may be associated with cognitive impairment in children with type 1 diabetes, no studies to date have evaluated whether hypoglycemia is a risk factor for dementia in older patients with type 2 diabetes. To determine if hypoglycemic episodes severe enough to require hospitalization are associated with an increased risk of dementia in a population of older patients with type 2 diabetes followed up for 27 years. A longitudinal cohort study from 1980-2007 of 16,667 patients with a mean age of 65 years and type 2 diabetes who are members of an integrated health care delivery system in northern California. Hypoglycemic events from 1980-2002 were collected and reviewed using hospital discharge and emergency department diagnoses. Cohort members with no prior diagnoses of dementia, mild cognitive impairment, or general memory complaints as of January 1, 2003, were followed up for a dementia diagnosis through January 15, 2007. Dementia risk was examined using Cox proportional hazard regression models, adjusted for age, sex, race/ethnicity, education, body mass index, duration of diabetes, 7-year mean glycated hemoglobin, diabetes treatment, duration of insulin use, hyperlipidemia, hypertension, cardiovascular disease, stroke, transient cerebral ischemia, and end-stage renal disease. At least 1 episode of hypoglycemia was diagnosed in 1465 patients (8.8%) and dementia was diagnosed in 1822 patients (11%) during follow-up; 250 patients had both dementia and at least 1 episode of hypoglycemia (16.95%). Compared with patients with no hypoglycemia, patients with single or multiple episodes had a graded increase in risk with fully adjusted hazard ratios (HRs): for 1 episode (HR, 1.26; 95% confidence interval [CI], 1.10-1.49); 2 episodes (HR, 1.80; 95% CI, 1.37-2.36); and 3 or more episodes (HR, 1.94; 95% CI, 1.42-2.64). The attributable risk of dementia between individuals with and without a history of hypoglycemia was 2.39% per year (95% CI, 1.72%-3.01%). Results were not attenuated when medical utilization rates, length of health plan membership, or time since initial diabetes diagnosis were added to the model. When examining emergency department admissions for hypoglycemia for association with risk of dementia (535 episodes), results were similar (compared with patients with 0 episodes) with fully adjusted HRs: for 1 episode (HR, 1.42; 95% CI, 1.12-1.78) and for 2 or more episodes (HR, 2.36; 95% CI, 1.57-3.55). Among older patients with type 2 diabetes, a history of severe hypoglycemic episodes was associated with a greater risk of dementia. Whether minor hypoglycemic episodes increase risk of dementia is unknown.
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