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1. A category 3 elderly patient is:
2. Obese elderly patients have:
3. Lean elderly patients primarily have:
4. Goals of diabetes management in the elderly should aim to:
5. When initiating insulin in the elderly, the clinician should:
Case 1 (revisited)
Patient: 78-year-old male, heavy smoker until one year ago
- Has colon cancer with liver metastasis, for which he underwent surgery. He is currently on chemotherapy
- Has diabetes for 15 years
- Has polyuria, polydipsia and severe weight loss.
- Metformin: 2g/day
- Gliclazide: 160mg/day
- Sitagliptin: 50mg/day
Patient looks ill, with central cyanosis and peripheral oedema
- Blood pressure: 124/58mmHg
- Pulse: 90b/min
- Has signs of hyperinflation and soft cardiac sounds
- He has surgical scar over the abdomen with poor wound healing and clinical hepatomegaly
- HbA1c: 12%
- Creatinine: 170µmol/l
- Estimated GFR: -36
6. In which functional category is the patient?
7. What should the patient’s individualised target HbA1c be?
8. Which treatment would you add?
Patient: 82-year-old female
- Living with a caregiver in her own cluster home
- Has diabetes, hypertension, dyslipidaemia and osteoporosis
- Had a stroke five years ago, and recovered mostly from it
- Experiences dizzy spells
- Diabetes: metformin 2g/day, gliclazide SR 120mg/day
- Hypertension: enalapril 10mg/day, amlodipine 10mg/day and hydrochlorothiazide 25mg/day
- Dyslipidaemia: atorvastatin 20mg/day and is on aspirin 81mg/day
- Osteoporosis: alendronate
The patient is pale, has memory impairment and is dyspnoeic. BP: 150/67mmHg with irregular pulse of 85b/min, BMI of 26kg/m2 with waist circumference of 100cm
- She has left ventricular hypertrophy and a soft systolic murmur is audible over the apex
- Basal inspiratory crackles
- HbA1c: 16%
- Creatinine: 150µmol/L
- Sodium: 130mmol/L
- Potassium: 5.1mmol/l
Patient has microalbuminuria.
9. What is the patient’s individualised HbA1c target?
10. Which drug would you add on this patient’s treatment?
11. What is the patient’s functional category?
Patient: 76-year-old male
- Living in a flat on the same premises as his family
- Walks on a daily basis – about 5km/day
- Eats healthy diet
- Has diabetes, hypertension and dyslipidaemia and history of prostate cancer from which he recovered fully
- Diabetes: glucophage 1g/day (he develops GIT side effects if he increases the dose), glimepiride 4mg/day, with simvastatin 10mg/day.
- Hypertension: CCB and ACE-Inhibitor combination.
- He measures his glucose regularly and has noticed increasing fasting glucose to up to 10mmol/l.
He looks very healthy for his age with blood pressure of 140/80mmHg and a regular pulse of 64b/min
- His cardiovascular examination was normal
- There was no diabetic nor hypertensive complications
- HbA1c: 10%
- eGFR: 89ml/min
- Sodium and potassium were normal, lipogram was not clinically significant.
12. In which functional category is this patient?
13. What is your individualised HbA1c target in this patient?
14. What is the fasting glucose target in this patient?
15. Which insulin regimen will you initiate to be appropriate in this patient?
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- Cefalu WT, et al, eds. CADRE Handbook of Diabetes Management. New York, NY: Medical Information Press; 2004.