How to manage an 88-year-old female with type 2 diabetes mellitus (E11.9) who requests to discontinue finger pricking for blood sugars and switch to oral diabetes medications instead?

Management of Diabetes in an 88-Year-Old Refusing Finger Sticks and Requesting Oral Medications

In this 88-year-old long-term care resident with type 2 diabetes, multiple comorbidities, and recent CVA, you should honor her request to discontinue finger-stick monitoring and transition from insulin to oral diabetes medications, as she falls into the "very complex/poor health" category where avoiding hypoglycemia and reducing treatment burden takes priority over tight glycemic control. 1

Patient Classification and Appropriate Goals

This patient clearly meets criteria for the "very complex/poor health" category based on:

• Advanced age (88 years)
• Long-term care residence
• Multiple chronic conditions (atrial fibrillation, CKD stage 2, history of CVA, depression)
• Multiple ADL dependencies (implied by LTC residence)

For patients in this category, the American Diabetes Association explicitly states that providers should consider deintensification when "the individual would like to decrease the number of injections and finger-stick blood glucose monitoring." 1 This is listed as a specific indication for treatment simplification in very complex/poor health patients.

Recommended Glycemic Targets

• Avoid reliance on A1C as a target 1
• Primary goal: Avoid hypoglycemia and symptomatic hyperglycemia 1
• Acceptable glucose range: 100-200 mg/dL when monitoring is performed 1
• Her current A1C of 6.9% is actually too low for her risk category and increases hypoglycemia risk 1

Specific Treatment Plan

Discontinue Current Insulin Regimen

• Stop the insulin aspart sliding scale immediately 1
• The sliding scale approach has no proven benefit and increases hypoglycemia risk in this population 2

Transition to Oral Medications

Continue metformin as the cornerstone agent (if not already on it—not listed in current medications):

• Metformin is the optimal first-line agent for type 2 diabetes 1, 3
• Does not cause hypoglycemia 1
• Can be used safely in CKD stage 2 with appropriate dose adjustment 2
• Well-tolerated and low cost 1

Consider adding a DPP-4 inhibitor (e.g., sitagliptin, linagliptin):

• Low hypoglycemia risk 4
• Well-tolerated in elderly patients
• Linagliptin requires no dose adjustment in CKD 4
• Once-daily dosing improves adherence

Avoid or discontinue medications with high hypoglycemia risk:

• Do not use sulfonylureas or meglitinides in this patient 1
• These agents pose excessive hypoglycemia risk in patients with cognitive dysfunction or inconsistent eating patterns 1

Monitoring Strategy

Dramatically reduce finger-stick frequency 1:

• Guidelines explicitly support reducing finger-stick testing frequency in very complex/poor health patients 1
• Consider checking only when symptomatic (feeling unwell, dizzy, confused) 1
• Staff should monitor for symptoms of hyper/hypoglycemia rather than routine glucose checks 1

Alert thresholds if occasional monitoring occurs 1:

• Call immediately if glucose <70 mg/dL 1
• Call for glucose 70-100 mg/dL (may need adjustment) 1
• Call for glucose >250 mg/dL in 24 hours 1

Rely on A1C every 6 months rather than frequent glucose monitoring:

• Target A1C of 7.5-8.5% is appropriate for this patient 1
• Current A1C of 6.9% suggests room to liberalize control 1

Critical Considerations

Deintensification is specifically indicated when A1C is below 6.5% in patients with limited life expectancy 1. This patient's A1C of 6.9% combined with her age >80 years and nursing home residence means the harms of intensive treatment outweigh benefits 1.

Quality of life and patient preferences are paramount 1:

• Patient autonomy includes the right to refuse testing and treatment 1
• Treatment burden reduction is an appropriate goal in this population 1
• Pain and discomfort from injections and finger sticks should be minimized 1

Hypoglycemia prevention is the priority 1:

• Severe hypoglycemia has immediate mortality risk in elderly patients 1
• Benefits of tight control require >10 years to manifest—not applicable here 1
• Her current regimen with insulin sliding scale poses unnecessary hypoglycemia risk 2

Practical Implementation

1. Discontinue insulin aspart sliding scale today 1
2. Initiate or optimize metformin (start 500mg daily, titrate to 1000mg twice daily as tolerated) 1
3. Add DPP-4 inhibitor (e.g., linagliptin 5mg daily) for additional glucose control without hypoglycemia risk 4
4. Reduce finger sticks to "as needed" for symptoms only 1
5. Check A1C in 3 months, targeting 7.5-8.0% 1
6. Educate staff to monitor for symptoms rather than numbers 1

This approach respects patient autonomy, reduces treatment burden, minimizes hypoglycemia risk, and aligns with evidence-based guidelines for very complex elderly patients in long-term care. 1