A neurologist’s perspective

Abstract

Type 2 diabetes mellitus is one of the leading modifiable risk factors for cognitive impairment and dementia, approximately doubling the risk of cerebrovascular disease while significantly increasing the likelihood of developing Alzheimer’s disease and vascular dementia. From a neurologist’s perspective, diabetes-related cognitive impairment is not driven by a single mechanism but rather by the complex interaction of microvascular and macrovascular injury, central insulin resistance, neuroinflammatory pathways, oxidative stress, mitochondrial dysfunction, and abnormalities in the metabolism of proteins such as β-amyloid and tau.

Cognitive impairment associated with diabetes should be viewed as a biological continuum in which vascular and neurodegenerative mechanisms converge. Clinically, it often presents with early executive dysfunction, slowed information processing, and attentional deficits. However, many patients exhibit mixed cognitive profiles due to the frequent coexistence of neurodegenerative pathology and cerebrovascular disease.

It is also important to emphasize that neurodegenerative disorders are currently regarded as mixed pathological entities with multiple underlying etiologies, in which vascular and metabolic factors are present in the vast majority of cases. Unlike many other pathogenic mechanisms, these factors are potentially modifiable and therefore represent important therapeutic targets.

This presentation will review the pathophysiological mechanisms linking diabetes and cognition, the latest epidemiological evidence, emerging biomarkers, neuroimaging findings, and the cognitive assessment strategies currently recommended in clinical practice. Particular attention will be given to identifying when neurologists should suspect a neurocognitive disorder in patients with diabetes and when diabetologists should refer patients for specialized neurological evaluation.

The therapeutic implications of this interaction will also be discussed, including the impact of optimal cardiovascular risk factor management, physical exercise, cognitive stimulation, and the potential effects of novel antidiabetic therapies on brain health. Special emphasis will be placed on ongoing clinical trials evaluating antidiabetic agents—particularly GLP-1 receptor agonists—as potential disease-modifying therapies for neurodegenerative disorders.

The aim of this presentation is to provide an integrated, multidisciplinary neurological perspective that facilitates the early recognition of cognitive impairment, contributes to optimizing diabetes management, and ultimately helps preserve patients’ autonomy and quality of life, highlighting the neurologist’s role as an essential member of the multidisciplinary team addressing one of the greatest challenges of population aging.