Acceptability of Continuous Glucose Monitoring in Elderly Diabetes Patients Using Multiple Daily Insulin Injections

Narrative Review: Continuous Glucose Monitoring (CGM) in Older Adults with Diabetes

INTRODUCTION

Continuous glucose monitoring (CGM) has revolutionised diabetes care, with proven effect on glycaemic control, adverse diabetic events (such as hypoglycaemia and diabetic ketoacidosis) and hospitalisations in the general population. However, the evidence for CGM in older people is less robust.

METHOD

We conducted a narrative review of trials reporting data comparing standard blood glucose monitoring (SBGM) and CGM in adults over 65 with type 1 or type 2 diabetes who were treated with insulin published between 1999 and 2024.

RESULTS

Seventeen studies were identified, including eight retrospective cohort studies and five randomised controlled trials (RCTs). Sixteen of the 17 papers were based in Europe or North America. The studies were highly heterogeneous; however, they provided clear evidence supporting the use of CGM in reducing hypoglycemia in older adults, with potential benefits for overall wellbeing and quality of life..

CONCLUSIONS

Current approaches to diabetes care in older adults may over-rely on HbA1c (haemoglobin A1c) as a measurement of control given accuracy may be reduced in older adults and propensity for hypoglycaemia. Although goals should be personalised, avoidance of hypoglycaemia is a key goal for many older people with diabetes. There is good evidence that CGM can improve time-in-range and reduce hypoglycaemia and glucose variability in older adults. CGM should be considered for older adults as a means of reducing hypoglycaemia and associated potential harm.

Use of Continuous Glucose Monitoring in Skilled Nursing Facilities: Strategies for Managing Implementation

PURPOSE

Continuous glucose monitoring (CGM) devices are increasingly used by older adults. Although these devices offer several advantages over traditional techniques, such as fingerstick capillary blood glucose, the current article discusses the impact and benefits of CGMs in the context of older adults in skilled nursing facilities (SNFs) and explores ways to improve and manage their use through the collaboration of an interprofessional team.

METHOD

Current evidence and guidance on implementing CGM devices in SNFs is reviewed.

RESULTS

Current strategies for the successful and safe use of CGM devices in SNFs include staff and patient education, close monitoring, operational workflow, and interprofessional collaboration.

CONCLUSION

To manage patients with diabetes in SNFs, an interactive, multidisciplinary, and multifaceted approach is needed. Larger studies on the management of CGM devices in SNFs are required. [Journal of Gerontological Nursing, 51(3), 7-12.].

Advancing elderly diabetes care: exploring the usability and acceptance of continuous glucose monitoring (CGM)

OBJECTIVES

This study aimed to evaluate the acceptability, usability, compliance, and satisfaction of Continuous Glucose Monitoring (CGM) among elderly diabetic patients.

DESIGN

Utilizing a mixed-methods approach, the study involved 30 participants, averaging 74.79 years in age. Participants wore two CGM devices, and their experiences, along with survey data, were comprehensively analyzed to gauge the effectiveness of CGM in managing diabetes.

RESULTS

The study demonstrated that -CGM- is highly usable and acceptable among elderly diabetic patients. Participants effectively utilized CGM to monitor and predict blood glucose trends, positively influencing their glucose control and lifestyle. The average adherence rate was found to be 81 %, indicating a substantial level of effective self-management and treatment decision-making.

CONCLUSION

The study recommends developing CGM educational programs tailored for the elderly, educating healthcare professionals, expanding insurance coverage for CGM, and promoting real-time CGM technology to improve usability and acceptance among the elderly.

[Continuous glucose monitoring devices in people over 65 years: literature review]

Background

The use of continuous glucose monitoring (CGM) in elderly patients with diabetes is not well documented. The present study search to know the current status of use of CGM devices in patients with diabetes over 65 years of age.

Methods

A systematic literature search was performed in PubMed and Scopus databases in November 2023. The following descriptors were used, linked using the Boolean operators AND and OR: Diabetes, Continuous glucose monitoring, Flash glucose monitoring, Glycemia, Glycemic control, Controlled diabetes, Diabetes care, Metrics, Older and Elder. The CASPe critical reading system and the PRISMA methodology were applied to document the review.

