Does Cognitive Dysfunction Impact Diabetic Foot Ulcer Outcomes?

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My name is Christopher Girgis and I'm a clinical assistant professor and podiatrist at the University of Michigan. I'm very much looking forward to sharing our data from this exciting study with you all.
 
What did your research find on the subject of DFUs and cognitive function?
 
So, to provide some context, our study aimed to evaluate how cognitive dysfunction affects outcomes in patients with diabetic foot ulcerations. We thought that this was an underlooked-at topic, and so we wanted to evaluate this. And so the way we did that was we conducted a 6-year retrospective study using an electronic medical record in ICD-9 and ICD-10 codes using a cohort discovery tool called DataDirect and basically it was able to pull electronic medical records from that 6-year time period and we were able to follow these patients for 2 years.
 
And so basically in order for the patient to be included, they needed to have diabetic foot ulceration and they were excluded if they did not have a diabetic foot ulcer or were not followed by a podiatrist, and if they screened positive for cognitive impairment within 5 years, then they were excluded from the group without cognitive impairment. And in order for them to be included to the group with cognitive impairment, they had to have some ICD-9, ICD-10 code that signified that they had some level of cognitive impairment.
 
And so what we found was we looked at them over the course of 2 years, they had to have a diabetic foot ulceration, and we looked at the outcomes of time to heal rate of amputations and then foot-related admissions during this period of time. And what we found was that patients with diabetic foot ulcerations and cognitive impairment had an increased risk of major amputations secondary to more severe ulcerations. They had an increased risk of foot-related admissions and more frequent nonhealing at 3 months and 6 months compared to those patients without cognitive impairment. So this suggests that cognitive impairment worsens the challenges and outcomes of diabetic foot ulcerations.
 
Why does cognitive dysfunction predispose patients to DFU complications?
 
Cognitive function has been shown to be crucial for diabetes self-management elsewhere in the literature, not only the diabetic foot. And so there have been multiple studies that have shown somebody's cognitive function and how that impacts their ability to conduct self-care behaviors.
 
For instance, there were multiple studies in 2012 that showed one's ability to follow through with diabetes self-care behaviors, like checking their blood sugar, for instance, was directly related to their cognitive function. And so if they had a diminished cognitive function, then their ability to follow through on these tasks was very, very poor.
 
And unfortunately, in the diabetic foot literature, there's limited evidence to support this, although when you think about it, I can't think of a larger and more difficult self-care behavior than managing a foot ulceration. So intuitively, you would think that that would apply. It's just that evidence isn't there just because there hasn't been many studies to evaluate that. And so that's what we sought to evaluate, was to see if somebody did have cognitive impairment. How would that impact diabetic foot ulceration outcomes? And with our retrospective data, it did show that they did perform poorly.
 
How the author’s own practice reflects this phenomenon
 
I have seen this phenomenon in my own practice. And that is a major reason for why I am very committed to this work. In my experience with patients who have diabetic foot ulcerations, it's relatively common to encounter individuals who show signs of cognitive impairment, which may affect their ability to follow through on what I'm recommending for them to do. However, a lot of these patients go without a formal diagnosis. So it's challenging to then address this effectively.
 
And so this raises an important question of if these patients do perform poorly with their wound care and have poor outcomes, how can we best (one), screen for them, screen for cognitive impairment and (two), what is the additional support that we can offer to these patients to help them improve their outcomes.
 
How can DPMs help prevent complications in patients with cognitive issues?
 
DPMs at this time, I believe can do a number of things to help decrease the risk of complications in this patient population. Now, a lot of my work and my time with this research is dedicated to formulating algorithms and treatment plans for which we can provide evidence to support these items. But I think at the very least, a DPM, if they have any concern about a patient's cognitive status, I think what we should not do is just to brush it away. I think at the very least, we should begin with a conversation with the primary care provider to determine if additional evaluations or referrals like a referral to neurology, if you're noticing significant changes over a specific period of time, would be necessary. So first and foremost, reaching out to the primary care provider to discuss these concerns with them.
 
The second would be involvement of a caregiver or consulting social work to see if there's additional support that we can offer these patients such as case management or home health services. So I think reaching out for caregiver help as well as you know social work to see if we could offer them more support would also be ideal.
 
The last piece of this would just be tailoring your educational modalities and patient follow-ups to maybe keep them on a closer eye and a closer follow-up so that you can more specifically help and offer these patients increased support. Those would be the 3 areas that I think that DPMs can offer support for this high-risk population.
 
I think that this is a very interesting topic. I think there's a lot of opportunities for future prospective work in this area as it relates to how we can best screen this patient population in the podiatry clinic and what evidence-based algorithms can we apply and deploy for these patients to ultimately improve outcomes.