This case study examines the complications arising from the use of semaglutide in an 86-year-old female patient with a history of severe dementia, diabetes, and obesity. The complications underscore the critical need for caution when managing geriatric patients, particularly those with cognitive impairments.
Patient Background
Age: 86 years
Gender: Female
Medical History:
- Severe dementia
- Diabetes (historically controlled on oral hypoglycemic agents)
- Obesity (BMI of 30)
Recent Health Issues:
- Flare of degenerative back pain necessitating injectable and oral steroids, leading to elevated blood sugar levels.
Medication Management
The patient was started on semaglutide to improve glycemic control. Despite being previously well-controlled on oral hypoglycemics, her recent health deterioration prompted the need for additional medications.
Initial Status:
- Finger-stick glucose levels: 250-300 mg/dL.
- Functional status: Required 24-hour supervision; needed assistance with more than two activities of daily living.
Follow-Up Monitoring:
- Most follow-up visits were conducted remotely due to mobility issues.
- Weight, HbA1c, and BMI could not be adequately monitored through virtual visits.
- Semaglutide dosage was gradually increased based on family reports of blood sugar improvements.
Office Visit Details:
- An in-person visit allowed a dose increase to 1 mg despite the patient being unable to stand on the scale.
- Point-of-care HbA1c at that visit: 8.6%, nearly at target, leading to further dosage increase.
Complications and Emergency Presentation
Six months after semaglutide initiation, the patient presented to the emergency department with severe symptoms:
Symptoms:
- Delirium
- Nausea
- Decreased appetite and oral intake
- 28-pound weight loss (BMI reduced to 24)
- Hypernatremia
- Kidney injury due to dehydration
Age-Related Risks and Considerations
Dr. Chitra Ganta, a Cleveland Clinic geriatrician, emphasizes the following points regarding the risks associated with GLP-1 agonists in older adults:
Cognitive Impairment: Patients with dementia may forget to eat and drink, complicating management when appetite suppression occurs. This can increase risks for dehydration and other serious complications.
Weight Loss Concerns: Significant weight loss in older adults (more than 10%) is linked to increased mortality risk, highlighting the need for careful monitoring beyond just blood sugar levels.
Mortality Risk: Dehydration and acute kidney injury pose immediate risks that can require hospitalization.
Management and Outcome
Upon hospitalization, the following interventions were undertaken:
Medication Adjustments:
Semaglutide was discontinued immediately.
Rehydration and Treatment:
Addressed symptoms and managed hydration status.
Gradual resolution of delirium, kidney injury, and hypernatremia.
Discharge Plan:
The patient was discharged to her family, now able to take small sips of water and consume soft foods.
Conclusion
This case highlights the necessity for cautious use of GLP-1 agonists, like semaglutide, in older adults, especially those with cognitive impairments such as dementia. While these medications can be beneficial for certain populations, healthcare providers must prioritize a holistic view of patient health, taking into account the potential risks of weight loss, dehydration, and the overall health status of geriatric patients.
As Dr. Ganta notes, “Clinicians must exercise great caution when managing older adults, in whom weight loss is a well-documented predictor of mortality.” The case reinforces the importance of thorough monitoring and individualized treatment plans tailored to the unique needs of geriatric patients.
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