Associate Professor Medha Munshi 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 - Metoprolol - Hydrochlorthiazide - Simvastatin - Acetaminophen - Aspirin - Multivitamin - 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 2.7-16.6 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 self-care 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