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Original research
Clinical characteristics and healthcare utilisation associated with undiagnosed cognitive impairment in elderly patients with diabetes in a primary care setting: a population-based cohort study
  1. Eugene Merzon1,2,
  2. Miriam Shpigelman3,
  3. Shlomo Vinker1,4,
  4. Avivit Golan Cohen1,4,
  5. Ilan Green1,4,
  6. Ariel Israel1,
  7. T Cukierman-Yaffe5,6,
  8. Roy Eldor7,8
  1. 1Medical Division, Leumit Health Care Services, Tel Aviv, Israel
  2. 2Dr Miriam and Sheldon G Adelson School of Medicine, Ariel University, Ariel, Israel
  3. 3Clalit Health Services, Dan Petach Tikva, Israel
  4. 4Department of Family Medicine, School of Medicine, Tel Aviv University, Tel Aviv, Israel
  5. 5Division of Endocrinology, Diabetes and Metabolism, Gertner Institute, Sheba Medical Center, Ramat Gan, Israel
  6. 6Epidmiology Department, Herczeg Institute on Aging, School of Medicine, Tel Aviv University, Tel Aviv, Israel
  7. 7Diabetes Units, Institute for Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
  8. 8School of Medicine, Tel Aviv University, Tel Aviv, Israel
  1. Correspondence to Dr Roy Eldor; eldorroy{at}


Objectives The objective of this study is to report the prevalence, clinical characteristics and healthcare utilisation of patients with type 2 diabetes (T2DM) and previously undiagnosed cognitive impairment who were identified as having a low Montreal Cognitive Assessment (MoCA) score.

Design A population-based cohort study comparing clinical characteristics, medications, outpatient and inpatient care of patients with a MoCA score <19 to MoCA >26 using descriptive statistics, linear regression and multivariate logistic regression.

Setting Electronic medical records of a large health maintenance organisation in Israel.

Participants 350 patients, age >65 with T2DM who participated in a cognitive function screening initiative using MoCA, and had a follow-up visit during the 12 months after screening.

Results 130 (37.1%) had a MoCA score >26 and 68 (19.4%) <19. Patients with MoCA<19 had more diabetes-related complications, poorer glycaemic and lipid control, fewer visits to their main primary care physician (PCP; 3.9±3.2 vs 7.3±4.2 visits/year p=0.008), shorter duration of PCP visits (8.3±4.5 vs 4.0±3.5 min, p=0.007), fewer nutritionist and endocrinologist visits, and lower participation in diabetes or smoking cessation workshops. They were less likely to be treated with glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 inhibitor (DPP-4), or sodium-glucose transport protein 2 (SGLT-2) inhibitors and more likely to receive insulin or sulfonylurea. Moreover, they had more emergency room visits (ER; 15 (11.5%) vs 16 (23.5%), p=0.019), hospitalisations (8 (6.2%) vs 22 (32.4%), p=0.001), and longer hospital stays (4.3±3.2 vs 14.5±9.8, p=0.001). Using statistical models, MoCA<19 was identified as a risk factor for fewer and shorter PCP visits and more ER visits and hospitalisations.

Conclusions This study highlights the high prevalence of undiagnosed severe cognitive impairment in elderly patients with T2DM and its association with poor outpatient care. Appropriate interventions are needed to improve outcomes and prevent hospitalisation in this high-risk population.

  • Primary Health Care
  • Dementia
  • General diabetes
  • Aged

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. No additional data are available.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. No additional data are available.

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  • Contributors EM, MS, SV, AGC, TC-Y and RE were involved in the conception, design and conduct of the study and the analysis and interpretation of the results. IG and AI were involved in the analysis and interpretation of the results. RE wrote the first draft of the manuscript, and all authors edited, reviewed and approved the final version of the manuscript. RE is the guarantor of this work and, as such, has full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.