3 Clinical Pearls: Elderly Case Study

An 89 year old male has a history of hypertension, diabetes, BPH, Advanced dementia, glaucoma, constipation, neuropathy, and osteoarthritis.  Current medications include:

  • Aspirin 81 mg daily
  • Lopressor 25 mg twice daily
  • Metformin 500 mg twice daily
  • Tamsulosin 0.8 mg daily
  • Proscar 5 mg daily
  • Combigan 1 gtt os twice daily
  • Tylenol #3 tab q 4 hr as needed
  • Nortriptyline 50 mg daily

This patient has been losing weight, and also has been getting significantly upset and angry with caregivers.  The timing of the behaviors appears sporadic.  There are also specific times of the day where he is very lethargic.  He has had minimal use of the Tylenol #3.

Current vitals: BP 130/66, Pulse 54, Temp = 97.3 F

Current labs include:  Hemoglobin = 14.7, creatinine 1.25, A1C 5.7

3 Clinical Considerations

The lethargy could be from the beta-blocker, I would love to have a few more pulses/BP’s to assess if metoprolol should be reduced in this elderly individual.

With this patient’s weight loss, I would first look at meds that can cause weight loss and or GI symptoms.  Both aspirin and metformin can cause GI issues.  Both are pretty low doses and with advanced dementia in play as well, it is really hard to know what exactly is going on.  It might be worth a shot to reduce/DC the metformin with A1C at 5.7.  Pain, BPH issues, advancing dementia, anticholinergic effects are just a few things to consider in contribution to the behavioral issues.

This patient has a history of neuropathy which nortriptyline is likely being used for.  With high dose Flomax and Proscar likely for BPH, I’m not a big fan of nortriptyline in a scenario like this.  Alternatives aren’t perfect either, and pain assessment is obviously difficult given dementia.  A trial reduction or transition to SNRI or Gabapentin might be a possibility to consider.

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  1. Grant C

    The American Diabetes Association and American Geriatric Society has offered framework for treatment of older adults with diabetes mellitus to reduce the potential for over-treatment associated with tighter glycemic control. Given his age and advanced dementia he is being over-treated for diabetes. An A1c goal of 8-8.5% can be reasonable for this population.

    Reference: “Diabetes in Older Adults: A Consensus Report” M. Sue Kirkman, MD, et.al. JAGS 60:2342-2356, 2012.

  2. Titus Agboka

    Given patient’s scr of 1.25 and episodes of lethargy and confusion (may be mild case of lactic acidosis), I will consider changing metformin from 500mg bid to Metformin ER 500 daily. A1c is under control and we don’t need a tight A1c control in this patient.
    I will also evaluate the Nortriptyline 50 mg daily in this patient. Nortriptyline is associated with modest weight loss.

    • L. C.

      He is an 89 year old gentleman with advanced dementia as well as many other chronic diseases. He has an A1c of 5.7% so why is he on metformin at all? Let his A1c trend up.


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Written By Eric Christianson

August 5, 2015

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