Automated Insulin Delivery Systems for Elderly Patients with Diabetes

Introduction to Automated Insulin Delivery

The American Diabetes Association recommends considering automated insulin delivery (AID) systems for older adults based on individual ability and support system, recognizing that these devices reduce treatment burden 1.
AID systems automatically adjust basal insulin delivery and provide correction boluses based on continuous glucose monitoring (CGM) data, eliminating the need for complex calculations that may be challenging for elderly patients with cognitive decline 1, 2.

The American College of Endocrinology suggests that AID systems improve time in range (TIR) and reduce hypoglycemia compared to sensor-augmented pump therapy, as demonstrated in the ORACL trial in 30 older adults (mean age 67 years) with type 1 diabetes 1, 2.
A recent randomized controlled trial in older adults with type 2 diabetes who were unable to manage insulin therapy independently showed a 27% increase in TIR over 12 weeks with AID use 1, 2.
Hypoglycemia prevention is paramount in elderly patients, and AID systems have consistently demonstrated reductions in hypoglycemia risk—a critical safety consideration given that older adults have greater risk of hypoglycemia and its consequences 1, 4.

The Endocrine Society recommends the Beta Bionics iLet as the first choice for elderly patients, requiring the least technical skill of all available systems—only body weight input and minimal carbohydrate announcements are needed, with the algorithm making most insulin dosing decisions autonomously 1.
The Omnipod 5 is a second choice, offering hybrid closed-loop functionality with automatic basal adjustments and tubeless design (no tubing to manage) 5.

Older adults who are otherwise healthy with few coexisting chronic illnesses and intact cognitive and functional status are ideal candidates for AID systems with glycemic goals of A1C <7.0-7.5% and TIR of 70% 1, 2.
Elderly patients must have either personal capability or caregiver support to handle device troubleshooting and site changes 1.

The American Geriatrics Society recommends CGM for all older adults with type 1 diabetes and should be offered to those with type 2 diabetes on insulin therapy to improve glycemic outcomes and reduce hypoglycemia 1, 2.
AID systems provide additional hypoglycemia protection beyond CGM alone by automatically suspending or reducing insulin delivery when glucose levels are predicted to go low 1, 2.
Ascertain and address episodes of hypoglycemia at routine visits because older adults with diabetes have greater risk of hypoglycemia, especially when treated with insulin 1.

Contact patients every 2-3 days in the first week to review glucose data and make adjustments, then weekly for the first month 6.
Frequency of follow-up does not influence long-term outcomes, so adjust based on patient stability after the initial period 5, 8.

Failure to rotate infusion sites leads to lipohypertrophy and erratic insulin absorption regardless of pump type—educate patients or caregivers to change sites every 2-3 days 3, 6.
All systems require backup supplies and knowledge of how to transition to injections in case of device failure—elderly patients are at risk for diabetic ketoacidosis within hours of pump failure due to lack of long-acting insulin reservoir 3, 6.