Type 1 Diabetes is typically a disease of the young but can present at any age. It is important to ensure correct categorisation as the acute complications related to insulin deficiency can occur and can be life threatening. It is important for physicians to maintain a high index of suspicion while dealing with newly diagnosed diabetes in an older patient. The following case report illustrates the fact that Type 1 Diabetes can present in the elderly.
A 94 year old woman, thinly built with no family history of diabetes presented to her general practitioner with a history of polyuria and vulvitis. Diabetes was diagnosed and there was no evidence of long-term diabetic complications. She was commenced on oral hypoglycaemic drugs. Despite maximum therapy with Gliclazide 160 mg BD and Metformin 500 mgs TDS her glycaemic control remained poor with pronounced osmotic symptoms and she was referred to the hospital clinic. HbA1c was 11.0 (Normal range is 3.5 to 5.5). Though there were no ketones on urinalysis, she was found to be positive for anti-GAD and anti-islet cell cytoplasm antibodies in high titres indicating a diagnosis of Type 1 diabetes. She was subsequently started on insulin (Humulin I) OD following which she improved with no further symptoms of hyperglycaemia. The oldest reported patient in the literature was aged 93.
Type 1 diabetes may not present as the classic rapid acute disease seen in children and adolescents because autoimmune destruction of beta -cells is usually slower than childhood onset disease. Thus type 1 diabetes can present in older patients without ketoacidosis (or ketonuria) and in subjects with a range of Body Mass Index. A high index of suspicion, careful clinical history and specific investigations can help achieve correct diagnosis and treatment.