Skip to main content Accessibility help

Magnitude of Cognitive Dysfunction in Adults with Type 2 Diabetes: A Meta-analysis of Six Cognitive Domains and the Most Frequently Reported Neuropsychological Tests Within Domains

  • Priya Palta (a1) (a2), Andrea L.C. Schneider (a1) (a2), Geert Jan Biessels (a3), Pegah Touradji (a4) and Felicia Hill-Briggs (a2) (a4) (a5)...


The objectives were to conduct a meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards to determine effect sizes (Cohen's d) for cognitive dysfunction in adults with type 2 diabetes, relative to nondiabetic controls, and to obtain effect sizes for the most commonly reported neuropsychological tests within domains. Twenty-four studies, totaling 26,137 patients (n = 3351 with diabetes), met study inclusion criteria. Small to moderate effect sizes were obtained for five of six domains: motor function (3 studies, n = 2374; d = −0.36), executive function (12 studies, n = 1784; d = −0.33), processing speed (16 studies, n = 3076; d = −0.33), verbal memory (15 studies, n = 4,608; d = −0.28), and visual memory (6 studies, n = 1754; d = −0.26). Effect size was smallest for attention/concentration (14 studies, n = 23,143; d = −0.19). The following tests demonstrated the most notable performance decrements in diabetes samples: Grooved Pegboard (dominant hand) (d = −0.60), Rey Auditory Verbal Learning Test (immediate) (d = −0.40), Trails B (d = −0.39), Rey-Osterreith Complex Figure (delayed) (d = −0.38), Trails A (d = −0.34), and Stroop Part I (d = −0.28). This study provides effect sizes to power future epidemiological and clinical diabetes research studies examining cognitive function and to help inform the selection of neuropsychological tests. (JINS, 2014, 20, 1–14)


Corresponding author

Correspondence and reprint requests to: Felicia Hill-Briggs, Welch Center for Prevention, Epidemiology and Clinical Research, 2024 East Monument Street, Suite 2-518, Baltimore, MD 21287. E-mail:


