CASE REPORT

130 Pract Diab Int April 2007 Vol. 24 No. 3 Copyright © 2007 John Wiley & Sons

Introduction‘Brittle’ diabetes is a rare and some-what controversial sub-group of type 1 diabetes characterised by lifedisruption due to hyper- or hypo-glycaemia1 and recurrent and/orprolonged diabetes-related hospital-isations.2–4 Though most patientswith this syndrome are young andhave recurrent diabetic ketoacidosis(DKA),5,6 there is also a small groupof elderly patients described withbrittle diabetes.4,7–9 These patientsappear to more often have organicthan functional causes to their gly-caemic instability4,7 but, because ofits rarity, information on ‘elderlybrittle diabetes’ is scarce. We reporthere a case of an elderly type 1 dia-betic patient in our care who hashad multiple hospitalisations withvarious types of glycaemic instability,clearly related to adverse life events.

Case reportAt the time of reporting, the patientwas 74 years old, and had had type 1diabetes for 42 years (age of onset 32years). She was married with onechild, and was on an insulin regimenof twice-daily Humulin M3 (totaldaily dose 32 units, 0.53 units/kg).Her body mass index (BMI) was22.0, and HbA1c 10.6% (DCCT-aligned HPLC method, non-diabeticreference range [4.2–6.0%]). In thepast she had also been treated withvarious insulin regimens includingother twice-daily mixtures of shortand intermediate acting insulins, aswell as three times daily short actingand night time intermediate insulin.Over the past 28 years (ages 48–76

years) she had been hospitalised dueto her diabetes 41 times, amassing ahuge set of case notes (Figure 1).The glycaemic reasons for theseadmissions were varied – 23 (56%)with hypoglycaemia, 11 (27%) DKA,and seven (17%) non-ketotic hyper-glycaemia. These are shown graphi-cally in Figure 2, and it can be seenthat hypoglycaemia was the mostcommon cause in the first 20 years,but thereafter admission causes wereglycaemically variable. Admissionscontinued despite considerable spe-cialist medical and nursing input.Her social and family life was prob-lematic, with a dysfunctional mar-riage (her husband drank alcoholexcessively, and she suffered psycho-logical abuse), family illnesses,bereavements, and depression. Atleast 20 (49%) of her admissionswere related to these life stresses andare shown graphically in Figure 3.

DiscussionThis case demonstrates a clear rela-tionship between family and life

stresses and hospitalisations in anelderly type 1 diabetic femalepatient with brittle diabetes. Thepatient is of interest because brittlediabetes in the elderly person is

An elderly type 1 diabetic patient with lifeevent-related brittle diabetesC Thomas, S Majid, J Wilding, M Wallymahmed, G Gill*

ABSTRACTThe case is presented of a 74-year-old lady with type 1 diabetes of 42 years’ duration,who had recurrent diabetes-related hospitalisations. These were due to both hypo- andhyperglycaemic emergencies and, over the last 20 years, 41 such admissions (2.0 peryear) had occurred – 56% hypoglycaemic, 27% diabetic ketoacidosis (DKA), and 17%with non-ketotic hyperglycaemia. There was a close relationship between social andfamily crises and admissions. This patient demonstrates the unusual syndrome of ‘elderlybrittle diabetes’. The mixed metabolic picture is typical of this syndrome, but thepsychosocial impact on hospital admission is more commonly seen in younger femalebrittle patients with recurrent DKA. Copyright © 2007 John Wiley & Sons.

Practical Diabetes Int 2007; 24(3): 130–131

KEY WORDSdiabetes mellitus; type 1 diabetes; ketoacidosis; hypoglycaemia

Cecil Thomas, MB, MRCP, RegistrarSamara Majid, MB, MRCP, Senior HouseOfficerJohn Wilding, MD, FRCP, ConsultantPhysician and Professor of MedicineMaureen Wallymahmed, RGN, RM, HV,BSc, MPhil, Diabetes Nurse Consultant

Geoffrey Gill, MD, FRCP, ConsultantPhysician and Professor of InternationalMedicineDepartment of Diabetes and Endocrinology,University Hospital Aintree, Liverpool, UK

*Correspondence to: Dr GV Gill,

Department of Diabetes and Endocrinology,University Hospital Aintree, Liverpool, L91AE, UK; e-mail: g.gill@liv.ac.uk

