What's the next course of treatment for a 90-year-old female patient with diabetes (diabetes mellitus) and dementia, experiencing hyperglycemia and intermittent hypoglycemia, currently taking Treva (NPH insulin) 28 units in the afternoon, Humalog (insulin lispro) 2 units preprandially, and a sliding scale?

From the Guidelines

For this 90-year-old female patient with diabetes and dementia experiencing both hyperglycemia and intermittent hypoglycemia, I recommend adjusting her insulin regimen to reduce hypoglycemic episodes while maintaining reasonable glycemic control, as suggested by the most recent guidelines 1. The current regimen should be modified by reducing her NPH insulin (Treva) from 28 units to 22-24 units in the afternoon and maintaining the Humalog (insulin lispro) at 2 units preprandially. The sliding scale should be adjusted to start supplemental insulin at higher blood glucose thresholds, perhaps beginning at 250 mg/dL, giving 2 units of short- or rapid-acting insulin, and for premeal glucose >350 mg/dL, giving 4 units of short- or rapid-acting insulin, as recommended in the latest standards of care 1. Additionally, implementing a less stringent HbA1c target of 7.5-8.5% would be appropriate given her age and comorbidities. Regular blood glucose monitoring should continue, with at least 3-4 checks daily, particularly before meals and at bedtime. Caregivers should be educated about hypoglycemia symptoms and management, including keeping glucose tablets or juice readily available. This modified approach balances the risks of hypoglycemia, which can worsen cognitive function and increase fall risk, against the need to prevent symptomatic hyperglycemia. In elderly patients with dementia, avoiding hypoglycemia takes precedence over tight glycemic control, as the cognitive consequences of low blood sugar can be particularly detrimental in this vulnerable population, as highlighted in previous studies 1. Key considerations in managing her diabetes include:

• Avoiding rapid- and short-acting insulin at bedtime
• Using individual and drug characteristics to guide decision-making
• Selecting additional agents as needed, based on finger-stick glucose testing performed before lunch and before dinner
• Adjusting insulin dose and/or adding glucose-lowering medications every 2 weeks, with a goal of 90–150 mg/dL before meals.

From the FDA Drug Label

Dosage modifications may be needed with changes in physical activity, changes in meal patterns (i.e., macronutrient content or timing of food intake), changes in renal or hepatic function or during acute illness [see Warnings and Precautions (5.2,5.3) and Use in Specific Populations (8.6,8. 7)]. Make any changes to a patient's insulin regimen under close medical supervision with increased frequency of blood glucose monitoring. Patients with renal or hepatic impairment may be at higher risk of hypoglycemia [see Use in Specific Populations (8.6,8. 7)].

The next course of treatment for the 90-year-old female patient with diabetes and dementia, experiencing hyperglycemia and intermittent hypoglycemia, should be made under close medical supervision.

• Monitor blood glucose levels frequently to adjust the insulin regimen as needed.
• Assess the patient's physical activity, meal patterns, and renal or hepatic function to determine if any changes are needed to the current insulin regimen.
• Consider the risk of hypoglycemia due to the patient's age, dementia, and intermittent hypoglycemia, and take steps to mitigate this risk, such as increasing the frequency of blood glucose monitoring.
• Adjust the dosage of Humalog and Treva as needed based on the patient's individual metabolic needs and glycemic control goals 2.

From the Research

Patient Profile

• 90-year-old female patient with diabetes and dementia
• Experiencing hyperglycemia and intermittent hypoglycemia
• Currently taking Treva (NPH insulin) 28 units in the afternoon, Humalog (insulin lispro) 2 units preprandially, and a sliding scale

Current Treatment Challenges

• Patient cannot use an insulin pump due to dementia
• Patient cannot carb count currently
• High risk of hypoglycemia with current insulin regimen

Potential Treatment Options

• Consider adding a glucagon-like peptide-1 (GLP-1) receptor agonist to the patient's treatment regimen, as it may help reduce the incidence of dementia 3
• GLP-1 receptor agonists have been shown to be effective in lowering blood glucose levels, promoting weight loss, and reducing the risk of hypoglycemia 4, 5
• However, GLP-1 receptor agonists may require dose reductions or discontinuation of insulin or sulfonylureas to minimize the risk of hypoglycemia 6

Considerations for Dementia

• Diabetes mellitus itself can cause an impairment of cognitive functions, regardless of patient's age or type of diabetes 7
• Prevention, timely diagnosis, and optimum treatment of diabetes may help reduce the incidence of dementia or cognitive functions' impairment 7

Next Course of Treatment

• Consult with a healthcare professional to determine the best course of treatment for the patient, taking into account her dementia, diabetes, and current medication regimen
• Consider adjusting the patient's insulin regimen to minimize the risk of hypoglycemia and optimize blood glucose control
• Discuss the potential benefits and risks of adding a GLP-1 receptor agonist to the patient's treatment regimen 4, 5, 3, 6