Elderly Patients With Diabetes: Special Aspects to Consider

Also driven by the progress made in the last decades in the area of diabetes technology (DT), even more patients with diabetes are reaching an older adulthood of 65+ years. The life expectancy of patients with diabetes approaches that of healthy individuals, albeit being still a bit lower. Many older patients with diabetes have been using DT on a regular basis to manage their diabetes and age is no contraindication to use DT. This includes the use of glucose meters for self-monitoring of blood glucose (SMBG), systems for continuous glucose monitoring (CGM), insulin pens and syringes, as well as insulin pumps (continuous subcutaneous insulin infusion, CSII). Many of these elderly patients with diabetes have smartphones and use apps and other opportunities offered by digitalization, such as bolus calculators, patient decision support systems (PDSS), and apps and gadgets (“wearables”) targeting a healthy lifestyle (eg, Fitbit). In the not too distant future, these patients with diabetes may also be candidates for the use of systems for automated insulin delivery (AID).

So, is everything well with diabetes therapy in elderly patients with diabetes? Not to our understanding—we see a number of critical issues that we would like to describe below and have outlined what we believe is very much needed to ensure successful and safe use of DT at an older age.

(Self-)management of Elderly Patients With Type 1 Diabetes

In general, diabetes management is an endeavor that has to be individually tailored to the patients with diabetes, his and her needs, characteristics, and capabilities. This is particularly true for the use of DT and even more so in elderly adults with type 1 diabetes (T1D). Cognitive decline and sensorimotor impairments that may be detrimental to the successful use of DT are common in elderly patients with T1D, with large and clinically significant variation between individuals. While a given patient with T1D may easily preserve his or her self-management skills and successfully use DT even with increasing age, other patients with diabetes may experience substantial visual impairments or memory decline that are significant—and possibly dangerous—barriers to DT use. ¹ Individually tailored regimens and DT options are called for that take into account possible age-associated impairments.

Elderly patients with T1DM diabetes are at risk of hypoglycemia. A study of the frequency of hypoglycemia in 199 adults with an age 60 years and above in the T1D Exchange study demonstrated: (1) CGM values <70 mg/dL for a median of 91 min per day; (2) on 53% of days, glucose levels continuously <70 mg/dl for ≥20 min; and (3) hypoglycemia strongly associated with glucose variability. ² Continuous glucose monitoring sensors for detecting hypoglycemia and providing an alarm can be useful for preventing hypoglycemia in this population. ³ In older adults with an age 60 years and above with long-standing T1D, greater hypoglycemia unawareness and glucose variability have been shown to be associated with an increased risk of severe hypoglycemia. ²

Elderly Patients With Type 1 Diabetes in Hospitals

When patients with T1D have to enter a hospital for inpatient treatment or surgery, this can lead to massive issues with their diabetes therapy. This is especially true for elderly patients using DT. All too often their insulin pump therapy is questioned (or even discontinued, which is a fear often experienced by elderly patients with T1D on CSII), solely on the grounds of a patient being old without paying attention to the individual’s diabetes self-management capabilities that—as we argued above—varies considerably across individuals. ⁴ While guidance and clinical recommendations for hospital treatment of patients with diabetes do exist, the population of the elderly patients with T1D has been neglected in this regard so far, particularly when it comes to recommendations concerning DTs.

Elderly Patients With Type 2 Diabetes in Daily Life

Many elderly patients with type 2 diabetes (T2D) have issues with their eyesight and manual abilities. ¹ For such patients, DT should exist that supports them with the handling of their blood glucose meter, selecting the insulin dose on their pen, and so forth. Some of such controlling functions might be done via an app.

In a registry study of over 215 000 patients with T2D from Germany and Austria, significant higher rates of severe hypoglycemia were observed in the presence (compared to the absence) of dementia, which tends to affect elderly people. ⁵ In geriatric patients with diabetes, a hyperglycemic crisis episode (defined as an episode of either diabetic ketoacidosis, hyperosmolar hyperglycemic state, or both) can increase the long-term mortality risk almost threefold. This finding was reported in a real world evidence study in Taiwan of 13 551 geriatric patients with new-onset diabetes. ⁶ To avoid serious states of extreme glucose dysregulation in geriatric patients with diabetes and especially in those geriatric patients with dementia, there is good reason for routine use of CGM systems with hypoglycemia alarms.

