Nov. 15, 2015


BGU researchers have conducted the first study to perform comprehensive cognitive assessments of patients with diabetic foot and compare them to diabetic patients without diabetic foot, thus enabling identification of cognitive differences associated with this condition. 

In fact, the cognitive profile presents significant differences between the two groups, PhD graduate Rachel Natovich found. While the estimated pre-morbid cognitive abilities of the two groups were found to be similar, the current cognitive status of patients with diabetic foot was significantly decreased in all indices of cognitive functioning. Those with diabetic foot remember less, have decreased concentration, difficulty with learning, decreased inhibition, slower cognitive and psycho-motor responses and decreased verbal fluency. This implies that diabetic patients with diabetic foot complication suffer cognitive difficulties above and beyond those known in the general diabetic population.  In terms of wellbeing, patients with diabetic foot complication have a lower perceived quality of life and health; are at higher risk of suffering from major depression; were found to have lower adherence to exercise, and higher adherence to performance of blood tests. Indices regarding efficiency of treatment showed HbA1C levels and BMI to be higher in the diabetic foot group, Natovich found. 

Natovich completed her PhD under Prof. Talma Kushnir of the Department of Public Health, Faculty of Health Sciences and Dr. Ilana Harman-Boehm from Soroka University Medical Center. Dr. Natovich was awarded several prizes for this research including the diabetic foot best presentation award from the American Diabetes Association. 

Diabetic foot is one of the most severe, but paradoxically, also one of the most preventable long-term complications of Diabetes Mellitus. It presents as non-healing foot ulcers and necrosis. Untreated, it could lead to repeated amputations. Treatment of diabetic foot is costly including recurrent hospitalizations for ulcer treatment, amputations and secondary costs due to lost work days and disability compensations. The lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25%. From a worldwide perspective, as increasing incidences of type 1 diabetes and an epidemic of type 2 diabetes emerge, the prevalence of diabetic foot ulcers will only rise. On the other hand this condition is preventable through relatively simple self-applied procedures like daily foot care and screening, appropriate footwear and medical follow up.  

However, successful adherence to medical recommendations requires considerable cognitive abilities like intact concentration, memory and executive functions. Presently, research regarding diabetic foot focuses mainly on epidemiology, prevention and ulcer treatment. There is no research focusing on the cognitive functioning of these patients, despite the fact that the micro and macro vascular changes underlying the diabetic foot are systemic, occurring in many different organs, including the brain.  

A multi-center case control study was begun in 2010 and completed recently. 99 participants with diabetic foot were recruited from the diabetic clinic of Soroka University Medical Center and from the orthopedic rehabilitation department of Sheba – Academic Medical Center Hospital. 95 control participants with diabetes were recruited from community based clinics of the Clalit HMO.  

“This study demonstrates that "diabetic foot" refers not only to a physical condition but rather to a more generalized complex state involving significant cognitive changes as well. This new information is an important contribution to healthcare of these patients due to their increased risk for medical complications and the unique challenge that they present to healthcare providers,” says Natovich. 

She proposes practical changes to the treatment strategy for such patients. 1. Patients with diabetic foot must be routinely monitored for cognitive changes. Early detection of cognitive decline will enable initiating proper intervention. 2. Due to difficulties with memory, attention and executive functions, the family and healthcare provider must take a more active role in patient care. 3. Patients with diabetic foot could benefit from participation in group treatment aimed at improving diabetic control, nutrition and physical activity. 

Additionally, diabetic patients should receive psycho-education regarding possible cognitive complications of the disease and the importance of proper disease control for preservation of cognitive abilities, Natovich recommends.