Glycemic and psychosocial outcomes of automated insulin delivery in older and high-risk populations with type 1 diabetes: a systematic review and meta-analysis.

BACKGROUND: Automated insulin delivery (AID) has revolutionized care for people with type 1 diabetes. However, its efficacy and safety in older adults (≥60 years) and high-risk populations, including those with impaired awareness of hypoglycemia, or cognitive or functional impairment, have not been systematically evaluated. MATERIALS AND METHODS: CENTRAL, PubMed, Web of Science, Scopus, and ClinicalTrials.gov from inception to March 10, 2026. Studies on automated insulin delivery in older and high-risk individuals with type 1 diabetes were included. The primary outcome was time in range (3.9-10.0 mmol/L [70-180 mg/dL]). Secondary outcomes included time above range, time below range, psychosocial well-being (Gold, Clarke, and Hypoglycemia Fear Survey score), and serious adverse events. Pooled effect sizes were estimated with random-effects models (PROSPERO, CRD420251273526). RESULTS: Twenty-three studies involving 967 participants (11 randomized controlled trials, 3 single-arm, and 9 cohort studies) were included. Automated insulin delivery increased time in range by 11.38% (95% CI: 8.07-14.70; I2 = 70%; P < .0001; very low certainty; equivalent to 2.7 hours/day). Time in range improvement was observed during the day (8.70%; 95% CI 5.18-12.22%) and overnight (13.35%; 95% CI 11.07-15.62%). Favorable improvement was also comparable among commercial and noncommercial systems. Automated insulin delivery reduced the time spent in hyperglycemia (-7.89%) and hypoglycemia (-1.16%). No significant differences in psychosocial well-being were observed. Diabetic ketoacidosis and severe hypoglycemia events were not significant. CONCLUSION: Automated insulin delivery exhibits favorable glycemic outcomes and safety profiles in older and high-risk individuals with type 1 diabetes, suggesting potential benefits for populations traditionally considered vulnerable, although no significant improvements were observed in psychosocial outcomes.