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Managing Clinical Problems in Diabetes, Case Study #4: Mr. ZM

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

DCMS30_CG_ImageThis week, we continue with Part 4 of our special series of case discussions.

CASE DISCUSSION: Mr. ZM

Mr. ZM was referred to an endocrinologist by his GP at the request of the nursing home staff.

“Mr. ZM is a 70-year-old man with dementia living in our nursing home. He has chronic poor control, and HbA1c last time was 8%. He is on bronchodilators and steroids for chronic respiratory disease due to a history of heavy smoking. He has Novolin 30/70, 26 units AM and 18 units PM with tea. (Editor’s Note: In Europe and some other countries, mixed insulins are written as the short acting percent first, followed by long acting percent. In addition many countries have more mixed choices that are not available in the US.) He is relatively inactive but wanders a lot and lately has been having hypos because he does not eat much. Sometimes it is very difficult to test his blood glucose. Can you please advise about a care plan for him?”…

 
Diabetes educator

Older people with diabetes have twice the risk of developing dementia. Dementia and Alzheimer’s disease are associated with under-nutrition and weight loss. 

Novolin or Humulin insulin, regardless of the proportion (20/80, 30/70, 27/75 or 50/50), is challenging for older people, especially those with dementia and unpredictable dietary intake. The Humalog or Novolog component of Novolin 30/70 (the 30% part of the entire pre-mixed insulin) starts to work 30 minutes after administration, can peak in around 4 hours and lasts up to 8 hours. This means that if Mr. ZM is given his morning insulin at 7.30 a.m., and eats breakfast at 8.00 a.m., the peak action of his insulin is just before lunch. If Mr. ZM refuses to eat lunch, he is then at a very real risk of hypoglycemia. 

Often the symptoms of hypoglycemia in people with dementia are quite different from other symptoms experienced by other people with diabetes. Behavior can deteriorate with the person becoming uncooperative or aggressive. Refusal to allow staff to perform capillary blood glucose testing may occur while the blood glucose levels are falling. This same scenario could be repeated at bedtime when the evening meal Novolin is peaking 4 hours after it is administered. 

The peak action of the 70% intermediate-acting component of Novolin occurs mid- to late afternoon following the breakfast dose and early morning from 2 a.m. onwards when it is administered with the evening meal. Reversal of hypoglycemia resulting from intermediate-acting insulin can be more difficult compared to rapid or fast-acting insulin and could result in more severe symptoms and therefore more difficult to manage behavioral changes. 

Mr. ZM’s HbA1c is 8%, and given his overall health, obtaining an improved HbA1c is not an objective; reducing hypoglycemia and thereby maximizing his safety and quality of life are the priorities. Two main issues need to be addressed: a review of his insulin regimen and developing strategies to increase carbohydrate intake when he refuses to eat.

 
Insulin 
  • Mr. ZM could be changed to a twice-a-day bolus analog premix insulin such as Novolog 30/70 or Humalog 25/75. The rapid-acting components of these two insulins, unlike Novolin 30/70, or Humulin 25/75 peak approximately 90 minutes after administration and last for 3-4 hours. Both insulins can be administered directly after food, which may be useful if Mr. ZM refuses breakfast or dinner. 
  • Novolin 30/70 could be ceased and a daily basal analog insulin such as Lantus prescribed. Lantus is a peakless insulin without the associated rises and falls in actions and could stabilize blood glucose levels more effectively, markedly reduce the incidence of hypoglycemia, and have a positive effect on behavior.
 
