... and a Few Other Health Problems

By M.J. Henderson, NP

Mrs. B is a frail 79-year-old woman who has had diabetes for 15 years. She has relied on a wheelchair for the past 5 years due to escalating spinal stenosis due in part to a motor vehicle accident and three subsequent and traumatic back surgeries. Mrs. B also has severe asthma, treated with prednisone, and until recently she was on continuous oxygen and frequent nebulizer treatments. She quit smoking 15 years ago.

With this limited information, the astute nurse practitioner is thinking about problems with diabetes control due to the prednisone. That is a good thought, but as with many older adults, Mrs. B has many other complicating factors that challenge her health care providers. The main goal is to control the diabetes and address all the other health issues at the same time.

Too Many Cooks Spoil the Broth

Another problem with managing Mrs. B's diabetes is the number of other providers she sees. Other than the gerontological NP (me) and the endocrinologist who care for her diabetes, she sees 14 other specialists. She regularly visits a cardiologist, pulmonologist, cardiovascular surgeon, podiatrist, psychiatrist, psychologist, rheumatologist, orthopedist, neurologist, neurosurgeon, gastroenterologist, urologist, internist and physical therapist. Mrs. B is a busy lady. It is hard to get an appointment with her!

Polypharmacy

The list of Mrs. B's medications is seemingly endless. For every medication beyond four, the possibility of drug interactions and adverse events goes up exponentially. Mrs. B takes more than 20 different medications daily, so her body is virtually humming with activity in the stomach, kidneys and liver:

• Lantus insulin 18 units at 6 p.m.

• Humalog insulin 7 units to 18 units before meals, three times a day

• prednisone 7.5 mg daily and increasing as needed

• Lanoxin 0.125 mg daily

• Pacerone 200 mg daily

• Plavix 75 mg daily

• Nitrodur patch 0.4 mg daily

• Demadex 40 mg daily

• Klor-Con 10 mEq/L twice a day

• Vytorin 10/10 mg/day

• Levoxyl 0.1 mg daily

• Duragesic patch 50 mcg per hour changed every 3 days

• Aciphex 20 mg daily

• Advair Diskus 500/50 twice daily

• nebulizer treatments as needed daily

• Abilify 2.5 mg daily

• Celexa 20 mg once a day

• Wellbutrin XL 150 mg daily

• Citracal one tablet twice a day

• iron sulfate 325 mg daily

• vitamin B₁₂ 500 mcg by mouth daily

• vitamin C 1,000 mg daily

• vitamin E 400 mg daily

• multivitamin one daily

• alpha lipoic acid one daily

• calcium 500 mg daily

• docusate calcium every other night.

The list of Mrs. B's diagnoses is as long as the medications, however most are under control. A few are not. Her health conditions encompass the simple to complex:

• asthma

• atrial fibrillation with pacemaker

• heart failure

• peripheral vascular disease

• coronary artery disease

• hypertension

• diabetes mellitus, type 2

• pedal neuropathy

• Bell's palsy

• cerebral vasculitis with 7^th cranial nerve damage

• hiatal hernia

• gallstones

• cataracts

• spinal stenosis

• urinary incontinence

• degenerative joint disease

• osteoarthritis

• hypothyroidism

• hyperparathyroidism

• presbycusis

• psychosis

• depression and anxiety.

The History

When Mrs. B first came to our office in 1997, she was taking glyburide (DiaBeta, Glynase, Micronase) once a day and her blood sugars were not in control. She was overweight and inactive due to her spinal stenosis, but interestingly her HgA1c was only 7. But Mrs. B's finger stick blood glucose (FSBG) readings were swinging wildly throughout the day, often fluctuating between 70 and 225 or higher, depending on her bagel and ice cream intake and prednisone. Her average was 176. In all fairness to Mrs. B, diabetes is almost impossible to control when patients are taking continuous steroids. In such patients, blood glucose levels tend to get higher and higher as the day goes along.

Diabetes Treatment Options

It was time to start something new. The oral medication metformin (Glucophage) was an option, but Mrs. B was fearful of possible diarrhea, due to her already compromised pelvic floor muscles. We opted for troglitazone (Rezulin) 400 mg daily, to break the insulin resistance. We also reduced the glyburide to 5 mg daily to avoid hypoglycemia. Her blood sugars improved and we were able to reduce and then discontinue the glyburide.

