Dementia in type 2 diabetes: risk factors, disease processes and opportunities for prevention across the lifespan

People with type 2 diabetes have a 60-70% higher risk of developing dementia than those without diabetes. Given the increasing number of older people living with diabetes, preventing dementia in this population is becoming increasingly important. However, dementia in individuals with type 2 diabetes is not a single entity and no diabetes-specific pathologies contributing to dementia have been identified yet. Here, we suggest that the relation between type 2 diabetes and dementia may be best understood through a probabilistic model that considers the context in which type 2 diabetes develops and the involvement of multiple dementia-related pathologies. Within this model, type 2 diabetes alters both the probability of dementia-related pathologies occurring and their downstream consequences. Opportunities for prevention of dementia evolve across the lifespan and comprise reducing cumulative exposures to dementia risk factors through a holistic approach rather than through targeting a single factor. Accordingly, beyond preventing type 2 diabetes itself, glucose-lowering medications with effects beyond glycaemic management (e.g. multihormone receptor modulators, such as glucagon-like peptide-1 receptor agonists, and sodium-glucose cotransporter 2 inhibitors), alongside traditional multi-domain cardiovascular risk management, may be most effective at lowering excess dementia risk in individuals with type 2 diabetes.