Elderly Patients With Type 2 diabetes in Hospitals and Nursing Homes

In view of the many millions of patients with T2D, it is clear that an ever increasing number of elderly patients has to receive medical treatment in hospitals or must live in nursing homes. Many issues that may arise are similar to those experienced by T1D individuals, such as lack of diabetes specialists involved in treatment and care and the possibility that DT use may be discontinued on the grounds of advanced age only. Too little attention has been paid to the large T2D population in nursing homes and residencies, where diabetes care specialists are probably even more scarce than in hospitals.

Continuous Glucose Monitoring

The DIAMOND Study separately compared CGM with usual care (ie, SMBG) in 158 adults with T1DM, ⁷ and 158 adults with T2DM. ⁸ Improvement in HbA1c at 24 weeks was significantly greater in both participants with T1D and those with T2D using a CGM system (compared to SMBG for each of the two types of diabetes). In an analysis of the 116 subjects age 60 years and above with T1D (n = 34) or T2D (n = 82) from both studies who were using MDI therapy and were randomly assigned to either CGM or SMBG, CGM use was associated with improved HbA1c and reduced glycemic variability. ⁹ This pooled analysis demonstrates the benefits of this type of CGM usage in adults age 60 years and above with T1D or T2D.

Telemedicine

An area where telemedicine may prove to be highly effective for older adults with diabetes is in providing medical care to the geriatric population. ¹⁰ A recent literature review of articles published between 2011 and 2016 about home telemedicine interventions for older adults with diabetes identified six articles. The authors of this review suggest that case management, education, closed-loop feedback and communication, home telemonitoring devices or units, and motivational interviewing or coaching can effectively decrease admissions, costs per person per year, mortality, and cognitive decline in older adults with diabetes. Three of the six articles were felt by the authors of the review to be of questionable quality, leaving the conclusions to be supported by only three high quality articles. ¹¹

The scarcity of outcomes data for telemedicine interventions for older patients with diabetes was illustrated in a review article published in 2018 about diabetes treatment in the elderly incorporating geriatrics, technology, and functional medicine. This article was intended to provide an updated summary of treatment strategies for community-dwelling older adults. The article contained a section on telemedicine strategies that presented no references at all of outcomes data for telemedicine interventions in older adults with diabetes. ¹²

Telemedicine appears to be potentially a useful tool for facilitating communication and improving outcomes in older patients with diabetes. More research is need to define the benefits and drawbacks of this technology for older adults with diabetes or subgroups of this population.

Summary and Recommendations

In summary, successful DT use in elderly patients with T1D or T2D faces significant barriers that have to be overcome given the demographic trend and the resulting increase in the number of patients. To do so, we propose very much needed actions that are first and foremost targeted at HCPs and developers and manufacturers of DT. These actions pertain to individualization and awareness.

As outlined before, successful DT use in elderly patients with T1D demands a dedicated individualization of the therapy and DT solutions that acknowledge the huge variation across individuals in domains such as cognitive function and sensorimotor skills. Alas, today’s DT products and solutions are delivered to market as “one-size-fits-all” solutions almost exclusively. Customizable features, such as adaptable displays or voice over options for the visually impaired or simplified menus for the cognitively challenged, are, per se, easy to implement. We are well aware that the current lack of meaningful FDA-cleared customizable features for data analysis and data sharing can be a limiting factor in personalizing the benefits of various technologies. ¹³

The current recommendations for achieving a “Personalized User Experience” put forth by the European Commission’s initiative European Innovation Partnership on Active and Healthy Ageing may offer some initial guidance in this regard. ¹⁴ Similarly, HCPs should learn increasingly to think “individualization,” particularly when it comes to inpatient treatment in hospitals, and voice the need for suitable and customizable DT solutions.

Dedicated guidance, recommendations, and clinical training is needed in this regard, particularly for HCPs who are not diabetes specialists but regularly treat elderly patients with diabetes, which is often the case in hospitals and nursing homes.

Finally, optimal design of devices specifically for elderly diabetes patients will enable these devices to be used most effectively. More research in device usability with a gerontological focus is needed. ¹⁵