Prescribing and Deprescribing in Older Adults with Dementia: A Person-Centred Approach to Diabetes and Anticholinergic Medications

Adj Assoc Prof Lim Si Ching
Education Director, SingHealth Duke-NUS Memory and Cognitive Disorder Centre;
Senior Consultant, Dept of Geriatric Medicine,
Changi General Hospital

Ayesha Saadiqah Binte Habeeb Mohamed
Medical Officer, Department of Geriatric Medicine,
Changi General Hospital

Managing diabetes in older adults with dementia requires careful balancing of safety and hypoglycaemia prevention while addressing long-term complications and maintaining nutrition, social factors and quality of life. We share how careful integration of guideline-based recommendations can reduce medication-related harm and optimise geriatric diabetes management.

Diabetes mellitus (DM) management in older adults, particularly those living with dementia, requires individualised, safety-centred strategies. Cognitive impairment increases hypoglycaemia risk, complicates medication adherence and alters therapeutic goals. Concurrent anticholinergic medication use may further exacerbate cognitive decline and precipitate delirium.

This article synthesises current evidence and guideline-based recommendations for diabetes care in elderly individuals with dementia, highlighting hypoglycaemia prevention, regimen simplification and deprescribing strategies.

A clinical case illustrates the impact of anticholinergic burden on functional decline. Integration of the 4Ms framework and adherence to the Beers Criteria can reduce medication-related harm and optimise geriatric diabetes management.

Individualising Care in Older Adults with Diabetes

Diabetes management in older adults differs from younger populations due to the presence of background multimorbidity, frailty, cognitive impairment, social and caregiver factors and increased vulnerability to medication-related adverse events. The American Diabetes Association recommends individualised glycaemic targets incorporating medical, functional, psychological and social domains.

However, in persons living with dementia (PLWD), strict glycaemic control may not provide meaningful benefit and may increase hypoglycaemia risk.

CASE STUDY

MEDICATION-RELATED FUNCTIONAL DECLINE

Background

An elderly gentleman presented in the Accident and Emergency Department with functional decline for many days, anorexia and insomnia. His significant past medical history included:

• Non-functioning pituitary macroadenoma 
• Type 2 diabetes mellitus 
• Hypertension

His son reported that his father experienced giddiness since taking new medication prescribed by his general practitioner and endocrinologist.

His daughter-in-law also noted inappropriate behaviour where the patient changed his underwear 20 times a day and undressed himself fully in front of the Buddha statue for his son to massage his back. Such behaviour had never happened before. He was also unable to recognise family members in the last few days.

Background cognitive history showed an incident when he lost his way home and was eventually brought home by a neighbour. His son also noted his father had occasionally left the water tap running. He required assistance with instrumental activities of daily living (IADL) but remained independent in basic ADLs. There were also no complaints of infective symptoms.

The patient was able to tell us that there had been a recent addition to his medication list and that the drugs did not suit him. He had been passing a lot of stool since starting the new medication, sometimes up to 20 times a day. He felt unwell, had difficulty sleeping and his appetite had been poor.

Investigations and Diagnosis

A physical examination showed that he was confused on and off, afebrile, with stable vital signs, and was otherwise unremarkable, with no localising neurological signs.

Initial investigations showed hyponatraemia, inflammatory markers were flat. A chest X-ray was normal and a CT brain scan performed later did not reveal any infarct, bleed or mass.

Medication reconciliation revealed the recent addition of Anarex (paracetamol plus orphenadrine) by his general practitioner and addition of metformin a month before by his endocrinologist. The diagnoses were functional decline and delirium secondary to Anarex given by his GP and hyponatraemia secondary to anorexia and loose stools due to gastrointestinal side effects of metformin.

Management

Immediate management included stopping metformin and Anarex. Loose stools and anorexia improved over a period of 2-3 days, and delirium resolved. He was referred to the subacute ward for a short stint of rehabilitation.

KEY LEARNING POINTS

This case underscores several critical principles in the care of older adults living with dementia. Functional decline of acute onset warrants full clinical assessment including medication review.

Medications with hidden anticholinergic burden may mimic new-onset dementia or worsening dementia. Deprescribing is a central component of pharmacological management in older persons living with dementia.

Frank Molnar & Allen Huang, University of Ottawa; Mary Tinetti, Yale University

HYPOGLYCAEMIA AND COGNITIVE DECLINE

Older adults with diabetes are at greater risk of hypoglycaemia, particularly when treated with insulin or sulfonylureas.

Cognitive impairment increases the likelihood of dosing errors and reduces awareness of decrease in hypoglycaemia with risks of neuroglycopenic injury. Recurrent hypoglycaemia has also been associated with dementia risk, reinforcing the importance of balancing the positive effects of tight glycaemic control against the risks of neurological damage from hypoglycaemia.

Hence, it is important to be mindful of the presence of cognitive impairment among diabetic elderly PLWD since dementia risk is higher among diabetics. Screening for dementia is not routinely recommended in the community.

However, case finding among at-risk individuals like diabetics is recommended at least annually. Screening can be done using the AD8, followed by bedside assessment like MMSE or MoCA if AD8 is positive for cognitive decline.

Individualised Glycaemic Targets

Healthy community-dwelling older adults with intact cognition may aim for target HbA1c levels of 7-7.5%, while those with frailty or cognitive impairment may aim for a less stringent target of ≤ 8% to avoid hypoglycaemia.

Management of cardiovascular risk factors should consider time-to-benefit. Medications for hyperlipidaemia such as statin therapy may only provide preventive benefit if life expectancy exceeds approximately two to five years.

