Risk stratification of Diabetic foot in Older Adults with Cognitive impairment

Abstract

INTRODUCTION: Type 2 diabetes mellitus (DM) represent a serious health and socioeconomic problem,
50% of people have no diagnosis, increasing the complications that underlie this pathology, since 25% will
develop a diabetic foot ulcer (DF). Furthermore, DM predisposes to cognitive impairment (CI) being a
relevant factor in DF patients, preventing proper personal care.
OBJECTIVE: To examine if the cognitive profile in patients with diabetes is related to the severity of
lesions in DF.
MATERIAL AND METHODS: Retrospective, observational and analytical study on 100 patients treated
in the retirement center "Las Palmas" January 2018/January 2019 who met the inclusion criteria. Variables
analyzed: Determination in blood of glucose and glycosylated hemoglobin (HbA1c). Degree of DF injury
according to the Texas scale. Evaluation of peripheral vascular lesion of the lower limbs using Doppler
ultrasound. CI evaluation using Mini-Mental. Statistics: Non-parametric variables were analyzed using Chisquare or Irwin Fisher and parametric variables with ANAVA, significance p<0.05.
RESULTS: We verified that the most frequent lesions were stage AI (33%) and stage B0 (28%), showing
significance with stage A0 (17%) and AII (12%)(p:0.01). Together, both stage AI and B0 showed a
significant higher percentage of lesions contrasted with stages AIII (3%), stage C0 (6%) and stage D0
(1%)(p:0.001). The Doppler ultrasound analysis showed (26%) of the patients registered triphasic waves
(14%) belonging to stage A0 of PD. Biphasic wave morphology was the most prevalent (53%) of patients
(p:0.001), of which (26%) were stage AI of DF, (15%) stage B0 and the difference was significant with
respect to AII (7 %) (p: 0.001). (21%) of patients registered monophasic waves, evidenced more frequently
in the stages with lesions C0 (6%) and D0 (1%). The increases in glucose and HbA1c analyzed showed a
significant relationship with the accentuation of the DF lesion. In relation to the stages of DF injury and the
Mini-Mental score, in patients assessed as mild to normal DC (26.82±2.27) we found a percentage of stage
A0, AI and AII. In patients with moderate to severe cognitive impairment, we found a percentage of stage
AII with scores (24.97±2.12) and AIII (23.67±1.15) both significant (p:0.01). In addition, B0 exhibited a
significant score (24.25±1.51) with respect to A0 and AI (p:0.01), C0 with a score (22.5±2.59) verified
significance with all stages A and B (p:0.001). In D0, the Mini-Mental result was 17 points, demonstrating
impaired cognitive functionality, showing significance in the DF injury stages A, B and C (p:0.001
respectively). The relationship between scored stages of cognitive impairment and HbA1c levels verified a
correlation coefficient (r=-0.56) showing a good inverse relationship between both variables. Poor
metabolic control of HbA1c and glycemia deteriorate the cognitive level.
CONCLUSIONS: CI in patients with type 2 DM causes a decrease in self-care 6 of DF lesions, which is
directly related to the severity of the lesions. Patients with increased levels of glucose and HbA1c exhibited
more severe stages of DF injury and monophasic recordings on Doppler ultrasound evaluation. Elevated
HbA1c levels were associated with a low score in the cognitive assessment. The development of strategies
for early identification of the progression of undiagnosed CI in vulnerable subjects is of great clinical
importance and should be resolved as soon as possible.