Brittle diabetes, as we now know it, can be difficult not only for the patients but to the family and health care team. While this condition most frequently occurs in the age group of 15-30 years old, there have been reports of this condition afflicting the elderly.
The new statistics prompted Drs. Susan Benbow of University Clinical Department of Medicine in Liverpool and Geoffrey Gill along with Angela Walsh of Diabetes Center in Liverpool to study the cause and characteristics of brittle diabetes in the elderly. How did they do this?
They sent out questionnaires to all United Kingdom hospital clinics for diabetic adults. They were able to secure reports for 55 patients who met the criteria in the elderly. What are these standards? In order to be included as subjects for this study, first, they have to be 60 years old or over.
Then they have to be on insulin treatment. And last but not least, they have had their lives disrupted by glycemic instability. In addition they must have been admitted to the hospital This hospitalization should have been long and frequent.
The mean age after calculation resulted in 74 years old. The number of cases for females is a high 71%. The investigators classified the brittle diabetes in the elderly into three types:
. mixed instability in 44%
. recurrent ketoacidosis in 29%
. recurrent hypoglycemia in 15%
Are you surprised the above percentages didn't add up to 100%? It's because adequate information was not available in some cases. Among two-thirds (66%) of the subjects, there was not a single cause. Rather the investigators found numerous causes for this diabetes in the elderly.
What did they find as the single cause of this condition? Well, they discovered that the single cause of the condition for 14% is medical disease. The researchers did not pinpoint the medical disease although another research work reported that their cases involved other chronic diseases. Another cause is that only 6% of the subjects were unaware of hypoglycemic episode.
They also found that problems regarding behavior and memory were not common. There were only four cases showing patients deliberately manipulated therapy. Another point is that 84% of the elderly who were suffering from brittle diabetes were living alone.
Among the four cases of therapy manipulation, the two with recurrent ketoacidosis were judged as seeking attention by leaving out insulin. One had marital troubles and possibly depression. The suspicion was that she would gain personally from her glycemic instability.
The fourth case was considered depressed and calculating. All her hypoglycemic episodes happened in public. But it should be pointed out here that in all these cases there were other factors that may have contributed to the instability, most particularly chronic non-diabetic medical condition.
The main sign of this condition in younger patients is recurrent ketoacidosis but this study seems to indicate that the elderly have different patterns and causes. Now with the older group using more and more insulin therapy, we are bound to see more of the same cases.
The diabetes care team found numerous causes of the condition as indicated above. But more importantly, the survey results show that brittle diabetes in the elderly exists and is a problem that cannot be ignored. It is not only troublesome for the family but for the health care team as well.
For the hospital admission for diabetics, the elderly gives different reasons. The most common is mixed brittleness. Compare this with studies for the younger group with ketoacidosis as the most common reason. As for the female/male ratio, there are more females among the elderly group which is not a surprise. So this ratio is not statistically important.
There is not much published on unstable diabetes in the older population. In Birmingham, UK 25% of those with recurrent episodes were over 59 years old. Griffith and Yudkin found most have mixed brittleness. No clear cause for the instability was noted.
Then in 1981, Gale et al from Nottingham reported that 33% of diabetic patients admitted over a period of 7 years were over 50 years old. It is clear that brittle diabetes in the elderly is here to stay and prevention and management will need a multidisciplinary approach.
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