Elise is a 68-year-old woman who was diagnosed in her early 20s with bipolar I disorder, hypertension, and poorly controlled diabetes. She has responded well to a combination of valproic acid and sertraline. Over the past 40 years, however, her treatment course has been compromised because she intermittently stops medications when she is euthymic, resulting in hypomanic or depressive episodes and, occasionally, hospitalization for manic episodes. Elise does not understand the need to take medications when she is feeling well. Her daughter Mabel became involved last month when Elise was hospitalized for hyperosmolar hyperglycemic nonketotic syndrome. Elise once again had stopped her medications, become slightly paranoid during her hypomanic episode, and refused diabetes medications because she was convinced they were contaminated. She is now taking all her medications as recommended; however, you are concerned about the medical consequences if she stops again. Mabel explains that she became frustrated and estranged from her mother when Elise refused to take medications consistently and ended up in the hospital. You recommend that Mabel and Elise attend family-focused psychoeducation courses and join the local National Alliance on Mental Illness (NAMI) chapter.

Over the next several months, you notice that Elise is having difficulty following some conversations, even though she insists that her mood is euthymic. You are concerned about medication compliance because she has episodes of hyperglycemia when she cannot remember to take insulin with meals. Mabel tells you that Elise is having cognitive difficulties with organizing complex tasks, such as knowing how to draw up and adjust the timing of her insulin, and cannot easily recall recent events. You refer Elise for a neuropsychological evaluation to determine whether she has a major neurocognitive disorder; the evaluation confirms your suspicion that she does have major neurocognitive disorder superimposed on bipolar disorder.

When you discuss this new diagnosis with Mabel, she complains that Elise is easily agitated, so you ask her to describe this agitation in more detail. Mabel explains that her mother sometimes resists insulin injections, yells or tries to walk away, and once almost stuck her with the needle. Mabel finds giving multiple injections quite frustrating and often does not even offer the long-acting insulin dose at night because she is so tired of trying to persuade Elise to agree. As you investigate this behavioral disturbance, you learn that Elise cannot consistently remember that she has diabetes, so you create a plan that will minimize her need for insulin injections and set a higher hemoglobin A_1c target goal because of her diagnosis of major neurocognitive disorder. You consult with your colleagues in geriatric medicine, endocrinology, and pharmacy to devise a diabetes medication regimen that requires only one injection of long-acting insulin per day and use of oral hypoglycemics.

Now when Mabel gives Elise an injection, she picks a time when Elise feels most relaxed and puts on music for distraction. She gives Elise a stuffed animal to hold so she is less likely to grab the hand holding the syringe. You advise Mabel to give Elise her regular evening trazodone about 30 minutes before the injection so she will be drowsy and more cooperative. The nutritionist works with Mabel to decrease Elise’s insulin by ensuring that only diabetic-friendly foods are present in the household. Elise had been snacking on cookies and eating ice cream, which increased her insulin requirement. Finally, Mabel and Elise work with the occupational therapist to develop physical activities that should further decrease the need for insulin. When you evaluate the effectiveness of your plan after 3 months, you learn that Elise’s episodes of agitation have resolved and the number of hyperglycemic episodes has decreased by 25% since she began consistently taking the long-acting insulin injection given once a day by her daughter.