Hide All
Alosco, M.L., Brickman, A.M., Spitznagel, M.B., Griffith, E.Y., Narkhede, A., Raz, N., Gunstad, J. (2013). The adverse impact of type 2 diabetes on brain volume in heart failure. Journal of Clinical and Experimental Neuropsychology, 35(3), 30 9318.
American Diabetes Association (ADA). (2013). Standards of medical care in diabetes-2013. Diabetes Care, 36(Suppl. 1), S11S66.
Atiea, J.A., Moses, J.L., Sinclair, A.J. (1995). Neuropsychological function in older subjects with non-insulin-dependent diabetes mellitus. Diabetic Medicine, 12(8), 679685.
Banks, W.A., Owen, J.B., Erickson, M.A. (2012). Insulin in the brain: There and back again. Pharmacology & Therapeutics, 136(1), 8293.
Biessels, G.J., Staekenborg, S., Brunner, E., Brayne, C., Scheltens, P. (2006). Risk of dementia in diabetes mellitus: A systematic review. Lancet Neurology, 5(1), 6474.
Brands, A.M., Van den Berg, E., Manschot, S.M., Biessels, G.J., Kappelle, L.J., De Haan, E.H., Kessels, R.P. (2007). A detailed profile of cognitive dysfunction and its relation to psychological distress in patients with type 2 diabetes mellitus. Journal of the International Neuropsychological Society, 13(2), 288297.
Christman, A.L., Vannorsdall, T.D., Pearlson, G.D., Hill-Briggs, F., Schretlen, D.J. (2010). Cranial volume, mild cognitive deficits, and functional limitations associated with diabetes in a community sample. Archives of Clinical Neuropsychology, 25(1), 4959.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates, Inc.
Cukierman, T., Gerstein, H.C., Williamson, J.D. (2005). Cognitive decline and dementia in diabetes – systematic overview of prospective observational studies. Diabetologia, 48(12), 24602469.
De Jong, R.N. (1950). The nervous system complications in diabetes mellitus with special reference to cerebrovascular changes. The Journal of Nervous and Mental Disease, 111, 181206.
Espeland, M.A., Miller, M.E., Goveas, J.S., Hogan, P.E., Coker, L.H., Williamson, J., Resnick, S.M. (2011). Cognitive function and fine motor speed in older women with diabetes mellitus: Results from the women's health initiative study of cognitive aging. Journal of Women's Health, 20(10), 14351443.
Gold, S.M., Dziobek, I., Sweat, V., Tirsi, A., Rogers, K., Bruehl, H., Convit, A. (2007). Hippocampal damage and memory impairments as possible early brain complications of type 2 diabetes. Diabetologia, 50(4), 711719.
Golden, S.H., Brown, A., Cauley, J.A., Chin, M.H., Gary-Webb, T.L., Kim, C., Anton, B. (2012). Health disparities in endocrine disorders: Bological, clinical, and nonclinical factors--an Endocrine Society scientific statement. Journal of Clinical Endocrinology and Metabolism, 97(9), E 1579E1639.
Gregg, E.W., Yaffe, K., Cauley, J.A., Rolka, D.B., Blackwell, T.L., Narayan, K.M., Cummings, S.R. (2000). Is diabetes associated with cognitive impairment and cognitive decline among older women? Study of Osteoporotic Fractures Research Group. Archives of Internal Medicine, 160(2), 174180.
Gur, R.C., Turetsky, B.I., Matsui, M., Yan, M., Bilker, W., Hughett, P., Gur, R.E. (1999). Sex differences in brain gray and white matter in healthy young adults: Correlations with cognitive performance. The Journal of Neuroscience, 19(10), 40654072.
Hassing, L.B., Grant, M.D., Hofer, S.M., Pedersen, N.L., Nilsson, S.E., Berg, S., Johansson, B. (2004). Type 2 diabetes mellitus contributes to cognitive decline in old age: A longitudinal population-based study. Journal of the International Neuropsychological Society, 10(4), 59 9607.
Helkala, E.L., Niskanen, L., Viinamaki, H., Partanen, J., Uusitupa, M. (1995). Short-term and long-term memory in elderly patients with NIDDM. Diabetes Care, 18(5), 681685.
Higgins, J.P., Thompson, S.G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine, 21(11), 15391558.
Hugenschmidt, C.E., Hsu, F.C., Hayasaka, S., Carr, J.J., Freedman, B.I., Nyenhuis, D.L., Bowden, D.W. (2013). The influence of subclinical cardiovascular disease and related risk factors on cognition in type 2 diabetes mellitus: The DHS-Mind study. Journal of Diabetes and its Complications. doi:10.1016/j.jdiacomp.2013.04.004
International Diabetes Federation (IDF). (2013). International Diabetes Federation (IDF) Atlas (5th ed). Alexandria, VA: International Diabetes Federation.
Jacobson, A.M. (2011). Diabetes and cognitive performance: A story that is still unfolding. Diabetologia, 54(7), 15931595.
