Impact of stepwise diabetes technology advances in older adults with type 1 diabetes: A systematic review and meta‐analysis of randomised trials

Objectives To evaluate the efficacy and safety of advancing to higher levels of diabetes technology in older adults with type 1 diabetes (T1D). Methods Web of Science, PubMed, Cochrane Library, and SCOPUS were searched. Inclusion criteria were randomised controlled trials (RCTs); aged ≥60 years with T1D. Interventions were pre‐specified into two domain comparisons: (1) Higher‐level insulin delivery (defined as automated insulin delivery, AID) versus lower‐level insulin delivery (comprising sensor‐augmented pumps and predictive low‐glucose suspend); and (2) Higher‐level glucose monitoring (defined as continuous glucose monitoring, CGM) versus lower‐level glucose monitoring (self‐monitoring of blood glucose). Co‐primary efficacy outcomes were time‐below‐range of <3.9 mmol/L(TBR3.9) and time‐in‐range of 3.9–10.0 mmol/L (TIR). Safety outcomes were episodes of diabetic ketoacidosis (DKA) and severe hypoglycemia (SH). Results Five RCTs (comprising six comparisons) with 482 participants were included. Three trials enrolled participants aged ≥60 years, and two trials enrolled those aged ≥65 years. Three crossover trials contributed to the AID comparison, and two parallel to the CGM comparison. The mean age was 69.2 years, with a mean T1D duration of 36.1 years. In the pooled analysis, higher‐level technologies significantly increased TIR (MD = +7.90%, 95% CI: 7.09 to 8.72, p <0.001) and reduced TBR3.9 (MD = –0.62%, 95% CI: −1.02 to −0.22, p = 0.002). Benefits were also observed for TBR <3.0 mmol/L, time‐above‐range >10.0 and >13.9 mmol/L, HbA1c, and glycemic variability (all p <0.05). Critically, SH risk was markedly lower with higher‐level technologies (Peto OR = 0.16, 95% CI: 0.06 to 0.41, p <0.001; number‐needed‐to‐treat = 20), without a significant increase in DKA risk (Peto OR = 3.72, 95% CI: 0.75 to 18.49, p = 0.11). Conclusions Advancing to higher‐level technologies for glucose monitoring and insulin delivery significantly and safely improve glycemic control in older adults with T1D. Physiological age alone should not be a primary barrier to prescribing these technologies, particularly for carefully selected older adults.