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Obesity and Diabetes Accelerate Cognitive Decline

While the wide-ranging adverse health effects of obesity are well-known, recent evidence reveals that higher BMI levels may be associated with cognitive decline – in particular, in older adults. In addition, sustained elevated glucose contributes to many adverse health consequences, increasing risk for heart disease stroke, kidney disease, vision and nerve problems and can also lead to cognitive decline in older patients, according to new research published in Journal of the American Geriatrics Society.

Diabetes is a consistent risk factor for cognitive decline and dementia in both midlife and later life, which when coupled with obesity can raise the risk of poor physical and mental health outcomes. Long-term prior research indicates that diabetes, high blood pressure, and high BMI should be examined together to determine their contribution to adverse cognitive outcomes.

Assessing the Role of Metabolic Markers

In a ten-year prospective population-based cohort study, a team of researchers led by Mary Ganguli, MD, MPH, investigated the potential mechanisms underlying the well-established association between diabetes and obesity along with its relationship to cognitive decline. They evaluated a cohort of 478 individuals aged 65 years or above by analyzing fasting blood markers of glycemia (glucose and hemoglobin A1c), insulin resistance (insulin and homeostatic model assessment of IR), obesity (resistin, adiponectin, and glucagon-like peptide-1), and inflammation (C-reactive protein). The team modeled the metabolic indices as predictors of the slope of decline in global cognition, conducted multivariable regression analyses, and stratified by sex-specific median waist-hip ratio (WHR). Results were adjusted for sex, education, age, APOE-4 genotype, WHR, depressive symptoms and systolic BP.

Obesity, Diabetes Associated with Cognitive Decline

Dr Ganguli and her colleagues found that HbA1c measures were significantly associated with cognitive decline in those with higher waist-hip ratios in the entire sample – the connection persisted in participants with higher WHR after stratifying by median WHR. Conversely, metabolic indices were not associated with cognitive decline in participants with lower WHR.

Further, the team found that individuals under the age of 88 with abdominal obesity were more predisposed to faster cognitive decline in the presence of even mild hyperglycemia. In participants under the age of 87, faster cognitive decline was associated with adiponectin of 11 or greater in those with lower WHR as well as with an HbA1c measure of 6.2% or greater in those with higher WHR. The study also introduces evidence of the hormone adiponectin as a likely novel risk factor for cognitive decline in older adults under the age of 87 without abdominal obesity, the researchers reported.

Dr. Ganguli and her team’s results reveal that even mild degrees of hyperglycemia can independantly predispose individuals under the age of 88 with abdominal obesity to faster cognitive decline. Those below the age of 87 without central obesity may be more affected by the novel independent risk factor adiponectin. Their findings indicate that abdominal obesity can significantly affect neurological health in individuals under the age of 87, however, after that threshold there seems to be no correlation between diabetes, obesity, and cognitive decline.

“Clinicians need to pay more attention to abdominal obesity and be concerned about prediabetes in those individuals,” Ganguli told Healio Psychiatry. “In those who don’t have abdominal obesity, we should perhaps pay more attention to unexplained weight loss. I’d like to see the adiponectin relationship be investigated further before saying adiponectin should be measured in the clinical setting.”

Need for Improved Patient Note Accuracy

As health information transparency continues to increase, over 44 million patients in the United States currently have ready access to their ambulatory visit notes online. Unfortunately, errors in electronic health records  (EHRs) occur frequently – as many as half of EHRs may contain an error as overburdened healthcare practitioners may propagate erroneous information, omit critical data, and import inaccurate records. These mistakes have grave potential implications as EHR data is often incorporated into clinical decision-making and can result in medication errors, incorrect treatment, delayed diagnoses, and worsened health outcomes.

However, limited data is available on the prevalence of documentation errors identified by patients in their post-visit notes and how these mistakes may inform patient safety. In addition, there is a lack of systems for checking the accuracy of notes at health care organizations. A study recently published in JAMA Network Open aimed to assess the frequency and types of mistakes patients who read ambulatory visit notes find as well as the types of mistakes they choose report.

Frequency of Patient Note Errors

To determine the frequency at which patients discovered errors in their ambulatory notes, researchers conducted a survey of over 136,000 patients at 3 health care organizations – Beth Israel Deaconess Medical Center, Geisinger, and the University of Washington Medicine. Of those, nearly 30,000 participants responded to the survey between June and October 2017. Data from patients who had at least 1 ambulatory note and had logged onto their patient portal at least one time in the past 12 months were included in the study. The main outcomes assessed the proportion of patients reporting errors in their records and how serious they perceived them to be; factors associated with errors defined by patients as serious; and the categories of these reported errors.

Serious Mistakes and Their Clinical Implications

The team of researchers found that 21.2% or 1 in 5 patients reported perceiving an error in their records, while 42.3% of those reported the mistake to be serious. After conducting multivariable analyses, the authors concluded that female patients, more educated patients, sicker patients, those between 45 and 64 years of age, those 65 and older, and those who read more than 1 note were statistically more likely to report errors they characterized as serious compared to other groups. Meanwhile, Asian patients were less likely to report finding a serious mistake in their records although, patients who identified as more than one race were more likely to report errors.

“After categorization of patient-reported very serious mistakes, those specifically mentioning the word diagnosis or describing a specific error in current or past diagnoses were most common (98 of 356 [27.5%]),” the study’s authors write, “followed by inaccurate medical history (85 of 356 [23.9%]), medications or allergies (50 of 356 [14.0%]), and tests, procedures, or results (30 of 356 [8.4%]).”

Of the 433 very serious errors reported, nearly 60% included at least 1 error potentially linked to the diagnostic process – including medical history, physical examination, tests, referrals, and communication. According to Healthcare IT News, researchers also noted examples of providers recording “ductal carcinoma in situ” as “disseminated cancer” or responding to questions that were reportedly not asked. Others reported errors of omission, reports of wrong test results, mistakes regarding medication allergies or dosages, and mistakes attributable to electronic health record glitches.

As millions of patients in the U.S. can access their post-visit notes, there has been an increase in access to electronic medical records via third-party apps and data-sharing across the nation. The latest findings also indicate potential patient privacy concerns, as a total of 6.5% of serious errors reflected notes that were written about different patients. According to the researchers, systematic checks of the content of notes have been primarily absent from clinical documentation thus far.

As evidenced by the latest findings, patient-reported mistakes can help prevent future medication, diagnostic, and treatment errors. The study’s authors emphasize the missed opportunity that is a lack of routine review of notes by patients, which could be used to improve EHR accuracy and support organizational learning. As health information transparency continues to increase, it is becoming even more important to encourage patients to report mistakes they perceive and to promote patient engagement within the clinical setting. This will require broad outreach strategies for patients across the population and will rely on practitioner support for patient feedback, systematic mechanisms for triage, and response to patient-reported errors.