Severely uncontrolled diabetes in the over-fifties

Abstract

Between 1969 and 1976, 317 adults were admitted to hospital in Nottingham with severely uncontrolled diabetes (plasma glucose over 33 mmol/l and/or venous bicarbonate less than 14 mmol/l). A third of episodes were in patients over the age of 50 years, of which 43% were fatal. In contrast, only 3.4% of episodes in patients under 50 years were fatal. In the older group, 65% of deaths occurred within 48 h of admission and in 44% no cause was found other than uncontrolled diabetes. Later deaths were due to underlying disease, infection or thromboembolism. Amongst older patients 38% were not previously known to have diabetes. Presentation to hospital was late and we conclude that many deaths were potentially avoidable by earlier detection in the community.

Incidence of IDDM during 1988?1992 in Zagreb, Croatia

“…However, the existing diabetes registry does not seem to be adequate for identifying incident cases in persons older than 50 years. Early fatality seems to influence the incidence rates in this age group, since 14 % of incident cases in this age group was identified solely through death certificates, thus supporting data on the high mortality of newly-diagnosed IDDM in the elderly [18]. Of the patients who died before being registered, none had had diabetes diagnosed previously.…”

Starting insulin therapy in elderly non-insulin-dependent diabetic patients at a health care centre. Methodological and economic aspects

“…The reasons for this are manifold. There is uncertainty about whether the patient will benefit from insulin treatment or will be able to leam the injection technique, as well as a fear of hypoglycaemia and weight gain (5, 8,10,11). When insulin treatment is really needed, many of these patients are referred to a hospital (12), although it has been shown that better metabolic control can also be obtained, in insulin dependent diabetic patients, if insulin treatment is started in an outpatient clinic (13.14).…”

Antiplatelet/anticoagulant drug therapy in severely uncontrolled diabetes mellitus

“…There are experimental findings to endorse the opposite view that insulin does not aggregate its own receptor [2,4,5]. Receptor aggregation, nevertheless, does occur in the natural state of certain tissues [2,9] and may not be necessary as a primary mechanism for insulin action.…”

“…There have recently been several reports of haemostatic changes in diabetic coma [2, 31 and, while a coagulopathy may exist, its association with fatal thromboembolic events has not been established. In the hope of decreasing mortality from fatal thromboembolism and, in turn, lowering overall mortality from uncontrolled diabetes (up to 50% in the elderly [4]) some investigators have proposed prophylactic anticoagulation in these patients [5][6][7][8]. This has gained increased support in the literature and while antiplatelet drugs are not recommended, it has been suggested that heparin may be warranted in high risk uncontrolled diabetic patients.…”

“…First the natural state of distribution of insulin receptors appears to be tissue specific [2,4,9]. Secondly dithiothreitol, a reducing agent, disperses the groups of Fm-] occupied receptors on adipocyte membranes [10], yet increases 125I-insulin binding to these membranes about threefold [11].…”