Case study 5: Diabetes and frailty
Background (age, sex, occupation, baseline function)
- 65 years old
- Male
- Mild frailty (assessed 2 months previously) Rockwood 5
History of presentation/reason for review
- Annual diabetic review
Current medical history and relevant co-morbidities
- Transient ischaemic attack (9 and 15 years previously)
- Type 2 diabetes mellitus – 14 years ago
- Essential hypertension - 21 years ago
- Ischaemic heart disease – 31 years ago
- Angina pectoris
- Acute myocardial infarction
- Family history of IHD (noted 14 years ago)
Current medication and drug allergies (include OTC preparation and herbal remedies)
- Alogliptin 25mg tablets – one tablet daily
- Bendroflumethiazide 2.5mg tablets – one tablet daily
- Citalopram 20mg tablets – one tablet daily
- Clopidogrel 75mg tablets – one tablet daily
- Furosemide 20mg tablets – one tablet daily
- Irbesartan 300mg tablets – one tablet daily
- Lercanidipine 10mg tablets – one tablet daily
- Metformin 500mg tablets – one tablet twice daily
- Simvastatin 40mg tablets – one tablet at night
Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity
- Frailty – mild
- Lives with wife, who does all the housework, preparing meals and shopping
- Mobilises with walking aid
- House on two levels, and requires help with stairs
- Eats a varied diet
- Weight stable
- Attends local optician
“What matters to me” (patient ideas, concerns and expectations of treatment)
- Although pharmacy manages supply of his medication (all on serial prescription) he is reluctant to take medication. “Can I stop any?”
- Often forgets lunchtime dose of metformin
Results e.g., biochemistry, other relevant investigations or monitoring
- Creatinine 101micromol/l; eGFR>60
- Weight 84.8kg; height 1.8m; BMI 26.17
- Calculated creatinine clearance 69 ml/min (IBW 75.3kg)
- Urine albumin 3mg/ml, urine creatinine 9.1mmol/l, ACR 0.3mg/mmol
- Recent LFTs, FBC normal
- Last 3 blood pressures: 130/80mmHg, 126/78mmHg, 127/75mmHg
- Serum cholesterol 4.3mmol/l, ratio 3.5
- HbA1c 51mmol/mol
Most recent relevant consultations
- Diabetic monitoring before annual review
- Limited contact with practice due to COVID restrictions
- Received all flu and COVID vaccines
7 Steps: Person specific issues to address for case study 4
1. Aims: What matters to the individual about their condition(s)?
Review diagnoses and consider:
- Therapeutic objectives of drug therapy
- Management of existing health problems
- Prevention of future health issues, including lifestyle advice
Person specific actions
- Simplify medication – “take less tablets”
- Maintain limited mobility
2. Need: Identify essential drug therapy
Identify essential drugs (not to be stopped without specialist advice*)
- Drugs that have essential replacement functions
- Drugs to prevent rapid symptomatic decline
* with advice from healthcare professional with specialist interest
Person specific actions
- None considered essential
3. Does the patient take unnecessary drug therapy?
Identify and review the continued need for drugs
- what is medication for?
- with temporary indications
- with higher than usual maintenance doses
- with limited benefit/evidence for use
- with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)
Person specific actions
- Citalopram – started 4 years ago, no indication if ongoing need, although higher incidence of depression in diabetes.
- Furosemide 20mg potentially unnecessary, if lercanidipine is causing swollen ankles
4. Effectiveness: Are therapeutic objectives being achieved?
Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives
- to achieve symptom control
- to achieve biochemical/clinical targets
- to prevent disease progression/exacerbation
- is there a more appropriate medication to achieve goals?
Person specific actions
- BP within target range, occasionally lightheaded but attributed to limited mobility. On triple therapy so review which most appropriate to reduce and stop.
- Diabetes well controlled, mild frailty potentially at risk of hypoglycaemia and complications. However takes alogliptin, which is less effective than other options which have positive cardiovascular outcomes, such as SGLT-2i*.
5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?
Identify individual safety risks by checking for
- appropriate individual targets
- drug-disease interactions
- drug-drug interactions (see ADR table)
- monitoring mechanisms for high-risk drugs
- risk of accidental overdosing
Identify adverse drug effects by checking for
- specific symptoms/laboratory markers
- cumulative adverse drug effects (see ADR table)
- drugs used to treat side effects caused by other drugs
Medication Sick Day guidance
Person specific actions
- Risk of falls due to anti-diabetic medicines and anti-hypertensives
- Increased risk of acute kidney injury due to combination of diuretics and metformin, especially if acutely unwell.
- Sick day guidance – withhold bendroflumethiazide, furosemide, irbesartan and metformin with dehydrating illness
6. Sustainability: Is drug therapy cost-effective and environmentally sustainable?
Identify unnecessarily costly drug therapy by
- considering more cost-effective alternatives, safety, convenience -
Consider the environmental impact of
- Inhaler use
- Single use plastics -
- Medicines waste
- Water pollution
Person specific actions
- None - prescribing in keeping with current formulary recommendations
- Patient advised to dispose of medicines through community pharmacy
- Advised patient to only order what is needed, do not stockpile medicines
7. Patient centeredness: Is the patient willing and able to take drug therapy as intended?
Does the person understand the outcomes of the review?
- Consider teach-back
Ensure drug therapy changes are tailored to individual’s preferences. Consider
- is the medication in a form they can take?
- is the dosing schedule convenient?
- what assistance is needed?
- are they able to take medicines as intended?
Agree and communicate plan
- discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
- include lifestyle and holistic management goals
- inform relevant health and social care providers of changes in treatments across the transitions of care
Person specific actions
- BP at target and lightheaded – stop lercanidipine as may also be contributing to swollen ankles
- Diabetic control good, often forgets metformin dose at lunchtime. Reduce dose to 500mg twice daily.
Future steps:
- If swollen ankles resolve, stop furosemide.
- Substitute alogliptin for SGLT-2i*, due to ASCVD (and renal) benefits.
- Discuss potential reduction of citalopram, if no symptoms.
Key concepts in this case
- Falls risk
- Mild frailty
- Tight blood pressure control
- Tight diabetic control
- Less suitable medication with co-morbidities
- Consider most appropriate anti-diabetic medication
- Duration of treatment course (antidepressant)
- Unnecessary indication – furosemide
Click on the table image to view a PDF version of the full 7 steps table.