SLR - June 2022 - Pooja Srivastava, DPM
Reference: Siru R, Burkhardt M, Davis W, Hiew J, Manning L, Ritter JC, Norman PE, Makepeace A, Fegan PG, Bruce DG, Davis T, Hamilton EJ. Cognitive Impairment in People with Diabetes-Related Foot Ulceration. J Clin Med. 2021. Jun 25;10(13):2808.Level of Evidence: III
Scientific Literature Review
Reviewed By: Pooja Srivastava, DPM
Residency Program: McLaren Oakland Hospital (Pontiac, MI)
Podiatric Relevance: Potential consequences of a chronic diabetic foot ulcer include sepsis, lower extremity amputation, and overall increased mortality rate. The mortality and morbidity associated with diabetic foot ulcers continue to be a tremendous burden on the healthcare system where podiatric surgery plays a role to prevent such deleterious consequences from manifesting via patient treatment and education. This observational cross-sectional study aimed to assess whether there is an excess of cognitive impairment in patients with type 2 diabetes mellitus (DMT2) who have foot ulcerations, potentially affecting outcomes during management.
Methods: This study took place between outpatient clinics from two hospitals in Perth, Australia. From the multi-disciplinary clinics (MDFU), 55 patients with diabetic foot ulcers were recruited. From the complex diabetes clinic (CDC), 56 patients with DMT2, but no ulcerations, were recruited. Aside from being DMT2, inclusion criteria also required being above the age of 18, having no prior history of cognitive impairment, and English fluency. Each subject underwent a 90-min comprehensive assessment at a single visit that included detailed questions pertaining to their diabetes duration, treatment regimen, complications, comorbidities, educational level, etc. Subjects also underwent assessments of cognitive impairment, mood, health literacy, and foot self-care. The Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MOCA) tests were used to assess cognitive impairment. Physical examination and blood and urine tests were also taken for clinical assessment.
Results: In terms of the primary outcome, there were no significant differences between the MDFU and CDC groups for MMSE and MOCA scores. However, there was a lower self-reported prevalence of depression/less use of antidepressants in the MDFU group. The MDFU group did demonstrate a lower Hemoglobin A1c, yet increased prevalence of peripheral neuropathy and previous lower extremity amputation in comparison to the CDC group.
Conclusions: This study did not find a significant difference in cognitive impairment in DMT2 patients with diabetic foot ulcer versus those without. Furthermore, the groups were similar in terms of potentially confounding comorbidities, but the MDFU subjects had significantly superior glycemic control and had greater adherence to foot self-care. This may suggest that a multi-disciplinary approach earlier on in diabetic management could be advantageous for preventing sequelae. Although there was no difference between cognitive impairment between both groups, approximately half of the recruited participants overall had at least mild cognitive impairment (based on MOCA scores) which may support the notion that we must tailor foot education interventions to account for potential cognitive dissonance.