Managing the Diabetic Patient with Dementia
Question: A 60-year-old woman with diabetes lives alone. She is taking multiple medications including a neuropathic agent and opioid. Her pain physician notes that she is progressively developing “so much mental impairment and dementia” that she can’t responsibly and safely take prescription medication. There is no family support, and finances are minimal. What should the pain physician do? What is his/her ethical responsibility/liability? Should medications be stopped?
Answer: An important requirement for taking any medication is that the person be able to take their medications responsibly. When the patient is unable to do so, the first step is to determine the cause. Some possible causes of her diminished cognition are dementia, psychiatric illness, addiction, or medication side effects. In each case, 1) the cause must be addressed, and 2) a plan put in place so that the patient is not deprived of necessary medications. In the case of mental status changes in a relatively young woman, the first step is a neurologic workup to identify the most likely cause. Perhaps it is the medications, but perhaps she has another neurologic disorder; a referral to a neurologist is in order.
If the pain medications are believed to have caused her symptoms, then the pain physician will need to adjust her medications. During the workup, and on an ongoing basis if the cause cannot be resolved, it is important to find another person to administer the medications to the patient, perhaps a friend or neighbor. Otherwise, the patient’s safety will be threatened because of the possibility of her underdosing or overdosing medications. This is as true of her diabetes medications as of her pain medications. It is inappropriate to prescribe medications to someone who cannot take them safely. At the same time, you don’t want to cut off her antidiabetes and analgesic medications if at all possible. If someone else administers her medications, switching her opioid regimen to an every-3-day fentanyl patch or weekly buprenorphine (Butrans) patch may simplify her pain management. If she’s on gabapentin, switching to one of the new once-per-day formulations can also help.
The patient’s lack of family support and money complicates her medical treatment and may make it difficult to prescribe branded formulations. If her mental impairment becomes chronic, the patient may need to move to an assisted living facility. Arizona, for example, has a program for indigent patients who need assisted living, and hopefully so does the patient’s state. That state’s Medicaid program should be consulted and a caseworker assigned. There might also be a volunteer organization in her city that can offer free help.
—Jennifer Schneider, MD, PhD
Internal Medicine, Addiction Medicine, and Pain Management