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Diabetes and Dementia Mario Barbagallo* and Ligia J Barbagallo and Dominguez. Int J Diabetes Clin Res 2015, 2:4 ISSN: 2377-3634 International Journal of Diabetes and Clinical Research Commentary: Open Access Diabetes and Dementia Mario Barbagallo* and Ligia J. Dominguez Geriatric Unit, Department DIBIMIS, University of Palermo, Italy *Corresponding author: Mario Barbagallo, UOC di Geriatria e Lungodegenza, AOUP Azienda Universitaria Policlinico, University of Palermo, Italy, Tel: +390916552885, Fax: +390916552952, E-mail: [email protected] speed and executive functions [13,14]. Not only frank dementia, Abstract but also mild cognitive impairment (MCI) is associated with DM2, Persons with type 2 diabetes mellitus (DM2) have an increased as well as an accelerated progression from MCI to dementia [15]. incidence of cognitive decline and dementia. An increased cortical Dementia is the most common comorbidity in persons with diabetes and subcortical atrophy has been found after controlling for in nursing homes [16]. vascular disease and inadequate cerebral circulation. A possible role of insulin resistance and hyperinsulinemia has been suggested Several studies on the cerebral structure of patients with diabetes to mediate the link between DM2 and Alzheimer’s Disease (AD). have evidenced increased cortical and subcortical atrophy (besides Altered insulin signaling may contribute to AD biochemical and increased leukoaraiosis and cerebrovascular disease), which were histopathological lesions. Both hyperglycemia and hypoglycemia associated with impaired cognitive performance [17,18]. Insulin may contribute to cognitive decline in DM2. Recurrent symptomatic and asymptomatic hypoglycemic episodes have been suggested itself and insulin resistance have been suggested as mediators of to cause subclinical brain damage, and permanent cognitive AD-type neurodegeneration. It has been proposed that AD may be impairment. Future trials are needed to clarify if cognitive decline termed as “type 3 diabetes”, indicating that AD may represent a form may be prevented by an adequate metabolic control, insulin- of diabetes that selectively involves the brain with molecular and sensitizing agents and avoiding hypoglycemia. biochemical features that overlap with diabetes mellitus [19]. Keywords Insulin has significant neurotrophic properties in the brain. The Dementia, Alzheimer’s disease, Type 2 diabetes, Aging, Cognitive hormone is rapidly transported to the level of the central nervous decline, Insulin, Insulin resistance, Hypoglycemia, Hyperglycemia. system through the blood-brain barrier by a transport mechanism mediated by insulin receptors, mainly localized at the level of the hippocampus, entorhinal cortex and frontal areas (areas known to Type 2 diabetes mellitus (DM2) and Alzheimer's disease (AD) be involved in memory and learning). Insulin is also involved in the are among the fastest growing epidemics of the third millennium, production of important neurotransmitters such as acetylcholine and which are both associated with aging of the population [1,2]. DM2 norepinephrine. A state of chronic hyperinsulinemia, as it occurs in is characterized by impairment in insulin action, insulin resistance insulin-resistance conditions and in DM2, may determine a down- and hyperinsulinemia. AD is pathologically distinguished by the regulation of the insulin receptors at the blood-brain barrier, thus presence of several hallmarks including neuronal loss, deposits of reducing the transport of insulin in the brain. Insulin metabolism amyloid beta (senile plaques), intracellular neurofibrillary tangles is linked to the deposition of precursors of amyloid in the brain. composed of aggregated hyperphosphorylated tau proteins in brain, The amyloid precursor protein (APP) is a transmembrane protein proliferation of astrocytes, and activation of microglia, associated consisting of 770 amino acids; it is known to be the precursor of the with mitochondrial dysfunction and alterations in neuronal synapses amyloid beta involved in the pathogenesis of AD. Whereas insulin is [3]. Most studies have suggested that the deposit of the toxic amyloid- a neurotrophic factor at moderate concentrations, hyper-insulinemia beta peptide (amyloid cascade hypothesis), may be a triggering factor with elevated concentrations of insulin in the brain may be associated contributing to the pathogenesis of AD. with reduced amyloid-beta clearance due to competition for their DM2 is associated with several and important changes in common and main degrading mechanism — the “Insulin-Degrading cognition, and it has been strongly associated with an increased risk Enzyme” (IDE). of developing dementia [4-6]. Thus, the