Continuous Subcutaneous Insulin Infusion Can Be Used Effectively and Safely in Older Patients with Type 1 Diabetes: Long-Term Follow-up

Ageing well with diabetes: the role of technology

Over the past two decades there has been a substantial rise in the adoption of diabetes therapeutic technology among children, adolescents and younger adults with type 1 diabetes, and its use is now also advocated for older individuals. Older people with diabetes are more prone to experience hypoglycaemia because of numerous predisposing factors and are at higher risk of hypoglycaemic events requiring third-party assistance as well as other adverse sequelae. Hypoglycaemia may also have long-term consequences, including cognitive impairment, frailty and disability. Diabetes in older people is often characterised by marked glucose variability related to age-associated changes such as variable appetite and levels of physical activity, comorbidities and polypharmacotherapy. Preventing hypoglycaemia and mitigating glucose excursions may have considerable positive impacts on physical and cognitive function and general well-being and may even prevent or improve frailty. Technology for older people includes continuous glucose monitoring systems, insulin pumps, automated insulin delivery systems and smart insulin pens. Clinical trials and real-world studies have shown that older people with diabetes benefit from technology in terms of glucose management, reductions in hypoglycaemic events, emergency department attendance and hospital admissions, and improvement in quality of life. However, ageing may bring physical impairments and other challenges that hinder the use of technology. Healthcare professionals should identify older adults with diabetes who may benefit from therapeutic technology and then adopt an individualised approach to education and follow-up for individuals and their caregivers. Future research should explore the impact of diabetes technology on outcomes relevant to older people with diabetes.

Impact of a tubeless, disposable insulin pump on emergency department visits and inpatient admissions among a Medicare population

BACKGROUND

A tubeless, disposable insulin pump (Omnipod DASH Insulin Management System, Insulet Corporation) has demonstrated improved glycemic outcomes for people with diabetes who require insulin. The impact of the system on downstream health care events has not been studied.

OBJECTIVE

To assess health care resource utilization for a Medicare population before and after starting tubeless, disposable insulin pump therapy.

METHODS

This retrospective, observational analysis used data from the Centers for Medicare & Medicaid Services 100% Research Identifiable Files. Study outcomes included change in event rates for diabetes-related emergency department (DRED) visits, all-cause emergency department (ACED) visits, diabetes-related inpatient (DRIP) admissions, and all-cause inpatient (ACIP) admissions among Medicare beneficiaries who started the tubeless, disposable insulin pump in 2020 (postpump observation period) as compared with the same duration and calendar period in 2019 (prepump observation period) with no pump use. Subgroup analyses were performed based on Medicare entitlement reason, diabetes type, and diagnosis status for depressive disorder.

RESULTS

A total of 811 users met the criteria for analysis: 46.2% had type 2 diabetes, a majority (59.2%) were aged 65 years or older, and 37.0% had a diagnosis for depressive disorder. Significant reductions were observed for DRED of -46.9% (95% CI = -63% to -23%); ACED of -29.0% (95% CI = -37% to -20%); ACIP of -19.9% (95% CI = -32% to -6%). DRIP rates declined notably (-36.6%; 95% CI = -61% to 4%). Event rates observed across subgroups demonstrated consistent downward trends; however, not all were statistically significant.

CONCLUSIONS

These findings demonstrate that use of the tubeless, disposable insulin pump was associated with reductions in DRED, ACED, and ACIP. Our results provide real-world evidence to support the use of the tubeless, disposable insulin pump among Medicare beneficiaries who require insulin, regardless of diabetes type or Medicare entitlement reason. Additional studies are recommended to further evaluate the effect of insulin pumps on health care utilization among the Medicare population and other insurance populations.

Insulin Pump Utilization in 2017-2021 for More Than 22,000 Children and Adults With Type 1 Diabetes: A Multicenter Observational Study

This large type 1 diabetes cohort study showed that insulin pump utilization has increased over time and that use differs by sex, insurance type, and race/ethnicity. Insulin pump use was associated with more optimal A1C, increased use of continuous glucose monitoring (CGM), and lower rates of diabetic ketoacidosis and severe hypoglycemia. People who used an insulin pump with CGM had lower rates of acute events than their counterparts who used an insulin pump without CGM. These findings highlight the need to improve access of diabetes technology through provider engagement, multidisciplinary approaches, and efforts to address health inequities.