Mrs. B's insurance company would not pay for the Rezulin, so we gave her samples. When Rezulin was pulled from the market, we were forced to go back to glyburide, this time using smaller doses of 2.5 mg in the morning and 1.25 mg in the evening and adding pioglitazone (Actos) 45 mg daily. Actos aggravated her edema and heart failure. We stopped Actos and tried rosiglitazone (Avandia) 4 mg instead. We increased the glyburide to 5 mg daily with breakfast because her blood glucose was still too high and fluctuating. Again the heart failure was aggravated and we stopped the Avandia. We then tried nateglinide (Starlix) three times a day, but this did not lower the blood glucose. We rechallenged with Avandia, but she went into atrial fibrillation. We subsequently stopped all oral medications and went with Humalog insulin 4 units twice daily. The advantage with this short-acting insulin is that you can finesse the blood sugar control because the insulin is in, out and gone in about 2 or 3 hours, thus avoiding lingering insulin and the ensuing low blood glucose.

Mrs. B's blood glucose was still not in control, so we increased gradually from 4 units of Humalog twice a day to 15 units four times a day, depending on the prednisone doses. We eventually added the long-acting Lantus insulin (lasts for 24 hours), and to be safe we added it in the morning. It is our experience that the onset of Lantus is slow, about 5 hours. By taking it in the morning, Mrs. B could see how her sugars were as the day progressed, knowing that the blood glucose would go up because of the prednisone.

Mrs. B's spinal stenosis induced a sedentary lifestyle. The midday bagel and the bowl of ice cream at bedtime were still compromising her blood sugar control, not to mention restaurant visits in the afternoon. So we moved the Lantus to 6 p.m. Mrs. B likes to stay up late and watch TV, so 5 hours after the 6 p.m. injection, she would be awake to know if she was going low or not. We reduced the Humalog to 8 to 10 units before meals to avoid driving the blood sugar too low. We added a sliding scale for before-meals Humalog because of her irregular eating habits and the hemoglobin A1C went down to 6.1, 6.8, then 6.5. It now rests at 6.1. The blood sugar is relatively stable now due to the prednisone being at the lowest level in a long time (7.5 mg daily). Her blood glucose does not go below 70 now, and she only has occasional blood glucose levels up in the 300s at night, depending on the dietary indiscretions of the day.

Mrs. B told me the other day, "I feel the best I have in a very long time."

Yes, Mrs. B has to give herself four injections a day, but the diabetes control is better and her general health is better. We have come a long way together since 1997.

Treat Aggressively

In our office, we believe in treating diabetes aggressively and utilizing all the medications available to maximize blood glucose control. The risk for hypoglycemia is higher with aggressive treatment, and thus oversight is imperative. Close contact with patients is essential. You can tailor the tightness of control to the individual patient by working with him or her to obtain the goal of a hemoglobin A1C <7.0 and fasting blood glucose <126. Hypoglycemia in a frail older adult like Mrs. B is dangerous and potentially life threatening. Conversely, symptomatic hyperglycemia is unacceptable. What is the nurse practitioner to do? We care for older adults like Mrs. B as we would want to be treated ourselves.

In its guidelines for treating diabetes in older adults, the American Geriatrics Society advises that "although control of hyperglycemia is important, in older persons with diabetes, greater reductions in morbidity and mortality may result from control of cardiovascular risk factors than from tight glycemic control" (J Am Geriatr Soc. 2003;51[5]:S265-S280). Therefore, treat hypertension and abnormal lipids, prescribe aspirin 81 mg daily if the patient's stomach can tolerate it, encourage yearly eye exams, perform foot exams at each visit, and assess for falls. Also check renal function tests and assess for incontinence annually, screen for depression and dementia, and assess and treat neuropathic pain. Discuss and promote diet and exercise at every visit, and counsel older adults to stop smoking.

It is a challenge to achieve the delicate balance between glycemic control and quality of life for the older adult, but when the patient says she feels the best she has in years, it is all worthwhile. As my Aunty B (not related to Mrs. B) always used to say, "It's a great life if you don't weaken!"

M.J. Henderson is a gerontological nurse practitioner who works in a private endocrinology practice in Los Gatos, Calif.