Type 1 diabetes is typically a disease of young but can present at any age. We present a case of a 93-year-old woman who presented with 10 days history of feeling lethargic, polydipsia and decreased appetite. Her capillary blood glucose was raised at 25 mmol/L with significant ketonaemia and venous blood gas showing metabolic acidosis. She had a background of primary hypothyroidism and vitamin B12 deficiency with weakly positive parietal cell antibodies. Laboratory investigations confirmed diabetes with HbA1c of 117 mmol/mol (12.9%). In view of high clinical suspicion of type 1 diabetes, her diabetes autoantibodies were checked which showed strongly positive anti-GAD antibody with titre of >2000 IU/mL (range<10) confirming our diagnosis. She was treated with diabetic ketoacidosis protocol with intravenous fluids and intravenous insulin. On recovery, she was discharged home on once daily insulin with aim to self-manage diabetes with support from district nurses and to avoid hypoglycaemia.
- healthcare improvement and patient safety
- drugs and medicines
Statistics from Altmetric.com
Type 1 diabetes mellitus (T1DM) can occur at any age but is typically diagnosed in the young population. Out of the 4.9 million known cases of diabetes in the UK around 8% are of type 1 diabetes.1 The data regarding the epidemiology of type 1 diabetes specifically in adults is scarce all over the world2 but clinical observations suggest that there is increasing diagnosis in the older age group. Literature review shows two cases of diagnosis of type 1 diabetes in over 90 years of age, a 94-year-old female patient in the UK in 20023and a 96-year-old male patient from Japan in 2016.4
A 93-year-old woman presented with a 10 day history of feeling unwell, with increased thirst, lethargy and decreased appetite. She complained of multiple episodes of urinary incontinence over the previous week. Her mobility was worsening and she had a fall 10 days prior. Capillary blood glucose was found to be 25 mmol/L with blood ketones of 7.0. Venous blood gas revealed metabolic acidosis with a pH of 7.26 and bicarbonate of 12. There was no evidence of adrenal insufficiency. She had history of anaemia, vitamin B12 deficiency and primary hypothyroidism. She was on treatment with levothyroxine 75 mcg and vitamin B12 injections. Further laboratory evaluation confirmed diabetes with HbA1c of 117 mmol/mol. There was a suspicion of T1DM therefore antidiabetes antibody profile was checked which revealed strongly positive anti-GAD antibody with titre of >2000 IU/mL (range<10). C peptide was low at 0.11 nmol/L (range 0.34–1.8). Given her background history, further autoantibody screen was arranged, which showed absence of thyroid peroxidase (TPO) antibody and weakly positive parietal cell antibodies.
Clinically, she has a very lean build. With her history, autoimmune association, body mass index (BMI) and presentation with possible diabetic ketoacidosis (DKA), we concluded that she has type 1 diabetes. She was treated as per our DKA protocol with intravenous fluids and intravenous insulin.
She was discharged home on basal insulin (Glargine) once daily only with a request to district nurses to monitor her capillary glucose level and administer insulin due to her age, high risk of hypoglycaemia and her being alone at home (figure 1).
Differential diagnosis of type 1 diabetes in this case includes latent autoimmune diabetes in adults (LADA) and autoimmune polyglandular syndrome type 3A and 3B.
LADA usually has a slower progression of disease and does not require insulin therapy at the time of diagnosis unlike in our case in which patient was insulin deficient at diagnosis and presented with DKA which is also unusual at the initial presentation in LADA.
Autoimmune polyglandular syndrome type 3A or 3B could be a possibility in our case as the patient had T1DM along with primary hypothyroidism (although TPO antibodies were negative) and vitamin B12 deficiency with weakly positive parietal cell antibodies but we did not stress too much on that diagnosis as the management would still be the same.
Other decompensating factors like bacteria/viral infection and medications were evaluated which could predispose type 1 diabetes. Our patient did not have any recent illness and was not any hyperglycaemia causing drugs.
Outcome and follow-up
Since diagnosis, she has been followed up in secondary care. After a few weeks of managing diabetes with the help of district nurses, she took over the management and has been checking her capillary glucose level and administering the insulin injection herself. Her serial HbA1c recorded since shows acquisition of excellent self-management skills and maintaining her independence.
T1DM, also known as autoimmune diabetes, is a chronic disease characterised by the deficiency of insulin due to loss of pancreatic β-cell and leads to hyperglycaemia. Although the age of symptomatic onset is usually during childhood or adolescence but symptoms can sometimes develop much later5 as in our case.