Diet strategies 
  • There are a variety of ways Mr. ZM’s carbohydrate intake could be increased throughout the day. If Mr. ZM refuses a meal, offer a carbohydrate-containing drink such as milk, Sustagen or juice, or provide carbohydrate food that appeals to Mr. ZM such as custard and fruit, or ice cream and fruit.
  •  Encourage Mr. ZM to eat carbohydrate foods with a lower glycemic index (GI) as this can help to reduce the risk of low glucose excursions. 
  • Identify the foods Mr. ZM usually eats. For example, does he always eat his breakfast? If so, another breakfast could be offered in place of the refused meals. 
  • Ask his family what foods he enjoys and encourage them to bring them in. Set up a specific box of food that the staff can offer Mr. ZM when he refuses a meal. For example, small tins of baked beans and small packets of fruitcake. 
  • Provide food on a plate or bowl from home — this might help reduce Mr. ZM’s anxiety. 
  • Have food available in Mr. ZM’s room or the residents’ lounge. For example, a plate of fruit pieces may allow Mr. ZM to graze. 
  • Offer smaller and more frequent meals to maintain the blood glucose level more effectively. 

Part of Mr. ZM’s management plan should include strategies to assist staff, including casual staff, to recognize the behavioral symptoms of hypoglycemia, the strategies used to reduce its occurrence, and the treatment most likely to work for Mr. ZM. Staff working as a team should try a variety of strategies and objectively document the degree of success.

 
Dietitian 

I would ask the GP and the nursing home staff the following questions: 

  • How long has Mr. ZM had diabetes?
  • Does he have type 1 or type 2 diabetes?
  • What is his understanding of diabetes and has there been a time when he self-managed the condition?
  • Is he still smoking? If so, has he been offered smoking cessation advice?
  • Are the staff in the nursing home adequately trained in evidence based diabetes care and treatments?
  • How severe is his dementia? Is he able to cope with diabetes self-management or should his diabetes be managed by the nursing home staff?
  • Does he inject his own insulin? If not, who does it for him? Have the insulin technique and insulin sites been checked?
  • It has been stated: “He does not eat much.” Is that due to poor appetite or does his dementia prevent him from sitting at a table and concentrating on the task?
  • Is his weight stable or is he losing weight? What is his BMI? Is he a healthy weight for his height?
  • His diabetes control is poor. Is he symptomatic? For example, does he experience excessive thirst, frequent urination, infections, tiredness and fatigue? 

I would also ask Mr. ZM some questions depending on the severity of his dementia:

  • Do you understand you have diabetes?
  • Do you know what diabetes is?
  • How much diabetes self-management are you willing to take on and how much are you willing to delegate? 

I would provide self-management education if appropriate or refer Mr. ZM to a diabetes educator. I would provide or ask the diabetes educator to provide education for the nursing home staff and advise them to:

  • try changing his insulin from Novolin 30/70 twice a day to a peakless long-acting insulin such as Lantus or Levemir;
  • improve his glycemic control if he is experiencing symptoms that affect his quality of life;
  • monitor his blood glucose if Mr. ZM is happy for them to do so;
  • prepare finger foods and nutritional drinks to improve his nutritional intake.

Diabetes educator 2

Managing older people with diabetes, especially with dementia and in nursing homes, is very difficult. Changing to Lantus is likely to reduce his hypoglycemia and may improve his glycemic control (Janka et al. 2005). It may also reduce the care burden on the nursing staff. Improving his glycemic control would be a first priority because it is very difficult to determine his mental status, degree of dementia, and cognitive and physical functioning when the blood glucose is erratic. If the hypoglycemia is not addressed it can become chronic, more difficult to control and likely to result in falls and possibly trauma.

His life expectancy is another consideration and may depend on the type of dementia Mr. ZM has. Discussing these issues with the family and explaining the factors affecting Mr. ZM’s erratic behavior are both important. Achieving a lower HbA1c might be less important than preventing hypoglycemia and managing any diabetes complications and other comorbidities present. His wandering, hypoglycemia, and agitation put him at significant risk of falling.

The wandering could be a consequence of his dementia, hypoglycemia, pain, or stress. These factors need to be excluded or managed. The wandering constitutes activity and may need to be considered when deciding on his insulin doses. Oral pain could be contributing to his food refusal. A dental check is indicated to determine whether he has any oral problems affecting his ability to eat.

 

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Another Case Discussion

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath