What is the ideal care plan for a 75-year-old female with type 2 diabetes, hypertension, dyslipidemia, vitamin B12 deficiency, coronary artery disease, atrial fibrillation, prior myocardial infarction (MI) and stent placement, pacemaker implantation, and valve replacement, experiencing lightheadedness, blurred vision, forearm aches and numbness, minor bruising, daytime hyperglycemia, and nocturnal hypoglycemia, while taking Basaglar (insulin glargine) twice daily, Ramipril 2.5mg, rosuvastatin 40mg, nifedipine XL (nifedipine) 30mg, metformin 1000mg twice daily, gliclazide 30mg, apixaban 5mg twice daily, amiodarone 200mg, aspirin 81mg, and iron, with an A1C of 6.5, random glucose of 12.9, and vitamin B12 level less than 74?

Care Plan for 75-Year-Old Female with Multiple Comorbidities

The ideal care plan for this patient requires immediate vitamin B12 supplementation, adjustment of her diabetes medications to prevent nocturnal hypoglycemia, and evaluation of potential medication interactions causing her symptoms.

Priority Interventions

1. Address Severe Vitamin B12 Deficiency

• Immediate action: Start vitamin B12 supplementation for severe deficiency (level <74)
• Recommended approach: Begin with intramuscular B12 injections rather than oral supplementation due to severity 1
• Initial dosing: 1000 mcg IM daily for 1 week, then weekly for 4 weeks, then monthly maintenance
• Monitor response with repeat B12 levels after 3 months
• This deficiency likely contributes to her neurological symptoms (forearm numbness, aches) 2

2. Adjust Diabetes Management

• Current issues: Daytime hyperglycemia (random glucose 12.9 mmol/L) with nocturnal hypoglycemia despite A1C of 6.5%
• Recommended changes:
  • Reduce or discontinue gliclazide (sulfonylurea) which increases hypoglycemia risk in older adults 3
  • Consider reducing Basaglar (insulin glargine) evening dose by 10-15% to prevent nocturnal hypoglycemia 4
  • Consider switching to once-daily basal insulin administration instead of twice daily 3
  • Target higher glucose goals (fasting 7.2-10.0 mmol/L) appropriate for her age and comorbidities 3
  • Increase blood glucose monitoring frequency, especially before bedtime 4

3. Evaluate Medication Interactions and Side Effects

• Potential issues:
  • Amiodarone + apixaban interaction may contribute to bruising
  • Metformin contributing to vitamin B12 deficiency 3, 2
  • Multiple antihypertensives may cause lightheadedness/orthostatic hypotension

Comprehensive Care Plan by System

Endocrine Management

• Target A1C: 7.0-8.0% (less stringent goal appropriate for elderly patient with multiple comorbidities) 3
• Medication adjustments:
  • Continue metformin but add B12 supplementation
  • Simplify insulin regimen to once-daily basal insulin 3
  • Consider discontinuing gliclazide to reduce hypoglycemia risk 3
  • Implement structured glucose monitoring before meals and bedtime

Cardiovascular Management

• Anticoagulation: Continue apixaban 5mg twice daily for atrial fibrillation
• Antiplatelet therapy: Consider discontinuing aspirin 81mg as she's already on apixaban (increased bleeding risk) 3
• Antiarrhythmic: Continue amiodarone but monitor for side effects
• Antihypertensives: Consider reducing dose of nifedipine if orthostatic hypotension is present
• Lipid management: Continue rosuvastatin 40mg as appropriate for secondary prevention 3

Neurological Symptoms

• For numbness/aches:
  • Vitamin B12 replacement as outlined above
  • Evaluate for diabetic peripheral neuropathy
  • Consider gabapentin if neuropathic pain persists after B12 correction

Hematologic Management

• For bruising:
  • Monitor INR/coagulation studies
  • Consider reducing apixaban dose if renal function is impaired
  • Continue iron supplementation for potential anemia

Monitoring Plan

1. Blood glucose: Daily monitoring with focus on bedtime and overnight readings
2. Vitamin B12 levels: Recheck after 3 months of supplementation
3. Complete blood count: Monthly during initial B12 replacement
4. Renal function: Every 3 months (important for metformin and apixaban dosing)
5. Orthostatic vital signs: At each visit to assess for postural hypotension

Follow-up Plan

• Schedule follow-up within 2 weeks to assess response to medication adjustments
• Arrange for comprehensive laboratory testing including HbA1c, lipid panel, kidney function, and liver function tests 4
• Consider cardiology consultation to review medications and potential interactions

Patient Education

• Instruct on hypoglycemia recognition and management
• Educate about signs of bleeding that require medical attention
• Provide dietary guidance appropriate for diabetes that maintains adequate caloric intake 3
• Emphasize importance of medication adherence while explaining changes to regimen

Common Pitfalls to Avoid

1. Overtreating diabetes in elderly patients (aiming for A1C <7% increases hypoglycemia risk) 3
2. Ignoring vitamin B12 deficiency in patients on long-term metformin 3, 2
3. Polypharmacy without regular medication reconciliation
4. Failing to adjust anticoagulation based on bleeding risk and renal function
5. Not considering orthostatic hypotension as a cause of lightheadedness in elderly patients on multiple antihypertensives

This care plan addresses the patient's immediate concerns while balancing the management of her multiple comorbidities with appropriate consideration for her age and quality of life.