What adjustments should be made to the insulin regimen for an 86-year-old female patient with hyperglycemia, currently taking Solostar (insulin glargine) 20 units QHS and short-acting insulin (SSI) TID?

Insulin Regimen Adjustment for Elderly Diabetic Patient with Hyperglycemia

The insulin regimen for this 86-year-old female with blood sugar of 9.3 mmol/L (167 mg/dL) should be simplified to basal insulin only, with insulin glargine (Solostar) 20 units in the morning rather than at bedtime, and the sliding scale insulin (SSI) should be discontinued to reduce hypoglycemia risk.

Assessment of Current Regimen

The patient is currently on:

• Insulin glargine (Solostar) 20 units at bedtime
• Sliding scale insulin (SSI) three times daily

This regimen has several issues for an elderly patient:

• Bedtime basal insulin increases risk of nocturnal hypoglycemia
• Multiple daily SSI injections increase complexity and hypoglycemia risk
• The current blood sugar of 9.3 mmol/L (167 mg/dL) indicates suboptimal control

Recommended Regimen Modifications

1. Basal Insulin Adjustment

• Change timing: Move insulin glargine from bedtime to morning administration 1
• Maintain dose: Keep at 20 units initially (within appropriate range for elderly)
• Monitoring: Check fasting glucose levels with target range 90-150 mg/dL (5.0-8.3 mmol/L) 1

2. Discontinue Sliding Scale Insulin

• SSI should be discontinued as it increases hypoglycemia risk in elderly patients
• The American Diabetes Association recommends simplification of insulin regimens in older adults 1

3. Dose Titration Protocol

• If 50% of fasting glucose values are above target: Increase dose by 2 units
• If >2 fasting glucose values/week are <80 mg/dL (<4.4 mmol/L): Decrease dose by 2 units 1
• Adjust every 1-2 weeks based on glucose patterns

Rationale for Recommendations

1. Age-appropriate targets: For elderly patients (>80 years), less stringent glycemic targets are appropriate to reduce hypoglycemia risk 1

2. Simplification benefits:

   • Reduced hypoglycemia risk
   • Improved adherence
   • Decreased medication burden
   • Better quality of life

3. Morning vs. bedtime dosing: Morning dosing of basal insulin reduces nocturnal hypoglycemia risk while maintaining efficacy 1, 2

4. Avoiding overbasalization: Current dose (20 units) appears appropriate as guidelines caution against basal doses >0.5 units/kg/day 1

Monitoring Recommendations

• Check fasting blood glucose daily initially, then 2-3 times weekly once stable
• Target range: 90-150 mg/dL (5.0-8.3 mmol/L) 1
• Monitor for symptoms of hypoglycemia, especially at night
• Consider HbA1c testing in 3 months to assess overall control

Common Pitfalls to Avoid

1. Overtreatment: Aggressive glucose targets in elderly patients increase hypoglycemia risk, which is associated with falls, cognitive decline, and increased mortality

2. Complex regimens: Multiple daily injections increase burden and error risk in elderly patients

3. Nocturnal hypoglycemia: Bedtime basal insulin increases risk of undetected overnight hypoglycemia

4. Insufficient monitoring: Elderly patients need regular follow-up to ensure the simplified regimen is effective and safe

By implementing these changes, we can optimize this patient's diabetes management with a focus on safety, simplicity, and quality of life while maintaining reasonable glycemic control.