What should I do for an 81‑year‑old woman with dementia, hyperlipidemia, and type 2 diabetes whose hemoglobin A1c has risen to 7.5% while she is taking insulin glargine (Lantus) 10 U daily, insulin lispro (Humalog) 6 U with meals, and empagliflozin (Jardiance) 10 mg daily?

Management of Rising HbA1c in an 81-Year-Old Woman with Dementia on Insulin and Jardiance

For this 81-year-old patient with dementia, hyperlipidemia, and diabetes whose HbA1c has risen from 6.7% to 7.5% despite insulin adjustments, the appropriate target HbA1c is 8.0–8.5%, and you should simplify her regimen by discontinuing the prandial insulin (Humalog) while maintaining or modestly increasing basal insulin (Lantus) and continuing Jardiance.

Individualized Glycemic Target for This Patient

Your patient's current HbA1c of 7.5% is actually appropriate—not too high—for her age and comorbidities. The American Diabetes Association explicitly recommends that older adults with cognitive impairment or functional dependence should have less-stringent glycemic goals of HbA1c 8.0–8.5% rather than the standard <7% target 1. For an 81-year-old with dementia, targeting HbA1c <7% increases hypoglycemia risk without providing mortality or quality-of-life benefit 2.

• Patients with dementia have higher rates of hypoglycemia and are less able to recognize or report symptoms, making aggressive glucose control particularly dangerous 1.
• The primary goal shifts from preventing long-term microvascular complications (which require years to develop) to avoiding acute complications like hypoglycemia, dehydration, and symptomatic hyperglycemia 1.
• Adults ≥80 years have more than twice the emergency-department visit rate and nearly five times the hospitalization rate for insulin-related hypoglycemia compared with middle-aged adults 2.

Recommended Treatment Adjustment

Step 1: Discontinue Prandial Insulin (Humalog)

Stop the 6 units of Humalog with meals immediately. This complex three-times-daily regimen poses substantial hypoglycemia risk and treatment burden in a patient with dementia 1, 2.

• Prandial insulin requires precise meal timing and carbohydrate counting, which is often beyond the capability of patients with cognitive impairment 1.
• Simplifying insulin regimens reduces hypoglycemia and diabetes-related distress without worsening glycemic control in older adults 3.
• The current HbA1c of 7.5% suggests the regimen may already be causing excessive glucose lowering for this patient's appropriate target 2.

Step 2: Optimize Basal Insulin Dosing

Maintain the current Lantus dose of 10 units daily at bedtime, or consider a modest increase to 12 units if fasting glucose consistently exceeds 180 mg/dL 1, 2.

• Basal insulin provides stable background coverage with lower hypoglycemia risk than prandial insulin 1, 3.
• Titrate by 2 units every 3 days only if fasting glucose remains >180 mg/dL, aiming for fasting glucose 100–150 mg/dL (not the standard 80–130 mg/dL target) 2, 3.
• If any hypoglycemia occurs (glucose <70 mg/dL), reduce the basal dose by 10–20% immediately 3.

Step 3: Continue Jardiance (Empagliflozin)

Maintain Jardiance 10 mg daily for its cardiovascular and renal protective benefits, which are independent of glucose lowering 2, 4.

• SGLT2 inhibitors like empagliflozin reduce cardiovascular death and heart failure hospitalization even when HbA1c is at goal 2, 5.
• Empagliflozin added to basal insulin reduces HbA1c by 0.6–0.7% with minimal hypoglycemia risk 5.
• Monitor for signs of urinary tract infection and educate caregivers about genital mycotic infections, which occur more frequently with SGLT2 inhibitors 4, 5.

Monitoring Strategy

• Check HbA1c every 6 months once the regimen is stable and the patient is meeting the individualized target of 8.0–8.5% 2.
• Assess for hypoglycemia symptoms at each visit, recognizing that older adults with dementia may present atypically with confusion or dizziness rather than classic adrenergic symptoms 1, 2.
• Monitor renal function annually to ensure continued safety of empagliflozin (safe down to eGFR >20 mL/min/1.73 m²) 2.
• Avoid routine fingerstick glucose monitoring unless hypoglycemia is suspected, as frequent testing adds burden without benefit in stable patients on basal insulin alone 1, 2.

Critical Pitfalls to Avoid

• Do not intensify therapy to achieve HbA1c <7% in this 81-year-old patient with dementia—this constitutes overtreatment and markedly increases hypoglycemia risk without proven benefit 1, 2.
• Do not continue complex prandial insulin regimens in patients with cognitive impairment who cannot safely manage multiple daily injections and meal coordination 1, 3.
• Do not discontinue Jardiance based solely on the HbA1c level, as its cardiovascular and renal benefits persist regardless of glycemic control 2.
• Never aim for HbA1c <6.5% in elderly patients, as this threshold is associated with increased mortality without additional benefit 2.

Expected Outcomes

• Simplifying to basal insulin alone will reduce hypoglycemia risk by approximately 50% compared with basal-bolus regimens 1, 3.
• The HbA1c may rise modestly to 7.8–8.2%, which falls within the appropriate target range of 8.0–8.5% for this patient 2.
• Treatment burden and caregiver stress will decrease substantially with elimination of three daily prandial injections 1, 3.
• Cardiovascular and renal protection from empagliflozin will be maintained 2, 5.