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Age and Ageing Advance Access published online on November 16, 2009
Age and Ageing, doi:10.1093/ageing/afp211
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© The Author 2009. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Commentary

Pathophysiology of cognitive dysfunction in older people with type 2 diabetes: vascular changes or neurodegeneration?

Hiroyuki Umegaki

Department of Geriatrics, Nagoya University Graduate School of Medicine, 65-Tsuruma-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan. Email: umegaki{at}med.nagoya-u.ac.jp

Recent studies have revealed that type 2 diabetes mellitus (T2DM) is a risk factor for cognitive dysfunction or dementia, especially those related to Alzheimer’s disease (AD). Basic research suggests that insulin accelerates Alzheimer-related pathology through its effects on the amyloid beta (Aβ). Several pathological studies with autopsy samples have demonstrated, however, that dementia subjects with diabetes have less AD-related neuropathology than subjects without diabetes. We and others have reported that small vessel diseases affect cognitive function in older diabetics. Asymptomatic ischemic lesions in T2DM subjects may lower the threshold for the development of dementia and this may explain the inconsistency between the basic research and clinicopathological studies. Longitudinal follow-up of T2DM subjects without overt dementia using both amyloid imaging and magnetic resonance imaging may elucidate these issues. Following up until the development of overt dementia would make it possible to compare both amyloid load and ischemic lesions before and after the development of dementia. Moreover, amyloid imaging in non-demented older people with or without insulin resistance would verify the role of insulin in the processing and deposition of Aβ. Vascular risk factors may represent a therapeutic target, while neurodegenerative pathologies have not yet been amenable to treatment. It remains to be investigated whether medical interventions on vascular risk factors have protective effects against the development and progress of dementia.

Keywords: Alzheimer’s disease, ischemic lesions, dementia, insulin, Aβ

Received 17 May 2009; accepted in revised form 16 October 2009.


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