Type 1 diabetes accounts for 5%–10% of the total cases of diabetes and ≥85% of all diabetes cases in young <20 years of age worldwide. In general, the incidence rate increases from birth and peaks between 10 and 14 years of age during puberty. Incidence rates decline after puberty and in young adulthood (15–29 years) it appears to stabilise. In adults, the incidence of T1DM is lower than in children, although in approximately one-fourth of persons are adults who are diagnosed with type 1 diabetes. Clinical presentation occurs at all ages and can be as late as the ninth decade of life.6
The majority of cases are attributable to the destruction of β cells due to the autoimmune process (type 1a) while a small minority of cases result from idiopathic destruction or failure of beta cells (type 1b).6 Certain environmental triggers such as certain dietary factors and viruses are thought to initiate the autoimmune process, leading to the destruction of pancreatic β-cell and consequent T1DM. In our case, there was no precipitating factor leading to type 1 diabetes and it was the result of declining β-cell function over decades of life.
Marked hyperglycaemic symptoms include polyuria, polydipsia, weight loss, sometimes polyphagia and blurred vision. Susceptibility to certain infections and impairment of growth may also accompany chronic hyperglycaemic. Acute, life-threatening consequences of uncontrolled diabetes are DKA and severe hypoglycaemic.
Out of the two previous cases of new diagnosed type 1 diabetes in elderly, the 94-year-old woman which was reported in the UK in 2002 was a bit different from our case as she had the milder presentation with no evidence of long-term diabetic complications at diagnosis. She was initially treated with oral hypoglycaemic agents and was subsequently switched to insulin therapy after confirmation of the diagnosis. On the other hand, our patient presented with DKA with marked endogenous insulin deficiency at presentation. The second case which was reported in Japan in 2016 of a 96-year-old male patient presented with diabetes complication with diabetic ketosis which was quite similar to our case. The authors of both these cases did not give any tentative explanation of the presentation of type 1 diabetes at such an old age.
There has been limited literature available regarding the best treatment approaches for older adults with type 1 diabetes. Treatment should be aimed at establishing acceptable glycaemic control and minimising the risk for acute complications (ie, hypoglycaemia and serious hyperglycaemia).
Healthy, older adults who are independently functioning should be treated more aggressively than those who are frail or have multiple comorbidities and disabilities, and they are associated with limited life expectancy. For healthy older individuals who have few coexisting chronic illnesses and are able to self-manage their diabetes, the HbA1C goal of <7.5% (58 mmol/mol) is recommended.7
For older adults who are frail and have reduced life expectancy and increased risk of hypoglycaemia and are either unable to perform or difficulty performing self-care tasks, the recommended HbA1C goal for them is 69 mmol/mol (<8.5%). Lower goals can be considered if they can achieve that without unwarranted burden and risk of hypoglycaemia.
An individualised approach is pivotal in managing type 1 diabetes in the older population group. It will be difficult for them to follow complex insulin regimens. Insulin therapy is required in order to prevent serious conditions such as severe hyperglycaemia and DKA. According to patients' preference, the insulin regimens should be simplified.
Frequent blood sugar monitoring is important to guide insulin therapy and to detect and avoid hypoglycaemia. Periodic diabetes education, family members’ and caretakers’ participation and regular diabetes clinic follow-up are crucial in effective diabetes management in this age group.
Physical activity should be encouraged to help maintain functional status and comprehensive geriatric assessments should be carried out on a periodic basis to identify functional and cognitive decline, as well as psychosocial concerns. Communication with the diabetes care team and the use of community resources on a frequent basis can be beneficial.7
To conclude, we can say that it is a very rare occurrence for a very elderly individual to be presenting with DKA at the time of diagnosis of diabetes. In our opinion, educating such individuals in self-management could prove to be very challenging depending on their physical and mental health, social circumstances and ability to learn. Our patient lived independently and has normal cognitive functions. She preferred to keep her independence and learnt to self-manage diabetes. In such age group preventing hypoglycaemic should be the most important aspect of treatment while avoiding symptomatic hyperglycaemic. It is evident that basal insulin once daily worked effectively in this very elderly patient with newly discovered T1DM, with absence of significant hypoglycaemia.
Diabetes can present at any age group and is not typically a disease of young.
Physicians should maintain a high index of suspicion while dealing with newly diagnosed diabetes in an older patient.
Educating such individuals in self-management could prove to be very challenging depending on their physical and mental health, social circumstances and ability to learn.
Patient consent for publication
Contributors WA planned the presented work. CB and LD conducted the work. Compiling and submission of the work was done by WA. NS supervised the work. WA and NS responsible for the overall content as guarantors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.