Prevalence and characteristics of brittle diabetes in Britain

Abstract

We investigated the prevalence and characteristics of 'brittle diabetes', defined as insulin-dependent diabetes mellitus associated with glycaemic instability of any type, leading to life disruption with recurrent and/or prolonged hospitalizations. A questionnaire was sent to all physicians and paediatricians running diabetic clinics in the UK, from lists held at the British Diabetic Association. A total of 414 brittle patients were reported (72% questionnaire return). Most were young (mean age +/- SD was 26 +/- 15 years), though there was a small peak at ages 60-70 years. There was an excess of females (66%) and overall clinic prevalence was 1.2 per 1000 diabetic patients and 2.9 per 1000 insulin-treated diabetic patients. On average, there was 1.0 brittle patient per diabetic clinic. The most common form of brittleness was recurrent ketoacidosis (59%), with 17% having predominant hypoglycaemia, and 24% mixed instability. Female excess was highest and mean age lowest in the recurrent ketoacidosis group, whilst the reverse was true for those with recurrent hypoglycaemia. Causes of brittleness were offered by 58% of consultants, and most (93%) considered various psychosocial problems as likely underlying factors. We conclude that brittle diabetes is a small but significant problem, currently affecting about 1 per 1000 diabetic patients. Most, but by no means all, are young females--often with recurrent ketoacidosis. Older age groups are more likely to have recurrent hypoglycaemic or mixed types of brittleness. Perceived causes of brittleness are usually psychosocial.

Brittle diabetes in the elderly

“…This is in contrast to studies in younger groups where recurrent DKA is usually the commonest (about 60%) form of instability 8 . Also, some studies in younger patients have shown a greater female excess than ours 5,12 , though this is not always a clear ®nding 7 Ðthus our ®gure of 71% female is not unlike the ®gure of 66% female in the large survey (n=414) by Gill et al 7 . The female excess in elderly brittle patients should not be interpreted too far, since there is a female excess in the elderly population in general.…”

“…Recurrent and long hospital admissions are the rule 1,5,6 . Most patients with brittle diabetes are in the second or third decade of life 7,8 , and they are typically admitted with ketoacidosis (DKA) rather than hypoglycaemia or mixed patterns of instability 7± 9 . Grif®ths and colleagues have reported 6 older patients with brittle type 1 diabetes 10 .…”

Untitled

“…In a study aimed at verifying the trend of parasuicides from drug self-poisoning in 1987–1988 and 1992–1993, Bialas et al[4] confirmed the prevalence of such behaviours among females and a female/male ratio of 1.13:1.…”

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

“…Most patients with brittle diabetes are in the second or third decade of life and they are typically admitted with diabetic ketoacidosis rather than hypoglycemia or mixed patterns of instability. A "second peak" of prevalence at the age of 60-70 years has been recorded though much smaller than the main peak at 15-30 years (Gill et al, 1996). Causes for this "second round" of "brittleness" include medical disease (14%) , hypoglycemic unawareness (6%), and memory or behavioral problems (8%).…”

“…Emergency admissions due to poor diabetic control are much more common and prolonged than in "stable" patients, and it is not unusual for patients with brittle diabetes to spend several months each year in hospital. Pragmatic definitions of lifestyle disruption and "brittleness" include frequency and duration of hospitalization, more frequent psychosocial disruptions, pregnancy complications (Kent et al, 1994;Gill et al, 1996) and higher risk of death due to diabetic ketoacidosis, hypoglycemia, and renal failure . Epidemiological studies in patients with brittle diabetes have established higher prevalence rates of psychiatric disorders, in particular mood and anxiety disorders.…”