Download managing clinical and social circumstances

An older patient with diabetes:
managing clinical and social circumstances
Associate Professor Medha Munshi
Case History Information
81 year old man with type 2 diabetes for 20
years. He was on glipizide, metformin, and
pioglitazone for 15 years. His oral medications
were stopped and insulin was started due to
inadequate glycaemic control. He is now on
insulin 70/30 twice a day.
HbA1c at his last visit 6 months ago was
60mmol/mol(7.6%),
today it is 68mmol/mol(8.4%)
Other medical conditions
– Coronary artery disease, myocardial infarct 5
years ago
– Hypertension
– Hypercholesterolaemia
– Osteoarthritis
– Situational depression due to death of spouse 6
months ago
– Recent weight loss of 15 lbs over 1 year.
– Hearing loss
Case History Information
Medications
- Lisinopril
- Hydrochlorthiazide
- Acetaminophen
- Multivitamin
- Metoprolol
- Simvastatin
- Aspirin
- Vitamin D
Finger-stick readings are performed periodically.
When performed, they show wide glucose fluctuations with
fasting glucose 4.4-11.1 mmol/l, and premeal glucose 2.716.6 mmol/l
The patient now lives alone.
Two children live out of town with no other close friends or
family nearby.
Main issues raised
Mixed insulin is a good choice for older adults for the
ease of use
When frail patients are unable to manage consistent
eating patterns to match their insulin doses, glucose
levels show wide excursions
The diabetes regimen in older adults may need to be
changed if clinical or social circumstances change.
Screening for geriatric syndrome such as cognitive
dysfunction, depression and physical disability should be
performed when an older adult starts to fail to self-care
Management plan to address key issues
The patient is probably not eating consistently, as there is a
recent change in social circumstances (spouse passed away)
and weight loss, it is important to assess the patient’s ability
to buy, cook and/or eat regular meals on time
The patient might be skipping insulin doses: reassess selfcare and medication adherence in the context of cognitive
function. Assess need for caregiver support
Depression: schedule diagnostic tests to see if
pharmacological interventions are needed
As far as balancing insulin and carbohydrate levels is
concerned: consider less complex therapy that can lower the
risk of hypoglycaemia and lower the self-care burden
Result of management decision
Community resources were engaged and the patient now has
assistance with shopping and is receiving one prepared hot meal a
day
It was found that the patient was able to take oral medications
consistently by using a pill-box (dosette), but missed insulin doses
a few times a week
The patient was found to have difficulty coping after the death of
his spouse and anti-depressant medication was started
With GFR>60 ml/mg, a trial of metformin twice a day combined
with long acting insulin once a day was started.
To avoid an excessive self care burden, the patient was asked to do
block testing with once or twice a day finger prick readings at
different times of the day, before meals or at bedtime.
Implication for clinical practice
A diabetes management plans need
to be adjusted to the older patient’s
changing circumstances.
Clinical, functional and psychosocial
barriers to self-care should be
evaluated when glycaemic control
deteriorates in older adults.
Treatment complexity in older
adults should match their coping
ability
Key learning points
When frail patients are unable to manage a consistent eating
pattern to match their insulin doses, glucose levels show
wide excursions
Screening for geriatric syndrome such as cognitive
dysfunction, depression and physical disability should be
performed when an older adult starts to fail to self-care
Clinical, functional and psychosocial barriers to self-care
should be evaluated when glycaemic control deteriorates in
older adults
The diabetes regimen in older adults may need to be
changed if clinical or social circumstances change