Received: 16 February 2007Accepted: 23 February 2007

Figure 1. Massive and disorganisedcase notes, containing records of 41hospitalisations over 28 years. (© Medical Illustration Department,University Hospital Aintree)

CR Gill 26.07.qxp 30/3/07 15:57 Page 2

CASE REPORT

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

described but poorly characterisedin the literature. Thus, Griffith andYudkin in 1989 described sixpatients, ages 65–83 years, with‘brittle’ patterns of instability.8More recently, as part of a nationalUK brittle diabetes survey,4 acohort of 55 brittle elderly patients(over 60 years of age) werereported.9

Younger persons with severe dia-betic instability tend to have stereo-typed patterns of dysglycaemia –usually recurrent DKA.2,4,10 In contrast, and as in the patient

described here, elderly brittlepatients often have ‘mixed instabil-ity’ – i.e. admissions with both hypo-and hyperglycaemia.9 Similarly,causes of brittle diabetes are morelikely to be psychosocial rather thanorganic in younger patients,2,4,10

but in the elderly patient thereverse is true.9 The patientdescribed here is therefore of par-ticular interest, as her multipleadmissions with varying types ofmetabolic decompensation wereclosely related to adverse family andlife events.11

References1. Tattersall R. Brittle diabetes. Clin

Endocrinol Metab 1977; 6: 403–419.2. Gill GV. The spectrum of brittle dia-

betes. J Roy Soc Med 1992; 85:259–261.

3. Kent LA, Gill GV, Williams G.Mortality and outcome of patientswith brittle diabetes and recurrentketoacidosis. Lancet 1994; 334:778–781.

4. Gill GV, Lucas S, Kent LA.Prevalence and characteristics ofbrittle diabetes in Britain. QJM 1996;89: 839–843.

5. Gill GV, Husband DJ, Walford S, et al.Clinical features of brittle diabetes.In Brittle Diabetes. Pickup JC (ed).Oxford: Blackwell Science, 1985;29–40.

6. Pickup JC, Williams G, Johns P, et al.Clinical features of brittle diabeticpatients unresponsive to optimisedsubcutaneous insulin therapy (continuous subcutaneous insulintherapy). Diabetes Care 1983; 6:278–284.

7. Benbow S, Gallagher M. Brittle dia-betes in the elderly. In Unstable andBrittle Diabetes. Gill GV (ed). London:Taylor & Francis, 2004; 179–196.

8. Griffith DNW, Yudkin JS. Brittle dia-betes in the elderly. Diabetic Med 1989;6: 440–443.

9. Benbow S, Walsh A, Gill GV. Brittlediabetes in the elderly. J Roy Soc Med2001; 94: 578–580.

10.Gill GV, Alberti KGMM. The syn-drome of recurrent diabetic ketoaci-dosis. In Unstable and Brittle Diabetes.Gill GV (ed). London: Taylor &Francis, 2004; 41–63.

11.Tattersall RB, Walford S. Brittle dia-betes in response to life stress:‘cheating and manipulation’. InBrittle Diabetes. Pickup JC (ed).Oxford: Blackwell Science, 1985;76–102.

Pract Diab Int April 2007 Vol. 24 No. 3 Copyright © 2007 John Wiley & Sons 131

Figure 3. Graphical illustration of hospitalisations and their relationship topsychosocial and family events. Note: ‘family stress’ includes domesticproblems, abuse and filing for divorce; ‘bereavements/illnesses’ includesdepression, husband’s bowel cancer, and the death of a sister and her son

Figure 2. Graphical illustration of reasons for hospitalisationKey points

• Brittle diabetes is a rare variant oftype 1 diabetes

• Though most common inyounger age groups, brittlediabetes can also occur in theelderly person

• Elderly brittle patients are morelikely to have mixed patterns ofglycaemic instability, with bothhypoglycaemia and ketoacidosis

• Brittle diabetes often reflectsadverse family and/orpsychosocial factors

1976 78 80 82 83 88 90 91 94 95 97 98 99 2000 01 02 04Year

Hyperglycaemia Ketoacidosis Hypoglycaemia7

6

5

4

3

2

1

0

No

of a

dm

issi

ons

per

yea

r

1976 78 80 82 83 88 90 91 94 95 97 98 99 2000 01 02 04Year

Family stress Unknown reasonFamily bereavements/illnesses7

6

5

4

3

2

1

0

No

of a

dm

issi

ons

per

yea

r

CR Gill 26.07.qxp 30/3/07 15:57 Page 3