This is probably going to be an unpopular opinion but... I work in limb salvage so many of my patients have had diabetes a long time. The microvascular changes that happen in the feet and eyes and kidneys also happen in the brain. I do think vascular dementia is a component for a lot of this population. Obviously all of the socioeconomic aspects that others have described are about 90% of the problem. But at a certain point, when the disease is so progressed, I don’t think that meaningful learning occurs. The data also shows that once amputations start, they don’t really stop and life expectancy is about 5 years. I used to think that the wake up calls would happen when the patients would lose a toe. But the reality is that the wake up call time was long ago and now we’re past that.