Insulin-dependent diabetes mellitus in older adults: Current status and future prospects

The recent increase in life expectancy has resulted in an increase in the number of older adults with diabetes mellitus. In addition to type 2 diabetes, in which aging is a well‐known risk factor, individuals with type 1 and other types of diabetes are also increasing owing to longevity in the general population and improved prognosis of the disease and comorbidities. Insulin‐dependent state in type 1 diabetes and other types of diabetes, such as diabetes after pancreatectomy, inevitably requires insulin treatment for survival; however, daily injection of insulin is often hampered in older adults due to impaired cognitive function or limited activities of daily living. In this review, we aimed to discuss the current situation of insulin‐dependent diabetes mellitus in older adults and highlight future prospects. Geriatr Gerontol Int 2022; 22: 549–553.

Closed-Loop Insulin Delivery Versus Sensor-Augmented Pump Therapy in Older Adults With Type 1 Diabetes (ORACL): A Randomized, Crossover Trial

OBJECTIVE

To assess the efficacy and safety of closed-loop insulin delivery compared with sensor-augmented pump therapy among older adults with type 1 diabetes.

RESEARCH DESIGN AND METHODS

This open-label, randomized (1:1), crossover trial compared 4 months of closed-loop versus sensor-augmented pump therapy. Eligible adults were aged ≥60 years, with type 1 diabetes (duration ≥10 years), using an insulin pump. The primary outcome was continuous glucose monitoring (CGM) time in range (TIR; 3.9-10.0 mmol/L).

RESULTS

There were 30 participants (mean age 67 [SD 5] years), with median type 1 diabetes duration of 38 years (interquartile range [IQR] 20-47), randomized (n = 15 to each sequence); all completed the trial. The mean TIR was 75.2% (SD 6.3) during the closed-loop stage and 69.0% (9.1) during the sensor-augmented pump stage (difference of 6.2 percentage points [95% CI 4.4 to 8.0]; P < 0.0001). All prespecified CGM metrics favored closed loop over the sensor-augmented pump; benefits were greatest overnight. Closed loop reduced CGM time <3.9 mmol/L during 24 h/day by 0.5 percentage points (95% CI 0.3 to 1.1; P = 0.0005) and overnight by 0.8 percentage points (0.4 to 1.1; P < 0.0001) compared with sensor-augmented pump. There was no significant difference in HbA1c between closed-loop versus sensor-augmented pump stages (7.3% [IQR, 7.1-7.5] (56 mmol/mol [54-59]) vs. 7.5% [7.1-7.9] (59 mmol/mol [54-62]), respectively; P = 0.13). Three severe hypoglycemia events occurred during the closed-loop stage and two occurred during the sensor-augmented pump stage; no hypoglycemic events required hospitalization. One episode of diabetic ketoacidosis occurred during the sensor-augmented pump stage; no serious adverse events occurred during the closed-loop stage.

CONCLUSIONS

Closed-loop therapy is an effective treatment option for older adults with long-duration type 1 diabetes, and no safety issues were identified. These older adults had higher TIR accompanied by less time below range during closed loop than during sensor-augmented pump therapy. Of particular clinical importance, closed loop reduced the time spent in hypoglycemic range overnight.

Use of Technology in Older Adults with Type 1 Diabetes: Clinical Characteristics and Glycemic Metrics

