Brittle diabetes in the elderly

Abstract

SUMMARYSeverely unstable, or brittle, diabetes can be disruptive to patients, carers and diabetes care teams. The peak age-group for brittle diabetes is 15±30, but there are reports of its occurrence in much older patients. To explore the characteristics and cause of brittle instability perceived by diabetologists in elderly patients we circulated a questionnaire to all UK hospital diabetic clinics for adults. 130 (56%) of 231 replied. Reports were obtained on 55 patients ful®lling our criteria for`elderly brittle diabetes'Ðnamely, age 560 years, on insulin treatment, and experiencing life-disrupting glycaemic instability of any kind associated with frequent or long admissions to hospital. Further information was obtained by a research nurse who visited the relevant clinics.The mean age of patients was 74 years (range 60±89) and 71% were female. The brittleness was classed as mixed glycaemic instability in 22 (44%), recurrent ketoacidosis in 16 (29%) and recurrent hypoglycaemia in 15 (27%). In 2 cases there was insuf®cient information for classi®cation. The diabetes care team judged the brittleness to have multiple origins in two-thirds of the cases: problems with memory or behaviour were rare, and in only 4 cases was deliberate manipulation of therapy considered a possibility. 84% of the patients were living independently.

An elderly type 1 diabetic patient with life event‐related brittle diabetes

“…‘Brittle’ diabetes is a rare and somewhat controversial sub‐group of type 1 diabetes characterised by life disruption due to hyper‐ or hypoglycaemia1 and recurrent and/or prolonged diabetes‐related hospitalisations 2–4. Though most patients with this syndrome are young and have recurrent diabetic ketoacidosis (DKA),5, 6 there is also a small group of elderly patients described with brittle diabetes 4, 7–9. These patients appear to more often have organic than functional causes to their glycaemic instability4, 7 but, because of its rarity, information on ‘elderly brittle diabetes’ is scarce.…”

“…Though most patients with this syndrome are young and have recurrent diabetic ketoacidosis (DKA),5, 6 there is also a small group of elderly patients described with brittle diabetes 4, 7–9. These patients appear to more often have organic than functional causes to their glycaemic instability4, 7 but, because of its rarity, information on ‘elderly brittle diabetes’ is scarce. We report here a case of an elderly type 1 diabetic patient in our care who has had multiple hospitalisations with various types of glycaemic instability, clearly related to adverse life events.…”

Brittle Diabetes: A Contemporary Review of the Myth and Its Realization

“…Steroid treatment might be useful for the improvement of glycemic control in such patients. Brittle diabetes in the elderly patients with diabetes is most frequent characterized by recurrent hypoglycemia (Benbow et al, 2001). In elderly patients with brittle diabetes, contributing factors to instability are chronic, nondiabetic medical diseases.…”

“…Causes of apparent or genuine insulin resistance in type 1 diabetes patients include: puberty (Amiel, 1996), overinsulinization (Rosenbloom & Giordano, 1977), the Mauriac Syndrome (Elder& Natarajan, 2010), chronic infections of the diabetic foot (Tentolouris et al, 1996;Tentolouris et al, 2010, Papanas & Maltezos, 2009, acromegaly (Elkeles et al, 1969), Cushing's Syndrome (Anagnostis et al, 2009), thyrotoxicosis (Jacobson et al, 1970) and phaeochromocytoma (Ishii et al, 2001). In few cases of recurrent diabetic ketoacidosis, there is some suggestion of a deliberate manipulation of diabetes control: patients with recurrent diabetic ketoacidosis are thought to be attention-seeking by omitting insulin due to marital problems and possible depression, and possibly personal gain from diabetic instability (Benbow et al, 2001); depression and manipulation are among the contributory factors to instability as well as chronic non-diabetic medical disease (Gill, 1992). The aetiology of recurrent hypoglycemia includes impaired awareness of hypoglycemia, which can be associated with long-standing type 1 diabetes (Ryder et al, 1990), or induced by antecedent hypoglycemic episodes (Lager et al, 1986;Janssen et al, 2000), overinsulinization (Widom & Simonson, 1992), endocrinopathies (Hardy et al, 1994), and gastrointestinal diseases such as self-induced vomiting by patients with anorexia and/or bulimia (Lloyd et al, 1987;Stancin et al, 1989;Crow et al, 1999).…”

Use of Insulin Pumps in India: Suggested Guidelines Based on Experience and Cultural Differences

“…Brittle diabetes is often encountered in T2DM subjects with a long history of uncontrolled diabetes and advancing age. 17 The insulin pump, because of its unique mechanism of preprogramming different basal profiles, enables use of up to 48 profiles per day (for example, with the Medtronic MiniMed Paradigm 715 or 722 pump), which is impossible with any other existing insulin regimen. Moreover, the patient can measure his or her blood glucose values before each meal and can decide on the exact dose of insulin to be administered using the Bolus Wizard (Medtronic MiniMed) function of the pump.…”