Lifestyle Management

Lifestyle modification remains important in diabetes management for older adults. Diabetes is recognised as an independent risk factor for frailty, as it is associated with reduced muscle mass, poor muscle quality and sarcopenia.

Lifestyle modification includes adequate protein intake. According to the American Diabetes Association, at least 0.8 g/kg body weight/day is needed for older adults with diabetes to maintain lean body mass and function.

Regular aerobic, weight-bearing exercises and resistance training are also recommended to maintain muscle health. Lifestyle management should be individually assessed and prescribed to suit the patient’s frailty status.

PHARMACOLOGIC CONSIDERATIONS

The first consideration is to use medications with lower risk of hypoglycaemia and to simplify complex treatment plans to once or twice daily regimens to decrease treatment burden.

In patients with co-existing cardiovascular risk factors, consider agents which have benefits on both cardiovascular and renal functions.

In addition to glycaemic control, weight management is also a consideration for older adults. The majority of our local seniors are undernourished, and weight loss is discouraged unless the older adult has a BMI > 30. The Obesity Paradox states that older adults with BMI 24-29 are healthier compared to leaner older adults with lower BMIs in terms of overall mortality, falls, cognition, frailty etc.

For elderly patients with dementia, it is also important to consider social factors such as the availability of live-in caregivers, erratic and inconsistent meal consumption as medication regimen complexity must align with caregiver support and cognitive ability.

ANTICHOLINERGIC BURDEN IN DEMENTIA

Anticholinergic adverse effects are common in many frequently prescribed drugs. Anticholinergic effects in older adults may cause delirium, cognitive decline, incident dementia, functional impairment and systemic side effects like constipation, dry mouth, dry eyes and urinary retention.

In persons with dementia, these medications can cause delirium, hallucinations and functional decline.

The relationship between anticholinergic burden and cognitive/functional decline is robust across multiple large cohort studies and anticholinergic medications are considered a modifiable risk factor for these outcomes.

These drugs competitively inhibit the neurotransmitter acetylcholine at muscarinic and nicotinic receptor sites in both central and peripheral nervous systems. In the central nervous system, anticholinergic drugs can impair cognitive function and motor control by inhibiting cholinergic neurotransmission, which is critical for attention, memory and movement regulation. The degree of central effects depends on the drug’s ability to cross the blood-brain barrier.

Persons with dementia are particularly susceptible due to blood-brain barrier changes and reduced cholinergic reserve. Muscle relaxants such as orphenadrine are listed in the Beers Criteria as potentially inappropriate in older adults.

NOTES TO GPs

• Functional decline warrants medication review. 
• Anticholinergic burden may mimic worsening dementia—use the anticholinergic burden scale to quantify the cumulative anticholinergic activity of all medications a patient is taking. 
• Deprescribing is a central component of pharmacological management in persons living with dementia—this means simplifying DM regimes to reduce hypoglycaemia, relaxing HbA1c targets based on cognitive and functional status and choosing medication that also targets cardiovascular and kidney disease risk at the same time. 
• Always check medication compliance before addition of new medication. 
• Beware of unexpected medication adverse effects among the older adults. 
• Treatment targets for the older adults may be different from the standard recommendations due to frailty status. Hence prescriptions should be personcentred. 
• Acute functional decline should be managed like delirium—remember to always exclude medication adverse effects.

CONCLUSION

Diabetes management in PLWD requires a personcentred, individualised approach that prioritises safety and hypoglycaemia prevention while preventing long-term complications and maintaining nutrition, social factors and quality of life.

Anticholinergic medications represent a significant and modifiable contributor to cognitive and functional decline in this population, especially in older adults with undiagnosed cognitive impairment.

Integration of the 4Ms framework and adherence to Beers Criteria recommendations can improve outcomes and reduce medication-related harm. Careful deprescribing, regimen simplification and alignment with patient goals are essential components of optimal geriatric diabetes care.

REFERENCES

1. American Diabetes Association. Standards of Care in Diabetes—Older Adults. Diabetes Care.
2. Munshi MN, et al. Realigning diabetes regimens in older adults. Lancet Diabetes Endocrinol.
3. American Geriatrics Society. Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.
4. Gray SL, et al. Cumulative use of strong anticholinergics and incident dementia. JAMA Intern Med.
5. Campbell NL, et al. The cognitive impact of anticholinergics. J Clin Interv Aging. To view all references, please refer to the online version of Defining Med by scanning the QR code on the cover page.

Adjunct Associate Professor Lim Si Ching is a Senior Consultant with the Department of Geriatric Medicine at Changi General Hospital (CGH). Prior to training in geriatric medicine, Dr Lim was a renal physician overseeing the largest dialysis centre in Brunei. After completing her specialist training in geriatric medicine at CGH, she went on to set up the inpatient service for geriatric medicine at Singapore General Hospital, including training for nurses, medical students, junior doctors and trainees.

Dr Ayesha Saadiqah Binte Habeeb Mohamed is currently a Medical Officer who obtained her MBBS from the University of Malaya in 2022. She has completed her House Officer rotations in General Medicine, General Surgery and Paediatrics. With a strong passion for community health, she will be entering Family Medicine Residency to further her commitment to holistic and accessible care. Dr Ayesha has also been involved in outreach initiatives such as Charity for Unity and has held leadership roles in medical and sports organisations, reflecting her dedication to teamwork, service, and continuous learning.

GPs can call the SingHealth Duke-NUS Memory & Cognitive Disorder Centre for appointments at the following hotlines:

• Singapore General Hospital 6326 6060
• Changi General Hospital 6788 3003
• Sengkang General Hospital 6930 6000
• National Neuroscience Institute 6330 6363