MKSAP quiz: Elevated HbA1c level, loss of energy in older patient
This month's quiz asks readers to evaluate a 71-year-old woman who reports no symptoms other than loss of energy. Her medical history is significant for hypertension, type 2 diabetes mellitus, and dyslipidemia.
A 71-year-old woman is evaluated during a routine examination. She reports no symptoms other than loss of energy. Medical history is significant for hypertension, type 2 diabetes mellitus, and dyslipidemia. Medications are metformin, liraglutide, chlorthalidone, amlodipine, and atorvastatin.
On physical examination, blood pressure is 145/85 mm Hg; other vital signs are normal. BMI is 22. She is slow in moving to the examination table and needs help stepping up. Early cataracts are present. Cardiac examination reveals an S4. The remainder of the examination, including depression screening, is unremarkable.
Laboratory results obtained early this week show a hemoglobin A1c level of 8.4%. Complete blood count, serum electrolyte levels, and creatinine level are normal.
Intensification of blood pressure and type 2 diabetes therapies is considered.
Which of the following should be done next to inform therapeutic decisions for this patient?
A. Cognitive assessment
B. Frailty assessment
C. Home blood pressure measurements
D. Repeat hemoglobin A1c measurement
MKSAP Answer and Critique
The correct answer is B. Frailty assessment. This item is available to MKSAP subscribers as item 5 in Extension Set 1 of the General Internal Medicine 1 section. More information about MKSAP is online.
A frailty assessment (Option B) should be performed to help inform therapeutic decisions. Frailty is a multifactorial geriatric syndrome characterized by unintentional weight loss, low energy and activity levels, weakness, and slow walking speed. Frailty is associated with increased mortality and poor prognosis with many medical and surgical interventions. Identifying frailty can help in tailoring goals of care for chronic medical conditions, including glycemic control and blood pressure targets; predicting response to and tolerance of surgical and chemotherapeutic cancer treatment; and predicting postoperative outcomes related to surgery. In this patient, if a diagnosis of frailty is confirmed, higher blood pressure or hemoglobin A1c targets may be reasonable, particularly if more aggressive goals cannot be achieved safely. In addition, discontinuation of screening and prevention interventions that would otherwise be indicated might be supported in a patient with frailty. Rapid screening tests for frailty safely may be useful to identify patients who might require more formal assessment. The FRAIL (Fatigue, Resistance, Ambulation, Illness, and Loss of weight) scale is an example of a rapid screening test that might be useful in this situation. The frailty index and frailty phenotype are more intensive tools for assessing potential frailty.
In the absence of symptoms, routine cognitive screening (Option A) is not recommended, owing to a lack of evidence that screening leads to effective intervention. Screening for cognitive dysfunction in this patient will not help assess for frailty or have an immediate impact on therapeutic decision making regarding blood pressure and diabetes control.
Although home blood pressure monitoring (Option C) may be used when assessing the need to start or intensify hypertension treatment, the fundamental issue is whether this patient will benefit from intensified blood pressure control. To that end, assessment of frailty is needed before considering whether more stringent blood pressure control is warranted.
Repeating hemoglobin A1c measurement (Option D) for an abnormally elevated value is typically not necessary. Similar to decisions regarding blood pressure control, it is unclear whether this patient's prognosis warrants aggressive glucose control. Frailty screening is the more appropriate initial assessment.
Key Points
- Frailty is a multifactorial geriatric syndrome characterized by unintentional weight loss, low energy and activity levels, weakness, and slow walking speed; it is associated with increased mortality and poor prognosis with many medical and surgical interventions.
- Identification of frailty may result in tailoring of therapeutic targets and decisions about routine screening and prevention services.