JAMA Intern Med:在老年糖尿病患者中 低血糖-痴呆症互为因果
2013-06-14 姜珊 编译 中国医学论坛报
美国一项研究表明,在老年糖尿病(DM)患者中,低血糖和痴呆症之间可能存在双向相关性。论文6月10日在线发表于《美国医学会杂志·内科学》(JAMAInternMed)。 该前瞻性研究纳入783例老年DM患者(平均74.0岁;47.0%为黑人;47.6%为女性),其均参与了始于1997年、基于人群的“健康、老龄化和身体成分研究”,基线时改良的简易精神状态检查评分≥80
美国一项研究表明,在老年糖尿病(DM)患者中,低血糖和痴呆症之间可能存在双向相关性。论文6月10日在线发表于《美国医学会杂志·内科学》(JAMA Intern Med)。
该前瞻性研究纳入783例老年DM患者(平均74.0岁;47.0%为黑人;47.6%为女性),其均参与了始于1997年、基于人群的“健康、老龄化和身体成分研究”,基线时改良的简易精神状态检查评分≥80分。主要终点为随访期间医院所记录的痴呆症诊断及低血糖事件。结果为,在12年的随访期间,61例(7.8%)发生低血糖,148例(18.9%)罹患痴呆症。与未发生过低血糖者相比,发生过低血糖者痴呆症风险增加1倍[34.4%对17.6%,校正风险比(HR)=2.1]。同样,与无痴呆症者相比,患痴呆症的老年DM患者发生低血糖的风险更高(14.2%对6.3%;校正HR=3.1)。进一步校正卒中、高血压、心肌梗死和认知改变评分,所得结果相似。
■ 同期述评
老年糖尿病患者过于严格的血糖控制 可能弊大于利
美国耶鲁大学医学院医学系内分泌科 利普斯卡(Lipska) 梅奥医院认知与评估研究室 蒙托里(Montori)
低血糖是2型DM患者降糖治疗的主要不良反应。过去十年,DM治疗指南和评价指标几乎完全专注于高血糖及其并发症的预防。然而,基于目标的降糖,可能导致所有的临床治疗“大小一刀切”,并产生副作用。据统计,在胰岛素或胰岛素促泌剂治疗每100患者-年中,约发作35~70次严重低血糖。
老年人发生低血糖的风险较高,这与老龄化相关的肾功能和药物清除能力的变化相关。此外,多种药物相互作用、合并症和热量摄入变化也是可能原因。
低血糖与预后不佳相关。与无严重低血糖的DM患者相比,有严重低血糖者5年内死亡风险升高3.4倍,且后者更容易发生急性心血管事件、跌倒相关性骨折、驾驶相关性事故和跌倒。低血糖的严重后果之一是认知功能损害,如上研究所述,低血糖与痴呆症之间存在双向关系。
显然,需要降低DM患者低血糖风险,以提高其生活质量和预防相关不良事件。较缓和的血糖控制可减少降糖药物用量、简化DM治疗、减少治疗失误并降低低血糖风险。当前的血糖控制方案均不尽完美,患者和临床医师应考虑改变糖化血红蛋白控制目标和降糖治疗方法,以提供更为安全的治疗。控制血糖时,应以患者为中心,而并非以疾病或血糖水平为中心,后一种做法对于患者而言,可能弊大于利。
Importance
Hypoglycemia commonly occurs in patients with diabetes mellitus (DM) and may negatively influence cognitive performance. Cognitive impairment in turn can compromise DM management and lead to hypoglycemia.
Objective
To prospectively evaluate the association between hypoglycemia and dementia in a biracial cohort of older adults with DM.
Design and Setting
Prospective population-based study.
Participants
We studied 783 older adults with DM (mean age, 74.0 years; 47.0% of black race/ethnicity; and 47.6% female) who were participating in the prospective population-based Health, Aging, and Body Composition Study beginning in 1997 and who had baseline Modified Mini-Mental State Examination scores of 80 or higher.
Main Outcome Measures
Dementia diagnosis was determined during the follow-up period from hospital records indicating an admission associated with dementia or the use of prescribed dementia medications. Hypoglycemic events were determined during the follow-up period by hospital records.
Results
During the 12-year follow-up period, 61 participants (7.8%) had a reported hypoglycemic event, and 148 (18.9%) developed dementia. Those who experienced a hypoglycemic event had a 2-fold increased risk for developing dementia compared with those who did not have a hypoglycemic event (34.4% vs 17.6%, P < .001; multivariate-adjusted hazard ratio, 2.1; 95% CI, 1.0-4.4). Similarly, older adults with DM who developed dementia had a greater risk for having a subsequent hypoglycemic event compared with participants who did not develop dementia (14.2% vs 6.3%, P < .001; multivariate-adjusted hazard ratio, 3.1; 95% CI, 1.5-6.6). Further adjustment for stroke, hypertension, myocardial infarction, and cognitive change scores produced similar results.
Conclusion and Relevance
Among older adults with DM, there seems to be a bidirectional association between hypoglycemia and dementia.
作者:姜珊 编译
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#痴呆症#
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#糖尿病患者#
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#老年糖尿病#
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