Background: The use of diabetes-related technology, both for insulin administration and glucose monitoring, has shown benefits in older adults with type 1 diabetes (T1D). However, the characteristics of older adults with T1D and their use of technology in real-world situations are not well documented. Methods: Older adults (age ≥65 years) with T1D, using insulin pump or multiple daily injections (MDI) for insulin administration, and continuous glucose monitoring (CGM) or glucometer (blood glucose monitoring [BGM]) for glucose monitoring were evaluated. Participants wore CGM for 2 weeks, completed surveys, and underwent laboratory evaluation. Results: We evaluated 165 older adults with T1D; mean age 70 ± 10 years, diabetes duration 40 ± 17 years, and A1C 7.4% ± 0.9% (57 ± 10 mmol/mol). For insulin administration, 63 (38%) were using MDI, while 102 (62%) were using pump. Compared to MDI, pump users were less likely to have cognitive dysfunction (49% vs. 65%, P = 0.04) and had lower scores on the hypoglycemia fear survey (P = 0.03). For glucose monitoring, 95 (58%) used CGM, while 70 (42%) used BGM. Compared to BGM, CGM users were more likely to report impaired awareness of hypoglycemia (IAH) (P = 0.01), and had lower A1C (P = 0.02). Participants who used any technology (pump or CGM) had lower A1C (P = 0.04, 0.006), less hypoglycemia ≤54 mg/dL (P = 0.0006, <0.0001) and <70 mg/dL (P = 0.0002, 0.0001), and fewer glycemic excursions (coefficient of variation %) (P = 0.0001, <0.0001), while reporting more IAH (P = 0.04, P = 0.006) and diabetes distress (P = 0.02, 0.004). Conclusion: Older adults with T1D who use newer diabetes-related technology had better glycemic control, lower hypoglycemia risk, and fewer glycemic excursions. However, they were more likely to report IAH and diabetes-related distress. Clinical trials.gov NCT03078491.

Clinical Considerations for Insulin Therapy in Older Adults with Type 1 Diabetes

Type 1 diabetes represents an autoimmune condition with a strong inherited background, and its incidence is increasing worldwide. About 25% of such cases are diagnosed in adulthood, some even as late as the ninth decade of life. The number of older adults with type 1 diabetes is increasing due to improvements in care and decreased mortality rate. However, there is a lack of clinical trials in people older than 70 years of age with type 1 diabetes complicated with comorbidities, frailty, and dependency. The management of type 1 diabetes and the goals of therapy should be individualized based on the patient's health status and life expectancy. In healthier older adults, insulin treatment regimens (multiple daily insulin injections or insulin pump therapy) that approximate the normal physiology of insulin secretion should be used to achieve lower glycemic goals, while reducing the risk of hypoglycemia with frequent glucose monitoring (preferably using continuous glucose monitoring systems). For frail individuals with poor health, simpler insulin regimens and less stringent glycemic targets would be more appropriate. Poor cognition, vision and hearing, impaired mobility, depression, and chronic pain can interfere with complex insulin regimens. In these individuals, the principal goals of therapy are to reduce the acute effects of hyperglycemia, minimize hypoglycemia risk, and optimize quality of life. The newer insulin preparations and technological advances in insulin delivery and blood glucose monitoring have enhanced the management of type 1 diabetes in all age groups.

Efficacy and safety of sensor augmented insulin pump therapy with low-glucose suspend feature in older adults: A retrospective study in Bogota, Colombia

BACKGROUND AND AIMS

The literature has supported the efficacy and safety of insulin pump therapy in young adults diagnosed with type 1 diabetes (DM1). However, there is limited evidence in older adults with DM1 and DM2.

METHODS

A retrospective cohort study was conducted in patients ≥60 years-old with DM1 and DM2, who started Sensor Augmented Insulin Pump therapy with low-glucose suspend feature (SAP + LGS) at Hospital Universitario San Ignacio diabetes center in Bogotá, Colombia. Patients were evaluated between 2009 and 2019 and were treated with Paradigm VEO or Medtronic MiniMed 640 insulin pumps and continuous glucose monitoring system. Glycated hemoglobin (A1c), severe hypoglycemia and hypoglycemia unawareness were assessed at least every 3 months, and hospitalizations and ketoacidosis episodes incidence were assessed yearly.

RESULTS

36 patients were analyzed, (67.36 ± 4.88 years-old) (body mass index 25.48 ± 4.61 kg/m2). The most common indications for starting SAP + LGS were hypoglycemia (58.3%), high glycemic variability (25.0%) and poor metabolic control (16.7%). 26 patients used VEO (72.2%) whereas 27.8% started 640 insulin pump. Data from 32 participants showed A1c decreased from 8.57 ± 1.73% to 7.42 ± 0.96 after a year of therapy (Mean difference -1.15%, p < 0.05); 28.12% reached A1c levels <7% and 42.85% < 7.5%. There was a significant decrease in the proportion of patients with at least one severe hypoglycemia (56.7 vs 3.3%), one or more hospitalizations (20 vs 3.3%), and hypoglycemia unawareness after the first year of follow-up (p < 0.05).