Results

Fourteen selected studies published between 2019 and 2023 were reviewed. Publications from European countries used small sample sizes and were intervention studies. The duration of the interventions was generally short: 7 were ≤14 days in duration and only 3 were 6-12 months in duration. Overall, the selected articles found that CGM improved glycemic outcomes due to a decrease in glycosylated hemoglobin value and an improvement in CGM metrics, and diabetes-associated complications in elderly patients with diabetes.

Conclusion

CGM seems to be a useful and effective tool to improving glycemic outcomes of people with diabetes over age 65. Further studies under real-world conditions and of longer duration are needed to expand and improve the evidence.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Towards Integrated Care for the Elderly: Exploring the Acceptability of Telemonitoring for Hypertension and Type 2 Diabetes Management

Introduction

Telemonitoring has been proposed as an effective method to support integrated care for older people with hypertension and type 2 diabetes. This paper examines acceptability of telemontioring, its role in supporting integrated care, and identifies scale-up barriers.

Methods

A concurrent triangulation mixed-methods study, including in-depth interviews (n = 29) and quantitative acceptability tool (n = 55) was conducted among individuals who underwent a 12-month telemonitoring routine. The research was guided by the Theoretical Framework of Acceptability. Interviews were analysed using template content analysis (TCA).

Results

TCA identified seven domains of acceptability, with twenty-one subthemes influencing it positively or negatively. In the quantitative survey, acceptability was high across all seven domains with an overall score of 4.4 out of 5. Urban regions showed higher acceptability than rural regions (4.5 vs. 4.3), with rural participants perceiving initial training and participation effort as significantly more burdensome than their urban counterparts.

Discussion

Patients described several instances where telemonitoring supported self-management, education, treatment, and identification elements of the integrated care package. However, there were barriers that may limit its further scale-up.

Conclusion

For further scale-up, it is important to screen patients for monitoring eligibility, adapt telemonitoring devices to elderly needs, combine telemonitoring with health education, involve family members, and establish follow-up programmes.

A scoping review of the patient experience with wearable technology

Objective

This scoping review explores patients' experience with wearable technology. Its aims are to: (a) examine studies that contain empirical findings related to patients' experience with wearables; (b) compare these findings within and across studies; and (c) identify areas in need of greater understanding.

Methods

A Preferred Reporting Items for Scoping Review (PRISMA) guided approach was followed. Four databases of peer-reviewed articles (CINAHL, EMBASE, PubMed, and Web of Science) were searched for empirical articles involving patients' experience of using wearable technology. A standardized data abstraction form recorded relevant information on the articles identified. Data analysis included frequency counts for all abstracted categories; and itemized (by study) findings related to patients' wearable experience including satisfaction.

Results

Forty-six studies comprised the final review sample. The research literature examining patients' wearable experience is characterized by variety in terms of sample sizes, medical situations and wearable devices examined, research settings, and geographic location. This literature supports a positive patient experience with wearables in terms of satisfaction and usability, although the evidence is mixed when it comes to comfort. The moderate to higher satisfaction, usability, and comfort findings across studies do not suggest any sort of pattern with respect to the type of wearable, medical situation, or location.

Conclusions

The review findings suggest that health care organizations should view wearable technology as a viable complement to traditional aspects of patient care. However, from a patient experience standpoint, there is still much to know and validate in this regard, especially as the technology continues to advance.

Health-Related Quality of Life Assessment in Older Patients with Type 1 and Type 2 Diabetes

Type 1 (T1D) and type 2 diabetes (T2D) are determinants of health-related outcomes including health-related quality of life (HRQOL). We aimed to determine differences in HRQOL between older adults with T1D and T2D and specific factors influencing HRQOL in this age group. This study used a cross-sectional design with 56 age- and HbA1c-matched T1D and T2D patients (aged 68.9 ± 7.8 years; 55% had T2D). We employed several validated questionnaires (Short Form-36 (SF-36) and the EuroQol-5 Dimensions/Visual Analog Scale (VAS)) to investigate the relationships between HRQOL domains and diabetes type, glycemic control, complications, and comorbidities. T1D was associated with better self-reported general health (assessed with the SF-36 general health domain (p = 0.048) and the EuroQol-5 VAS (p = 0.002), whereas no significant differences in the other SF-36 domains, self-reported diabetes distress, anxiety, or depression were found. Most HRQOL domains were not associated with HbA1c or the presence of diabetes complications. The most significant reduction in HRQOL was experienced by patients with higher BMIs, irrespective of the diabetes type. The obtained HRQOL data could be used in clinical settings for evidence-based patient education focused on specific subgroups of patients, as well as in national healthcare policies, e.g., interventions designed to alleviate obesity.

