Case Study: Semaglutide Use in Older Patient with Severe Dementia

An 86-year-old female patient with a history of dementia, diabetes and obesity was started on semaglutide by her medical subspecialist to improve glycemic control. The patient’s diabetes was historically well controlled on oral hypoglycemic agents, but a recent flare of degenerative back pain required the use of injectable and oral steroids, resulting in elevated blood sugar levels and the need for additional medications.

When semaglutide was initiated, the patient’s BMI was 30; her finger-stick glucose level was 250-300 mg/dL; and her functional status was poor, requiring 24-hour supervision and help with more than two activities of daily living. Most of the follow-up visits with her specialist had been remote due to the patient’s difficulty with mobilization. Her weight, HbA1c and BMI could not be adequately monitored with virtual visits, but the semaglutide was gradually increased based on the family’s reports of improving blood sugar levels.

Although the patient had an in-person office visit when the semaglutide was increased to 1 mg, she was unable to stand on the scale and could not be weighed. Her point-of-care HbA1c at that visit was 8.6% and noted to be nearly at target, yet the decision was made to increase the dose to further improve her glycemic control.

Six months later, she presented to the emergency department with delirium, nausea, decreased appetite and oral intake, 28-pound weight loss (BMI 24), hypernatremia and kidney injury caused by dehydration.

Age-related risks

This case illustrates the importance of using caution and careful monitoring when prescribing GLP-1 agonists to older adults, explains Cleveland Clinic geriatrician Chitra Ganta, MD. “These medications are truly revolutionary, and I have personally seen them work phenomenally for patients with metabolic conditions, particularly diabetes and obesity,” she says. “However, the appetite suppression and weight loss they can cause may not be desired in older adults.”

Although the American Diabetes Association urges providers to use caution when prescribing GLP-1 medications to older adults who are experiencing unexplained weight loss, current guidelines do not address dementia, Dr. Ganta notes. “That’s of particular concern because it’s not uncommon for individuals with dementia to forget to eat and drink regularly or have difficulty communicating their need for water and food to caregivers,” she says. “If we add the common side effects of GLP1 agonists – chiefly appetite suppression and weight loss – to this mix, we increase the immediate risk of dehydration, delirium, electrolyte imbalance and acute kidney injury.”

In addition, providers who are overly focused on a geriatric patient’s sugar levels may lose sight of the bigger picture, she adds. “Weight loss of more than 10% in older adults confers a greater than 114% risk of mortality over the next couple of years, and dehydration poses immediate risks that may require hospitalization, so it’s essential for clinicians to be vigilant.”

Cautionary tale

The patient in this case was hospitalized and the semaglutide was stopped. Once her symptoms were addressed and she was rehydrated, her delirium gradually subsided, as did her kidney injury and hypernatremia. She was discharged to her family and is once again at home, taking sips of water and eating soft foods.

The case, which was presented at the 2024 annual meeting of the American Geriatrics Society, highlights the need to avoid GLP-1 agonists in older patients with dementia, especially those who cannot be monitored closely, says Dr. Ganta.

“There’s no question that these medications can do wonderful things for the right subset of patients,” she says. “However, clinicians must exercise great caution when managing older adults, in whom weight loss is a well-documented predictor of mortality.”