Journals Watch - Diabetes, insomnia and fatigue

Too busy to read the the journals? Let Dr Alison Glenesk bring you up to date on the latest research.

Testing for mild cognitive impairment Dement Geriatr Cogn Disord 2009; 27: 224-31

Mild cognitive impairment (MCI) is usually thought to be a state between normal brain functioning and Alzheimer's, when the patient has abnormalities on testing, but with minimal effect on everyday functioning.

CT scans of Alzheimer’s disease (arrows indicate low activity): progression from MCI is not inevitable (BSIP, CAVALLINI JAMES / SCIENCE PHOTO LIBRARY)

The aim of this study was to track patients who had received a diagnosis of MCI. These are the results after one year.

A total of 115 patients, aged 65-75, who attended a tertiary memory clinic underwent baseline and follow-up psychometric testing. Of them, 54 had MCI and 61 were controls.

Ten patients (23 per cent) diagnosed with MCI were normal on subsequent testing, while 13 (21 per cent) who were originally unaffected went on to develop MCI. Those diagnosed with MCI on both assessments tended to be older and had worse cognitive performance on original testing. Interestingly, none developed Alzheimer's disease.

This study provides hope that MCI is reversible.

Mortality rates in type-2 diabetes Am J Epidemiol 2009; 169: 455-61

The aim of this study was to compare the mortality rate of people with type-2 diabetes with that of the general population.

A total of 48,556 patients with type-2 diabetes diagnosed between 1996 and 2006 were identified from 197 practices participating in the UK general practice research database. There were 6,630 deaths in this population during the period.

Expected mortality for the general public was estimated using UK life tables.

For diabetics, the age-standardised all-cause mortality decreased by 0.82 per 1,000 per year for men and 0.49 per 1,000 per year for women, with a constant decrease during the study period.

Relative mortality for patients diagnosed in 2001 was 13 per cent lower than for those diagnosed in 1996, and for patients diagnosed in 2006, relative mortality was 26 per cent lower than those diagnosed in 2001.

The mortality rate for the general population also decreased during this period, but at a slower rate than for diabetics.

Statin use and musculo-skeletal symptoms Fam Pract 2009; 26: 88-95
This study aimed to investigate the association between statin use and reporting of muscular complaints by patients. A cross-sectional study was carried out of 1,031 patients over 50 years old, at 26 practices in Germany.

Of those taking lipid-lowering drugs, 44 per cent had muscular complaints compared with 39 per cent of those not taking these drugs.

It appears that statins are associated with 1.5-fold increased risk of muscular complaints. Unfortunately, though, this does not help us differentiate between those induced by statins and those occuring anyway.

Natural history of insomnia Arch Intern Med 2009; 169: 447-53
A population of 388 adults (61 per cent female; mean age 44.8 years) complaining of insomnia were selected and sleep/insomnia questionnaires administered annually for three years.

At each follow up, participants were classified into three groups: insomnia syndrome, insomnia symptoms, and good sleep using standard diagnostic criteria, with the second group having some features of insomnia but being less severely affected.

They found that 74 per cent of insomnia patients experienced it for at least one year, and 46 per cent of patients were affected over the entire three-year period. This was more common, not surprisingly, in those who were more severely affected at the outset.

There was a remission rate of 54 per cent but 27 per cent of these relapsed.

Predictive risk of type-2 diabetes: England and Wales BMJ 2009; 338: b880
This huge study has produced a tool we can use in everyday general practice.

The aim was to develop and validate a new diabetes risk algorithm for the estimation of the 10-year risk of developing type-2 diabetes (QDScore).

This prospective open cohort study used routinely collected data from 355 research practices in England and Wales, and from a further 176 practices to validate the score. A total of 2,540,753 patients aged 25-79 contributed 16,436,135 patient-years of observation. Of these, 78,081 developed diabetes. In the validation cohort, 37,535 of the 1,232,832 patients developed the disease.

The predictive variables found to be important were: ethnicity, age, sex, BMI, smoking status, family history of diabetes, deprivation score, treated hypertension, cardiovascular disease and current use of corticosteroids.

These paramaters explain about 10 per cent of variation, and give higher discrimination than previous scoring methods.

This work is neatly encapsulated in a simple on-line calculator at www.qdscore.org.

Ordering blood tests for unexplained fatigue Br J Gen Pract 2009; 59: 243-9
In this study, GPs were randomised into three groups to investigate the relationship between diagnoses and the occurrence of abnormal blood test results among patients with unexplained fatigue.

Group 1 was to order immediate blood tests, and groups 2 and 3 (limited and expanded sets of blood tests) to delay for one month. A total of 173 patients underwent immediate testing, and 8 per cent turned out to have a somatic illness (e.g. anaemia or thyroid disease).

Of the 111 patients in the postponement group only 24 consulted again after four weeks, one of whom had diabetes.

The recommendations are to try to postpone blood testing and to stick to FBC, ESR, glucose and TSH.

This worries me on two counts: I am not sure it's acceptable to delay diagnosis in even a small number of patients for one month, and what about the patients who did not come back - can we be sure they were okay, and had not simply given up and gone away?

An interesting study, but it raises more questions than it answers.

  • Dr Glenesk is a GP trainer in Aberdeen and a member of our team who regularly review the journals.

The Quick Study

  • Mild cognitive impairment can be detected at early stages but does not always progress to Alzheimer's disease.
  • Type-2 diabetes appears to be associated with a decreasing mortality rate compared with 1996.
  • Statins are associated with 1.5-fold rise of muscular complaints.
  • Insomnia was found to be more likely to last if it was more severe at the outset.
  • QDScore is a risk prediction algorithm used to estimate the 10-year risk of type-2 diabetes.
  • Postponing blood testing may be a useful in patients presenting with unexplained fatigue.

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