How should I manage a 68-year-old woman with early-onset Alzheimer’s dementia, coronary artery disease, hypertension, hyperlipidemia, and type 2 diabetes (hemoglobin A1c 7.8%), who presents for routine follow-up, has normal blood pressure and heart rate, hyperglycemia (blood glucose 178 mg/dL), cannot recall her insulin glargine (Lantus) dose or recent meals, and is taking amlodipine, enalapril, metoprolol, metformin, pioglitazone (Actos), glipizide, insulin glargine (Lantus), aspirin, rosuvastatin, nitroglycerin PRN, donepezil (Aricept) 10 mg twice daily (should be once daily), and memantine (Namenda) 10 mg daily (target 20 mg)?

Management of a 68-Year-Old Woman with Early-Onset Dementia and Multiple Comorbidities

Immediate Medication Safety Concerns

The most critical issue is medication overtreatment and polypharmacy creating substantial hypoglycemia risk, compounded by cognitive impairment preventing recognition of symptoms and appropriate self-management. 1, 2

Discontinue Glipizide Immediately

• Glipizide must be stopped today due to unacceptable hypoglycemia risk in an elderly patient with dementia who is already on basal insulin. 2, 3
• Sulfonylureas are the first agents to eliminate in elderly patients with diabetes, particularly when combined with insulin, as they dramatically increase hypoglycemia risk without providing meaningful benefit at her current A1C. 2, 3
• The patient's inability to recall her insulin dose or recent meals makes hypoglycemia detection and prevention nearly impossible with a sulfonylurea on board. 1

Simplify and Reduce Diabetes Regimen

• Discontinue pioglitazone (Actos) to reduce pill burden, cost, and side effects (fluid retention, fracture risk) without compromising glycemic control at her current A1C of 7.8%. 1, 2
• Continue metformin 1000 mg twice daily as first-line therapy with low hypoglycemia risk, provided renal function is adequate (eGFR ≥30 mL/min/1.73 m²). 2, 3, 4
• Metformin is associated with lower dementia risk in patients with diabetes and should be maintained. 4

Adjust Insulin Dosing

• Reduce Lantus to 8-10 units daily (approximately 70% of current dose) given discontinuation of glipizide and pioglitazone, to prevent hypoglycemia. 2, 5
• Administer insulin in the morning at the same time daily to improve adherence and allow family monitoring. 1, 5
• Target fasting glucose of 90-150 mg/dL, adjusting insulin by 2 units if >50% of readings exceed goal or if any reading is <80 mg/dL. 2

Establish Appropriate Glycemic Targets

For this 68-year-old woman with early-onset dementia and multiple comorbidities (CAD, hypertension, hyperlipidemia), the target A1C should be 8.0%, not <7%. 1, 3

• Her current A1C of 7.8% is already at goal and requires deintensification, not intensification. 1, 2, 3
• Patients with dementia and multiple chronic conditions fall into the "complex/intermediate" health status category, warranting an A1C target of <8.0%. 1, 3
• Tighter glycemic control (A1C <7%) in elderly patients with dementia increases hypoglycemia risk and mortality without providing cardiovascular or microvascular benefit. 1, 3
• The patient's cognitive impairment prevents recognition of hypoglycemia symptoms, which may present atypically as confusion or dizziness rather than classic adrenergic symptoms. 1, 3

Correct Dementia Medication Dosing Errors

Donepezil (Aricept) Dosing Error

• Reduce donepezil from 10 mg twice daily to 10 mg once daily in the morning. 1
• The current twice-daily dosing is incorrect; donepezil is dosed once daily. 1
• Morning administration may reduce insomnia, a common side effect when taken at bedtime. 1
• Donepezil may cause bradycardia and syncope, though these effects are uncommon; monitor for these given her cardiac history. 6

Memantine (Namenda) Dosing

• Increase memantine from 10 mg daily to 10 mg twice daily (20 mg total daily dose) as the target therapeutic dose. 1
• The current 10 mg daily dose is subtherapeutic for moderate dementia. 1
• Memantine provides modest cognitive benefit in vascular cognitive impairment and Alzheimer's disease. 1

Cardiovascular Risk Management

Blood Pressure Control

• Continue current antihypertensive regimen (amlodipine 5 mg, enalapril 10 mg, metoprolol 100 mg daily) as blood pressure is well-controlled at 116/72 mmHg. 1
• For patients with cognitive impairment and vascular risk factors, blood pressure should be maintained <140/90 mmHg, which is currently achieved. 1
• Intensive blood pressure control (<120 mmHg systolic) reduces risk of mild cognitive impairment but has not been studied specifically in patients with established dementia and CAD. 1
• All antihypertensive medications should be taken in the morning to improve adherence and allow family monitoring. 1

Lipid Management

• Continue rosuvastatin (Crestor) 20 mg daily for secondary prevention given her coronary artery disease. 7
• Statin therapy should be continued in patients with dementia and established cardiovascular disease unless life expectancy is very limited or side effects occur. 7

Antiplatelet Therapy

• Continue aspirin 81 mg daily for secondary prevention of cardiovascular events given her CAD. 1, 8
• Aspirin does not improve cognitive outcomes in dementia but is indicated for cardiovascular risk reduction. 8

Medication Management and Safety Systems

The family's concern about medication adherence requires immediate implementation of supervised medication administration. 1

• Designate a family member to fill weekly pillboxes and supervise medication administration, particularly for insulin and morning medications. 1
• Provide the family with a simplified medication list showing drug names, doses, timing, and purpose. 1
• Consider morning-only dosing for all medications to improve adherence and allow family supervision. 1
• The patient's inability to recall her insulin dose indicates she should not be self-administering insulin without supervision. 1

Monitoring Plan

• Recheck A1C in 3 months to confirm glycemic control remains adequate (target 7.5-8.5%) after medication simplification. 2, 3
• Monitor fasting glucose 3-4 times weekly during the first month after medication changes to guide insulin titration and detect hypoglycemia. 2
• Check renal function (eGFR, creatinine) within 2-4 weeks and then every 3-6 months given age and metformin use. 2
• Assess for hypoglycemia symptoms at each visit, recognizing atypical presentations (confusion, falls, dizziness) in elderly patients with dementia. 1, 3
• Monitor cognitive and functional status every 6 months to reassess glycemic targets and medication appropriateness. 1, 3

Common Pitfalls to Avoid

• Do not pursue tighter glycemic control (A1C <7%) in this patient, as this increases hypoglycemia risk and mortality without improving outcomes. 1, 3
• Do not continue glipizide "at a lower dose"—the medication should be discontinued entirely given the patient's age, dementia, insulin use, and hypoglycemia risk. 2, 3
• Do not add additional diabetes medications when A1C is already at goal; this represents overtreatment. 1, 2
• Do not assume the patient can reliably self-administer medications given her inability to recall basic information about her regimen. 1
• Do not apply standard adult diabetes targets to elderly patients with dementia and multiple comorbidities. 1, 3

Simplified Final Medication Regimen

Morning medications (all taken together with family supervision):

• Amlodipine 5 mg
• Enalapril 10 mg
• Metoprolol 100 mg
• Metformin 1000 mg
• Rosuvastatin 20 mg
• Aspirin 81 mg
• Donepezil 10 mg
• Memantine 10 mg
• Lantus 8-10 units subcutaneously

Evening medications:

• Metformin 1000 mg
• Memantine 10 mg

Discontinued medications:

• Glipizide 8 mg (hypoglycemia risk) 2, 3
• Pioglitazone 30 mg (unnecessary polypharmacy) 1, 2

As needed:

• Nitroglycerin sublingual for chest pain