Mental Status Exam Cognition

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A cross-sectional study was conducted in a group of 346 type 2 diabetic outpatients attended at the diabetes clinic of the State University of Rio de Janeiro. Patients were considered to have type 2 diabetes when diabetes was diagnosed after 30 years of age, without insulin use in the first year after the diagnosis and without history of ketonuria.

Exclusion criteria were blindness, illiterately, stroke, Alzheimer disease and psychiatric disorders. Patients were asked to undergo the Mini-Mental State Examination (MMSE) during routine ambulatory visits between April 2006 and January 2007.

Demographic characteristics such as sex, age, years of study, 'per capita' income and duration of diabetes, and medical history of hypertension, dyslipidemia, smoking, and treatment of diabetes were assessed.

Hypertension was defined as systolic blood pressure (sBP) ≥140 mmHg and/or diastolic blood pressure (dBP) ≥ 90 mmHg or any value in patients under anti-hypertensive treatment. Dyslipidemia was defined as total cholesterol ≥ 200 mg/dl and/or HDL ≤ 45 mg/dl and/or LDL ≥ 100 mg/dl and/or triglycerides ≥ 150 mg/dl and/or use of statins or fibrates.

Smoker and former smoker were considered those who make or have made use of any amount of cigarettes, respectively and were considered together in a group of ever smokers.

Patients who need help to take their medications were considered those who need a second person to administer medications as prescribed.

Glycated Haemoglobin (A1c) was determined using a high performance liquid chromatography (HPLC) reference value of 4 - 6.2%. FBG, triglyceride, HDL cholesterol and total cholesterol levels were measured using an auto-analyzer (Cobas-Mira Roche) with enzymatic techniques. LDL cholesterol was calculated according to Friedewald when triglycerides levels were less than 400 mg/Dl . Weight and height were measured to the nearest 0.1 Kg and 0.1 cm respectively. Body mass index (BMI) (Kg/m2) was calculated using these measurements.

A standard MMSE form (22) was administered to each of the 346 subjects. The MMSE scale ranges from 0 to 30 points, with higher number indicating better performance. Instructions were identical for each subject.

The MMSE consists in 19 questions designed to assess the patient's mental status in the following 5 categories: 10 orientations questions (year, season, date, day, month, state, city, close street, floor and location); 2 memories items (repeat the words car, window and vase and after delayed recall); 1 calculation item; 5 language items (naming 'watch-pencil', repeat 3 words 'No ifs, ands, or buts' (adapted to Portuguese language as 'nem aqui, nem ali, nem lá'), 3 step-command, read and follow the sentence 'close your eyes' and write a sentence) and 1 constructional item (copy overlapping pentagon) (Appendix 1).

The stratification of the cut-off points was done in accordance to years of study in order to prevent the possibility of education level to mask the performance in this test. We used a score system validated on Brazilian population , with the following interpretation to possible dementia: MMSE score < 26, if patient had more than 8 years of study; MMSE score < 18 if patient had between 1 and 8 years of study.

Statistical analysis

The Kruskal-Wallis and Mann-Whitney U tests were used for comparisons between groups of variables not normally distributed and the Student t-test and ANOVA were used for the other comparisons. ANCOVA was used for controlling for the following variables (age, gender, duration of diabetes, years of study, hypertension, dyslipidemia, HbA1c). The Chi-square test with Yates correction was used for comparison of categorical variables. Pearson correlation and partial correlation controlling for the following variables (age, gender, duration of diabetes, years of study, hypertension, dyslipidemia, HbA1c) using Pearson's correlation coefficient was also performed.

These analyses were performed using the statistical package for the social science (SPSS, version 13.0). Values were expressed as mean (SD) or median (interquartile range). A two-sided P value less than 0.05 was considered to be significant.

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