incidence of dementia and Insulin is degraded by the IDE, which is also involved in the the risk of developing AD are significantly higher in persons with metabolism and degradation of amyloid beta. Thus, IDE competitively DM2 than in those without diabetes [7-9]. In a community-based degrades both insulin and amyloid-beta peptide in the AD brain [20]. controlled study, frank diabetes (35%) or glucose intolerance (46%) Since IDE is much more selective for insulin than for amyloid beta, was present in up to 80% of patients with AD [10], and longer diabetes a condition of hyperinsulinemia may deprive amyloid-beta of its duration has been associated with a higher risk for developing main clearance mechanism, favoring its accumulation in the brain, dementia [6,11,12]. The areas of cognitive functions that have been and its consequent neurotoxic effects [21]. Hyperinsulinemia and suggested to be mainly affected in persons with diabetes are attention, insulin resistance have been associated with more hippocampal and learning and memory, mental flexibility, psychomotor efficiency, amygdalar atrophy on MRI in persons with DM2 when compared Citation: Barbagallo M, Dominguez LJ (2015) Diabetes and Dementia. Int J Diabetes Clin Res 2:038 ClinMed Received: July 26, 2015: Accepted: July 31, 2015: Published: August 03, 2015 International Library Copyright: © 2015 Barbagallo M. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. to matched non-diabetic controls, regardless of vascular pathology a major role. Future trials are required to clarify the mechanistic [13,17]. link and to address the question whether cognitive decline may be prevented by an adequate metabolic control, and the possible role Plasma glucose itself is a risk factor for cognitive dysfunction and of insulin-sensitizing agents. Clinicians treating older persons with dementia; both higher (hyperglycemia) and lower (hypoglycemia) diabetes should start to routinely search for cognitive impairment levels of glucose may have deleterious effects on the brain. In a as well as they search for other common complications of diabetic prospective, community-based cohort study, higher plasma glucose disease. We believe that there is sufficient evidence to include concentrations were associated with an increased risk of dementia in cognitive evaluation in future diabetic guidelines. populations with and without diabetes [22], and the risk of incident dementia increased in diabetic and in non-diabetic persons according References to the average glucose concentrations during the preceding 5years [22]. 1. Barbagallo M, Dominguez LJ (2014) Type 2 diabetes mellitus and Alzheimer’s Hyperglycemia and hyperinsulinemia may accelerate brain aging also disease. World J Diabetes 5: 889-893 by inducing tau hyperphosphorylation and amyloid oligomerization, 2. Kukull WA, Higdon R, Bowen JD, McCormick WC, Teri L, et al. (2002) as well as by leading to widespread brain microangiopathy. Persons Dementia and Alzheimer disease incidence: a prospective cohort study. Arch with diabetes also develop accelerated leukoaraiosis (white matter Neurol 59: 1737-1746. high-intensity lesions) [23]. 3. Mattson MP (2004) Pathways towards and away from Alzheimer's disease. The effect of diabetes treatment and glycemic control on dementia Nature 430: 631-639. risk are less clear. It has been suggested that glycemic control may 4. Akomolafe A, Beiser A, Meigs JB, Au R, Green RC, et al. (2006) Diabetes have a role in preserving cognitive performance among patients with mellitus and risk of developing Alzheimer disease: results from the Framingham Study. Arch Neurol 63: 1551-1555. DM2. Using baseline cognitive measures collected in the Memory in Diabetes (MIND), sub-study of the Action to Control Cardiovascular 5. Wrighten SA, Piroli GG, Grillo CA, Reagan LP (2009) A look inside the Risk in Diabetes (ACCORD) trial, the authors found that a 1% higher diabetic brain: Contributors to diabetes-induced brain aging. Biochim Biophys Acta 1792: 444-453. glycated hemoglobin A1c (HbA1c) value was associated with a significant lower performance and memory score test in patients with 6. Ott A, Stolk RP, van Harskamp F, Pols HA, Hofman A, et al. (1999) Diabetes mellitus and the risk of dementia: The Rotterdam Study. Neurology 53: 1937- diabetes [24]. 1942. HbA1c was also identified as an additional risk factor for a greater 7. Biessels GJ, Staekenborg S, Brunner E, Brayne C and Scheltens P (2006) Risk rate of brain atrophy. Significant differences in brain atrophy rates of dementia in diabetes mellitus: a systematic review. Lancet Neurol 5: 64-74. measured by MRI were found by quartiles of HbA1c levels [25]. The 8. Allen KV, Frier BM, Strachan MW (2004)
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