Kanaya, A.M., Barrett-Connor, E., Gildengorin, G., Yaffe, K. (2004). Change in cognitive function by glucose tolerance status in older adults: A 4-year prospective study of the Rancho Bernardo study cohort. Archives of Internal Medicine, 164(12), 13271333.
Kawamura, T., Umemura, T., Hotta, N. (2012). Cognitive impairment in diabetic patients: Can diabetic control prevent cognitive decline? Journal of Diabetes Investigation, 3(5), 413423.
Kodl, C.T., Seaquist, E.R. (2008). Cognitive dysfunction and diabetes mellitus. Endocrine Reviews, 29(4), 494511.
Koekkoek, P.S., Ruis, C., van den Donk, M., Biessels, G.J., Gorter, K.J., Kappelle, L.J., Rutten, G.E. (2012). Intensive multifactorial treatment and cognitive functioning in screen-detected type 2 diabetes – the ADDITION-Netherlands study: A cluster- randomized trial. Journal of the Neurological Sciences, 314(1–2), 7177.
Kumar, R., Anstey, K.J., Cherbuin, N., Wen, W., Sachdev, P.S. (2008). Association of type 2 diabetes with depression, brain atrophy, and reduced fine motor speed in a 60- to 64-year-old community sample. American Journal of Geriatric Psychiatry, 16(12), 989998.
Kumar, R., Looi, J.C.L., Raphael, B. (2009). Type 2 diabetes mellitus, cognition and brain in aging: A brief review. Indian J Psychiatry, 51(Suppl1), S35S38.
Larrabee, G.J., Millis, S.R., Meyers, J.E. (2008). Sensitivity to brain dysfunction of the Halstead-Reitan vs. an ability focused neuropsychological battery. The Clinical Neuropsychologist, 22, 813825.
Lezak, M.D., Howieson, D.B., Loring, D.W. (2004). Neuropsychological assessment (4th ed.). New York, NY: Oxford University Press, Inc.
Lindeman, R.D., Romero, L.J., LaRue, A., Yau, C.L., Schade, D.S., Koehler, K.M., Garry, P.J. (2001). A biethnic community survey of cognition in participants with type 2 diabetes, impaired glucose tolerance, and normal glucose tolerance: The New Mexico Elder Health Survey. Diabetes Care, 24(9), 15671572.
Logroscino, G., Kang, J.H., Grodstein, F. (2004). Prospective study of type 2 diabetes and cognitive decline in women aged 70–81 years. British Medical Journal, 328(7439), 548.
Loring, D.W., Strauss, E., Hermann, B.P., Barr, W.B., Perrine, K., Trenerry, M.R., Bowden, S.C. (2008). Differential neuropsychological test sensitivity to left temporal lobe epilepsy. Journal of the International Neuropsychological Society, 14(3), 394400.
Lozano, R., Naghavi, M., Foreman, K., Lim, S., Shibuya, K., Aboyans, V., Memish, Z.A. (2012). Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380(9859), 20952128.
Lyketsos, C.G., Chen, L.S., Anthony, J.C. (1999). Cognitive decline in adulthood: An 11.5-year follow-up of the Baltimore Epidemiologic Catchment Area study. The American Journal of Psychiatry, 156(1), 5865.
Manly, J.J., Jacobs, D.M., Sano, M., Bell, K., Merchant, C.A., Small, S.A., Stern, Y. (1998). Cognitive test performance among nondemented elderly African Americans and whites. Neurology, 50(5), 12381245.
McCrimmon, R.J., Ryan, C.M., Frier, B.M. (2012). Diabetes and cognitive dysfunction. Lancet, 379(9833), 22912299.
Mogi, N., Umegaki, H., Hattori, A., Maeda, N., Miura, H., Kuzuya, M., Iguchi, A. (2004). Cognitive function in Japanese elderly with type 2 diabetes mellitus. Journal of Diabetes and its Complications, 18(1), 4246.
Murray, C.J., Vos, T., Lozano, R., Naghavi, M., Flaxman, A.D., Michaud, C., Memish, Z. (2012). Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380(9859), 21972223.
Mussell, M., Hewer, W., Kulzer, B., Bergis, K., Rist, F. (2004). Effects of improved glycaemic control maintained for 3 months on cognitive function in patients with Type 2 diabetes. Diabetic Medicine, 21(11), 12531256.
National Institutes of Health (2011). Advances and emerging opportunities in diabetes research: A strategic planning report of the Diabetes Mellitus Interagency Coordinating Committee. Bethesda, MD: National Institutes of Health.
Rabin, L.A., Barr, W.B., Burton, L.A. (2005). Assessment practices of clinical neuropsychologists in the United States and Canada: A survey of INS, NAN, and APA Division 40 members. Archives of Clinical Neuropsychology, 20(1), 3365.
Reijmer, Y.D., Brundel, M., de Bresser, J., Kappelle, L.J., Leemans, A., Biessels, G.J. (2013). Microstructural white matter abnormalities and cognitive functioning in type 2 diabetes. Diabetes Care, 36, 137144.