Use of Continuous Glucose Monitors to Manage Type 1 Diabetes Mellitus: Progress, Challenges, and Recommendations

Type 1 diabetes (T1D) management has been revolutionized with the development and routine utilization of continuous glucose monitoring (CGM). CGM technology has allowed for the ability to track dynamic glycemic fluctuations and trends over time allowing for optimization of medical therapy and the prevention of dangerous hypoglycemic events. This review details currently-available real-time and intermittently-scanned CGM devices, clinical benefits, and challenges of CGM use, and current guidelines supporting its use in the clinical care of patients with T1D. We additionally describe future issues that will need to be addressed as CGM technology continues to evolve.

Real-world study of flash glucose monitoring among adults with type 2 diabetes within the Swedish National Diabetes Register

BACKGROUND

The Swedish National Diabetes Register (NDR) initiated registration of the FreeStyle Libre® system and other continuous glucose monitoring (CGM) systems in June 2016. We investigated change in HbA1c for people with type 2 diabetes (T2DM) using FreeStyle Libre in Sweden.

METHODS

We included adults with T2DM, registered in the NDR after January 1, 2014, and an index date for first use of FreeStyle Libre of June 2016 or later. Methodology was a before/after comparison of HbA1c within 6 months before the index date versus HbA1c around 6 and 12 months after the index date.

RESULTS

711 adults with T2DM using FreeStyle Libre had HbA1c measurements within the study period. Mean HbA1c was significantly reduced at 6 months (-0.50%-unit) and at 12 months (-0.52%-unit) in this group. Degree of change was negatively correlated to baseline HbA1c. Reductions in HbA1c were observed in incident users of FreeStyle Libre with T2DM who were truly naïve to CGM or had unknown prior experience of CGM, and aged 25-74 years.

CONCLUSIONS

This real-world study on the Swedish NDR shows that people with T2DM using FreeStyle Libre system for 6 and 12 months significantly reduced their HbA1c.

Use of Continuous Glucose Monitoring in Older Adults: A Review of Benefits, Challenges and Future Directions

Many new technologies have been developed over the past decade, and these have substantially changed the way diabetes is managed. Continuous glucose monitoring is now the standard of care for many people living with diabetes, and among its numerous benefits, it has been shown to improve glycaemic outcomes and enhance quality of life. Older adults carry a high burden of diabetes and have a high risk of hypo-glycaemia and hypo-glycaemic unawareness, and continuous glucose monitoring can help to improve glycaemic management in this vulnerable population. Unfortunately, only a few trials have evaluated the effectiveness of continuous glucose monitoring in older adults. Certainly, the implementation of continuous glucose monitoring in older adults can come with many challenges, including logistical, educational and reimbursement barriers. This article will discuss the benefits of continuous glucose monitoring in older adults with diabetes, the clinical studies that support its use and the barriers to its optimal implementation in this population.

The Impact of a Recently Approved Automated Insulin Delivery System on Glycemic, Sleep, and Psychosocial Outcomes in Older Adults With Type 1 Diabetes: A Pilot Study

BACKGROUND

Older adults with type 1 diabetes (≥65 years) are often under-represented in clinical trials of automated insulin delivery (AID) systems. We sought to test the efficacy of a recently FDA-approved AID system in this population.

METHODS

Participants with type 1 diabetes used sensor-augmented pump (SAP) therapy for four weeks and then used an AID system (Control-IQ) for four weeks. In addition to glucose control variables, patient-reported outcomes (PRO) were assessed with questionnaires and sleep parameters were assessed by actigraphy.

RESULTS

Fifteen older adults (mean age 68.7 ± 3.3, HbA1c of 7.0 ± 0.8) completed the pilot trial. Glycemic outcomes improved during AID compared to SAP. During AID use, mean glucose was 146.0 mg/dL; mean percent time in range (TIR, 70-180 mg/dL) was 79.6%; median time below 70 mg/dL was 1.1%. The AID system was in use 92.6% ± 7.0% of the time. Compared to SAP, while participants were on AID the TIR increased significantly (+10%, P = .002) accompanied by a reduction in both time above 180 mg/dL (-6.9%, P = .005) and below 70 mg/dl (-0.4%, P = .053). Diabetes-related distress decreased significantly while using AID (P = .028), but sleep parameters remained unchanged.

CONCLUSIONS

Use of this AID system in older adults improved glycemic control with high scores in ease of use, trust, and usability. Participants reported an improvement in diabetes distress with AID use. There were no significant changes in sleep.

Help when you need it: Perspectives of adults with T1D on the support and training they would have wanted when starting CGM

AIMS

The purpose of this study was to explore preferences that adults with type 1 diabetes (T1D) have for training and support to initiate and sustain optimal use of continuous glucose monitoring (CGM) technology.

METHODS

Twenty-two adults with T1D (M age 30.95 ± 8.32; 59.1% female; 90.9% Non-Hispanic; 86.4% White; diabetes duration 13.5 ± 8.42 years; 72.7% insulin pump users) who had initiated CGM use in the past year participated in focus groups exploring two overarching questions: (1) What helped you learn to use your CGM? and (2) What additional support would you have wanted? Focus groups used a semi-structured interview guide and were recorded, transcribed and analyzed.

RESULTS

Overarching themes identified were: (1) "I got it going by myself": CGM training left to the individual; (2) Internet as diabetes educator, troubleshooter, and peer support system; and (3) domains of support they wanted, including content and format of this support.

CONCLUSION

This study identifies current gaps in training and potential avenues for enhancing device education and CGM onboarding support for adults with T1D. Providing CGM users with relevant, timely resources and attending to the emotional side of using CGM could alleviate the burden of starting a new device and promote sustained device use.

Health Care Disparities in Use of Continuous Glucose Monitoring

Numerous studies have demonstrated that use of continuous glucose monitoring (CGM) improves glycemic control and reduces diabetes-related hospitalizations and emergency room service utilization in individuals with diabetes who are treated with intensive insulin regimens. Recent studies have revealed disparities in use of CGM within racially and ethnically diverse and lower socioeconomic populations, leading to underutilization of CGM in these populations. This article reviews the scope and impact of these disparities on utilization of CGM and explores the factors that may be contributing to this issue.

Hypoglycemia unawareness and autonomic dysfunction in diabetes: Lessons learned and roles of diabetes technologies

Impaired awareness of hypoglycemia (IAH) is a reduction in the ability to recognize low blood glucose levels that would otherwise prompt an appropriate corrective therapy. Identified in approximately 25% of patients with type 1 diabetes, IAH has complex pathophysiology, and might lead to serious and potentially lethal consequences in patients with diabetes, particularly in those with more advanced disease and comorbidities. Continuous glucose monitoring systems can provide real-time glucose information and generate timely alerts on rapidly falling or low blood glucose levels. Given their improvements in accuracy, affordability and integration with insulin pump technology, continuous glucose monitoring systems are emerging as critical tools to help prevent serious hypoglycemia and mitigate its consequences in patients with diabetes. This review discusses the current knowledge on IAH and effective diagnostic methods, the relationship between hypoglycemia and cardiovascular autonomic neuropathy, a practical approach to evaluating cardiovascular autonomic neuropathy for clinicians, and recent evidence from clinical trials assessing the effects of the use of CGM technologies in patients with type 1 diabetes with IAH.

Glycemic variability: adverse clinical outcomes and how to improve it?

Glycemic variability (GV), defined as an integral component of glucose homoeostasis, is emerging as an important metric to consider when assessing glycemic control in clinical practice. Although it remains yet no consensus, accumulating evidence has suggested that GV, representing either short-term (with-day and between-day variability) or long-term GV, was associated with an increased risk of diabetic macrovascular and microvascular complications, hypoglycemia, mortality rates and other adverse clinical outcomes. In this review, we summarize the adverse clinical outcomes of GV and discuss the beneficial measures, including continuous glucose monitoring, drugs, dietary interventions and exercise training, to improve it, aiming at better addressing the challenging aspect of blood glucose management.