ODP202 Geriatric Type 1 Diabetes- unique management challenge
Authors: Patel Toral , Arora Gunjan 
Published: November 2022

Case Presentation

A 87 year old female with a past medical history of Type 1 Diabetes Mellitus (DM), Parkinson's disease and osteoporosis was sent from an assisted living facility to the emergency department for evaluation of elevated blood glucose levels. She had a long standing history of type 1 DM and further review revealed that she had extremely labile (brittle) blood sugars, with multiple prior hospitalizations for both hypoglycemia and hyperglycemia. Assisted living facility staff reported that her blood sugars were persistently elevated despite receiving scheduled insulin doses. On presentation, she did not have any specific complaints except for polydipsia and polyuria. She was hemodynamically stable, alert and oriented to time, place and person. Initial lab work included serum glucose 754 (70-79 mg/dL), bicarbonate 25 (21-31 mmol/L), anion gap 10 (6-14 mmol/L), ketone 0.9 (&lt; 0.6 mmol/L), leukocyte count 4.7 (4-11 k/mm u) and creatinine 1. 06 (0.6-1.2 mg/dL). Urinalysis showed glycosuria and proteinuria but no evidence of infection. IVF and insulin were started. Extensive infectious work-up was negative. Her blood glucose levels stabilized with basal-bolus regimen and correctional doses of insulin. Tight glycemic control was avoided due to her history of hypoglycemic unawareness and multiple previous episodes for severe and recurrent hypoglycemia.

Discussion

Brittle diabetes is a disorder commonly seen in patients with Type 1 DM and is characterized by extreme swings in blood glucose levels (severe recurrent hypoglycemic and hyperglycemic episodes) without a clear cut precipitating cause requiring hospitalizations. It has been linked to autonomic dysfunction, hormonal imbalance, psychological issues, nutrient malabsorption and autoimmune conditions. Geriatric Type 1 DM presents great challenges in management as it combines micro and macro vascular complications of long standing DM with geriatric syndrome - concurrent comorbidities, cognitive losses of various degrees, vision and hearing loss, loss autonomic and hormonal counter-regulation, and progressive frailty leading to severe glycemic instability makes self management of DM near impossible. Our patient was an elderly female with osteoporosis, Parkinson's and hypoglycemic unawareness. Great care was taken to maintain her blood glucose levels in the optimal range both during and after hospitalization. Daily insulin was being administered by staff after checking blood glucose levels, avoiding the possibility of dose omission or errors. Detailed instructions on administration of the correct dose of insulin according to caloric consumption and physical activity were provided. With this case, we wish to highlight the unique challenge Brittle Diabetes in geriatric presents, and as this sector of population is growing owing to better treatment options for diabetics and longer life expectancy, there is a growing need to recognize this entity, adopt a multi-disciplinary patient centered approach and prioritize prevention of both hypoglycemia and extreme hyperglycemia over tight glycemic control.

Presentation: No date and time listed