Reijmer, Y.D., van den Berg, E., Ruis, C., Kappelle, L.J., Biessels, G.J. (2010). Cognitive dysfunction in patients with type 2 diabetes. Diabetes/Metabolism Research and Reviews, 26(7), 507519.
Ryan, C.M. (2006). Diabetes and brain damage: more (or less) than meets the eye? Diabetologia, 49(10), 22292233.
Ryan, C.M., Geckle, M.O. (2000). Circumscribed cognitive dysfunction in middle-aged adults with type 2 diabetes. Diabetes Care, 23(10), 14861493.
Ryan, C.M., Williams, T.M., Orchard, T.J., Finegold, D.N. (1992). Psychomotor slowing is associated with distal symmetrical polyneuropathy in adults with diabetes mellitus. Diabetes, 41(1), 107113.
Spreen, O., Strauss, E. (1998). A compendium of neuropsychological tests: Administration, norms and commentary (2nd ed.). New York, New York: Oxford University Press.
Strachan, M.W., Deary, I.J., Ewing, F.M., Frier, B.M. (1997). Is type II diabetes associated with an increased risk of cognitive dysfunction? A critical review of published studies. Diabetes Care, 20(3), 438445.
Strachan, M.W., Frier, B.M., Deary, I.J. (1997). Cognitive assessment in diabetes: The need for consensus. Diabetic Medicine, 14(6), 421422.
Takeuchi, A., Matsushima, E., Kato, M., Konishi, M., Izumiyama, H., Murata, Y., Hirata, Y. (2012). Characteristics of neuropsychological functions in inpatients with poorly-controlled type 2 diabetes mellitus. Journal of Diabetes Investigation, 3(3), 325330.
Toro, P., Schonknecht, P., Schroder, J. (2009). Type II diabetes in mild cognitive impairment and Alzheimer's disease: Results from a prospective population-based study in Germany. Journal of Alzheimers Disease, 16(4), 687691.
van den Berg, E., de Craen, A.J., Biessels, G.J., Gussekloo, J., Westendorp, R.G. (2006). The impact of diabetes mellitus on cognitive decline in the oldest of the old: A prospective population-based study. Diabetologia, 49(9), 20152023.
van den Berg, E., Dekker, J.M., Nijpels, G., Kessels, R.P., Kappelle, L.J., de Haan, E.H., Biessels, G.J. (2008). Cognitive functioning in elderly persons with type 2 diabetes and metabolic syndrome: The Hoorn study. Dementia Geriatric Cognitive Disorders, 26(3), 261269.
van den Berg, E., Kessels, R.P., Kappelle, L.J., de Haan, E.H., Biessels, G.J. (2006). Type 2 diabetes, cognitive function and dementia: vascular and metabolic determinants. Drugs of Today, 42(11), 741754.
van Harten, B., Oosterman, J., Muslimovic, D., van Loon, B.J., Scheltens, P., Weinstein, H.C. (2007). Cognitive impairment and MRI correlates in the elderly patients with type 2 diabetes mellitus. Age Ageing, 36(2), 164170.
Vanhanen, M., Karhu, J., Koivisto, K., Paakkonen, A., Partanen, J., Laakso, M., Riekkinen, P. Sr. (1996). ERPs reveal deficits in automatic cerebral stimulus processing in patients with NIDDM. Neuroreport, 7(15–17), 27672771.
Vanhanen, M., Kuusisto, J., Koivisto, K., Mykkanen, L., Helkala, E.L., Hanninen, T., Laakso, M. (1999). Type-2 diabetes and cognitive function in a non-demented population. Acta Neurologica Scandinavica, 100(2), 97101.
von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P. (2007). The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Annals of Internal Medicine, 147(8), 573577.
Watari, K., Letamendi, A., Elderkin-Thompson, V., Haroon, E., Miller, J., Darwin, C., Kumar, A. (2006). Cognitive function in adults with type 2 diabetes and major depression. Archives of Clinical Neuropsychology, 21(8), 787796.
Whitmer, R.A. (2007). Type 2 diabetes and risk of cognitive impairment and dementia. Current Neurology and Neuroscience Reports, 7(5), 373380.
Williamson, J.D., Miller, M.E., Bryan, R.N., Lazar, R.M., Coker, L.H., Johnson, J., Launer, L.J. (2007). The action to control cardiovascular risk in diabetes memory in diabetes study (ACCORD-MIND): rationale, design, and methods. Am J Cardiol, 99(12A), 112i122i.
Zakzanis, K.K. (2001). Statistics to tell the truth, the whole truth, and nothing but the truth: Formulae, illustrative numerical examples, and heuristic interpretation of effect size analyses for neuropsychological researchers. Archives of Clinical Neuropsychology, 16(7), 653667.


Type Description Title
Supplementary materials

Palta Supplementary Material
Supplementary Material

 PDF (700 KB)
700 KB


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed