NR 580 Week 2 Capstone Case Presentation Example

Case Presentation: A 76-Year-Old With Diabetes, Stage 3b Kidney Disease and Heart Failure, Three Low Sugars and Two Falls, With the Two Weak Joints of My Reasoning Marked

Student Name

College of Nursing, Chamberlain University

NR 580: Adult-Gerontology Primary Care Capstone and Intensive

Instructor Name

Month Day, Year

Case Presentation: A 76-Year-Old With Diabetes, Stage 3b Kidney Disease and Heart Failure, Three Low Sugars and Two Falls, With the Two Weak Joints of My Reasoning Marked

Who the Patient Is

A 76-year-old retired bus mechanic who shares a one-level house with a spouse. Type 2 diabetes for 21 years, stage 3b chronic kidney disease, heart failure with reduced ejection fraction and mild cognitive impairment. Seen in the primary care capstone clinic after two falls and three episodes of low blood sugar in six weeks.

What Was Found

Medicines, read off the bottles the spouse brought in: glargine, 24 units at 22:00; glipizide, 10 mg with breakfast and again with supper; carvedilol, 12.5 mg morning and evening; sacubitril with valsartan, 24/26 mg morning and evening; furosemide, 20 mg in the morning; atorvastatin, 40 mg at night.

Glucose log: readings of 54, 61 and 58 mg/dL, all between 03:00 and 07:00, over six weeks; most fasting readings between 90 and 130.

A1c: 6.4%, three weeks ago.

Kidney function: estimated glomerular filtration rate 38, stable over a year; potassium 4.8.

Ejection fraction: 35% on an echocardiogram eight months ago.

Blood pressure lying 128/72; standing at three minutes 104/64, with lightheadedness. Pulse 64.

Falls: one at 05:30, walking to the bathroom, with a glucose of 58 found after; one at 14:00, getting up from the couch, glucose 142.

Cognition: Montreal Cognitive Assessment 23 a year ago.

What the Spouse Added

The spouse described the two low sugars that woke the patient: sweating, shaking and confusion, treated with orange juice, each taking about 20 minutes to settle. The spouse also mentioned that the glipizide had been prescribed by a doctor who retired, and that nobody had reviewed it since. Neither detail was in the record. Both went onto the problem list that same afternoon, with the spouse named as the source, so the next clinician can see where they came from.

What Was Concluded

First: the low sugars are caused by a combination of glipizide, a long-acting insulin dose set when kidney function was better and an A1c target tighter than this patient needs. In a national sample of older adults with diabetes, about a quarter had tight control on insulin or sulfonylureas, the drugs most likely to cause low sugar (Lipska et al., 2015), and this patient is one of them. Second: the falls have two causes, one hypoglycemic and one orthostatic; the 24-point standing drop sustained at three minutes meets the definition of orthostatic hypotension (Freeman et al., 2011). Third: the heart failure medicines are below target doses, and raising them would worsen the standing drop.

Weak Joint 1: Two Causes for the Falls

I am least sure of the claim that the falls have two separate causes. The morning fall came with a glucose of 58, which supports hypoglycemia. The afternoon fall came with a normal glucose and followed standing up, which supports orthostatic hypotension. But one fall each is thin evidence, and I have no blood pressure taken at the moment of either fall.

Expected question: "Could both falls be orthostatic, with the low sugar a coincidence?" Answer held in reserve: yes, possibly. The plan treats both causes, so the decision does not depend on which is right, but I would not present the two-cause explanation as proven.

Weak Joint 2: Whether to Add an SGLT2 Inhibitor Now

The second point I am unsure of is timing. An SGLT2 inhibitor would help the heart failure and the kidneys, and it lowers blood pressure only modestly. In a large trial in patients with reduced ejection fraction, dapagliflozin lowered the composite of heart failure worsening and cardiovascular death (McMurray et al., 2019). But adding it while glucose-lowering drugs are being reduced, in a patient who falls, adds a medicine that can cause volume loss.

Expected question: "Why not add it today?" Answer: because I want to see the effect of the diabetes changes first, and I would add it at the next visit once the low sugars have stopped. I hold this view less firmly than the first conclusion.

Findings That Changed the Plan and Findings That Did Not

The medication history from the bottles changed the plan: the list in the record showed glipizide once daily, and the bottle showed twice. The standing pressure changed the plan, because without it the heart failure medicines would have been raised. The foot examination, which found reduced sensation, did not change today's plan but was recorded for podiatry. The cognitive score from last year did not change the plan, though it shaped who was taught the overnight checks: the spouse, not the patient.

What Was Done

Glipizide stopped. Glargine reduced from 24 to 16 units. A1c target relaxed to below 8%, as recommended for older adults with several conditions and a history of hypoglycemia. Furosemide timing kept at 08:00. Spouse taught to check glucose at 03:00 twice a week for two weeks. Advice to pause, seated at the bedside, before getting up.

Questions I Expect From the Room

On the glipizide: "Why not reduce it instead of stopping it?" Because the geriatric prescribing criteria advise against sulfonylureas in older adults, the patient has kidney disease and the low sugars were overnight, when a smaller dose of a long-acting drug would still act. On the A1c target: "Isn't 8% too loose?" For an older adult with several conditions and recent hypoglycemia, a target below 8% is within published recommendations, and the patient chose safety from falls over a lower number. On the heart failure: "Who decides the doses?" The cardiologist, with whom I spoke on the phone before the visit ended.

What I Would Want the Room to Tell Me

The two weak joints above are where I would welcome challenge. If someone in the room has seen an SGLT2 inhibitor started safely during insulin reduction in a patient who falls, I would like to hear how it was monitored.

Timing of the Presentation

The presentation runs about seven minutes: one for who the patient is, two for the findings, one for the conclusions, two for the weak joints and one for the plan and return visit. The weak joints get the most time relative to their length, because they are where the discussion should happen.

When the Patient Is Seen Again

Two weeks, in clinic, with the glucose log and standing blood pressures; earlier by phone if any reading is below 70.

References

Freeman, R., Wieling, W., Axelrod, F. B., Benditt, D. G., Benarroch, E., Biaggioni, I., Cheshire, W. P., Chelimsky, T., Cortelli, P., Gibbons, C. H., Goldstein, D. S., Hainsworth, R., Hilz, M. J., Jacob, G., Kaufmann, H., Jordan, J., Lipsitz, L. A., Levine, B. D., Low, P. A., . . . van Dijk, J. G. (2011). Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome. Clinical Autonomic Research, 21(2), 69-72. https://doi.org/10.1007/s10286-011-0119-5

Lipska, K. J., Ross, J. S., Miao, Y., Shah, N. D., Lee, S. J., & Steinman, M. A. (2015). Potential overtreatment of diabetes mellitus in older adults with tight glycemic control. JAMA Internal Medicine, 175(3), 356-362. https://doi.org/10.1001/jamainternmed.2014.7345

McMurray, J. J. V., Solomon, S. D., Inzucchi, S. E., Kober, L., Kosiborod, M. N., Martinez, F. A., Ponikowski, P., Sabatine, M. S., Anand, I. S., Belohlavek, J., Bohm, M., Chiang, C.-E., Chopra, V. K., de Boer, R. A., Desai, A. S., Diez, M., Drozdz, J., Dukat, A., Ge, J., . . . Langkilde, A.-M. (2019). Dapagliflozin in patients with heart failure and reduced ejection fraction. New England Journal of Medicine, 381(21), 1995-2008. https://doi.org/10.1056/NEJMoa1911303