CONCLUSIONS

These results suggest that SAP + LGS is safe and effective in people 60 years or older after one year of therapy. Future randomized clinical trials are needed in the elderly.

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry

AIM

To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuous subcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII.

RESEARCH DESIGN AND METHODS

Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N = 1404 CSII; N = 8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes.

RESULTS

CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA_1c [60.7 mmol/mol (7.7 ± 0.1%) vs. 62.8% (7.9 ± 0.1%)], lower daily insulin dose (0.49 ± 0.02 vs. 0.61 ± 0.01 IU/kg), fewer days in hospital (8.1 ± 0.12 vs. 11.2 ± 0.11 days/person-year), fewer severe hypoglycaemic events (0.16 ± 0.02 vs. 0.21 ± 0.03 events/person-year) and fewer diabetic ketoacidosis (0.06 ± 0.01 vs. 0.08 ± 0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy.

CONCLUSIONS

A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII.

Efficacy and safety of long-term insulin pump treatment in patients with type 1 diabetes aged over 50 years

Continuous subcutaneous insulin infusion (CSII) therapy using insulin pumps has become widely used in the treatment of type 1 diabetes mellitus (T1DM). This retrospective study aimed to assess the efficacy and safety of long-term insulin pump treatment in patients with T1DM aged ≥50 years. The study included patients aged ≥50 years, who had a diagnosis of T1DM based on clinical criteria and/or presence of autoantibodies characteristic of autoimmune diabetes, and had received ≥5 years of recent and uninterrupted treatment with a personal insulin pump. We analyzed records on HbA1c levels across the entire observation period. The cohort comprised 17 patients, of whom 6 (35%) were men and 11 (65%) were women. The mean duration of observation was 6.6 years, during which patients had a mean of 8.4 HbA1c measurements. Mean HbA1c level over the entire observation period was 6.7% (range, 5.3-7.4%). Overall, 11 patients (65%) had mean HbA1c levels at the ADA-recommended target of <7% and 5 patients (29%) had mean HbA1c <6.5%. Mean HbA1c level was significantly lower at the end of the observation period than at the start (6.52% versus 6.91%; difference, -0.39%; p < 0.01), indicating an improvement in glycaemic control over time. On average, patients experienced one level 1 hypoglycaemia episode every 2.4 days. This retrospective analysis of at least 5 years of follow-up of selected patients with T1DM aged ≥50 years at the start of observation, showed that CSII is a safe and effective treatment option in this age group.

Benefits and Challenges of Diabetes Technology Use in Older Adults

With successful aging of adults with type 1 diabetes, there is an increased opportunity to use technology for diabetes management. Technology can ease the burden of self-care and provide a sense of security. However, age-related cognitive and physical decline can make technology use difficult. Guidelines using technology in the aging population are urgently needed, along with educational material for the clinicians and caregivers. In this article, we review the evidence supporting the use of diabetes-related technologies in the older population and discuss recommendations based on current data and the authors' clinical knowledge and experience.

Has Technology Improved Diabetes Management in Relation to Age, Gender, and Ethnicity?

PURPOSE OF REVIEW

To review the current state of diabetes technology adoption and describe impact on outcomes in the context of age, gender, and ethnicity. We will discuss barriers and propose solutions that may help facilitate the adoption.

RECENT FINDINGS

We are witnessing rapid evolution and increase in adoption of diabetes technology in all its forms, including insulin delivery and glucose monitoring devices, mobile medical applications, and telemedicine. This technology has a great potential to improve diabetes-related outcomes, including acute and chronic complications as well as quality of life for people living with diabetes. However, currently available outcome data are showing modest efficacy and evidence for disparities when it comes to age, gender, and ethnicity. Despite multiple barriers, the adoption of technology is steadily increasing. It is clear that disparities exist in terms of access to and use of technology, but they may be at least in part driven by unmet needs of end users and as such are not unsurmountable. While more research is needed to identify the specific causes for the disparities, future development of diabetes technology that is based on adaptation of behavioral theories has a potential to address the gaps. The disparities can be lessened by understanding the needs of end users and with improvement in personalization of technology, allowing the right device to be used by the right patient. Targeted interventions to increase awareness and education and help navigate the processes involved in currently available technology may help diminish the gaps in health equity.