Self-care barriers and facilitators in older adults with T1D during a time of sudden isolation.

Older adults with type 1 diabetes (T1D) have unique challenges and needs. In this mixed-methods study, we explored the impact of isolation during a pandemic on diabetes management and overall quality of life in this population. Older adults (age ≥ 65 years) with T1D receiving care at a tertiary care diabetes center participated in semi-structured interviews during COVID-19 pandemic isolation between June and August 2020. A multi-disciplinary team coded transcripts and conducted thematic analysis. Thirty-four older adults (age 71 ± 5 years, 97% non-Hispanic white, diabetes duration of 38 ± 7 years, A1C of 7.4 ± 0.9% (57.3 ± 10.1 mmol/mol) were recruited. Three themes related to diabetes self-care emerged regarding impact of isolation on: (1) diabetes management and self-care behaviors (how isolation prompted changes in physical activity and dietary habits); (2) emotional stress and anxiety (related to isolation and lack of support system, economic concerns); and (3) concerns regarding the COVID-19 pandemic (impact on timely medical care and access to information). Our findings identify modifiable barriers and challenges faced by older adults with T1D during isolation. As this population has a higher risk of decline in physical and psychosocial support even during non-pandemic times, clinicians will benefit from understanding these issues to improve care of this population.

Use of Telemedicine in Adults with Type 1 Diabetes: Do Age and Use of Diabetes-Related Technology Matter?

Objective: Older adults are generally less proficient in technology use compared with younger adults. Data on telemedicine use during the COVID-19 pandemic in older persons with type 1 diabetes (T1D) and the association of telemedicine with the use of diabetes-related technology are limited. We evaluated care delivery to older adults compared with younger adults with T1D in a prepandemic and pandemic period. Methods: Data from electronic health records were evaluated for visit types (in-person, phone, and video) from two sequential 12-month intervals: prepandemic (April 2019-March 2020) and pandemic (April 2020-March 2021). Results: Data from 2,832 unique adults with T1D were evaluated in two age cohorts: younger (40-64 years) and older (≥65 years). Half of each group used continuous glucose monitoring (CGM), whereas 54% of the younger and 37% of the older cohort used pump therapy (p < 0.001). During the pandemic compared with the prepandemic period, visit frequency increased in both the younger (0.65 vs. 0.76 visits/patient/quarter; p < 0.01) and older (0.72 vs. 0.80 visits/patient/quarter; p < 0.01) cohorts. During the pandemic, older adults used more phone visits compared with younger adults (48% vs. 32%; p = 0.001). Patients using either pump therapy or CGM were more likely to use video visits compared with phone visits in both younger (41% vs. 24%; p < 0.001) and older cohorts (53% vs. 42%; p < 0.001). Conclusions: Adults using diabetes-related technologies, independent of age, accessed more video visits than those not using devices. Telemedicine visits appeared to maintain continuity of care for younger and older adults with T1D, supporting the future of a hybrid-care model.

Use of Telecommunication and Diabetes-Related Technologies in Older Adults With Type 1 Diabetes During a Time of Sudden Isolation: Mixed Methods Study.

BACKGROUND: The COVID-19 lockdown imposed a sudden change in lifestyle with self-isolation and a rapid shift to the use of technology to maintain clinical care and social connections. OBJECTIVE: In this mixed methods study, we explored the impact of isolation during the lockdown on the use of technology in older adults with type 1 diabetes (T1D). METHODS: Older adults (aged ≥65 years) with T1D using continuous glucose monitoring (CGM) participated in semistructured interviews during the COVID-19 lockdown. A multidisciplinary team coded the interviews. In addition, CGM metrics from a subgroup of participants were collected before and during the lockdown. RESULTS: We evaluated 34 participants (mean age 71, SD 5 years). Three themes related to technology use emerged from the thematic analysis regarding the impact of isolation on (1) insulin pump and CGM use to manage diabetes, including timely access to supplies, and changing Medicare eligibility regulations; (2) technology use for social interaction; and (3) telehealth use to maintain medical care. The CGM data from a subgroup (19/34, 56%; mean age 74, SD 5 years) showed an increase in time in range (mean 57%, SD 17% vs mean 63%, SD 15%; P=.001), a decrease in hyperglycemia (>180 mg/dL; mean 41%, SD 19% vs mean 35%, SD 17%; P<.001), and no change in hypoglycemia (<70 mg/dL; median 0.7%, IQR 0%-2% vs median 1.1%, IQR 0%-4%; P=.40) during the lockdown compared to before the lockdown. CONCLUSIONS: These findings show that our cohort of older adults successfully used technology during isolation. Participants provided the positive and negative perceptions of technology use. Clinicians can benefit from our findings by identifying barriers to technology use during times of isolation and developing strategies to overcome these barriers.

Closed-Loop Insulin Therapy in Older Adults with Type 1 Diabetes: Real-World Data.

Objective: To assess the impact of initiation of closed-loop control (CLC) on glycemic metrics in older adults with type 1 diabetes (T1D) in the real world. Methods: Retrospective analysis of electronic health records from a single tertiary diabetes center of older adults prescribed CLC between January and December 2020. Results: Forty-eight patients (mean age 70 ± 4 years, T1D duration 42 ± 14 years) were prescribed CLC and 39/48 started on the CLC. Among the CLC starters, 97.5% and 95% were prior pump and continuous glucose monitoring (CGM) users, respectively. CGM metrics showed an increase in time-in-range (62% ± 13% to 76% ± 9%; P < 0.001), a reduction in both time spent <70 mg/dL [2% (1%-3%) to 1% (1%-2%); P = 0.03] and >180 mg/dL (30% ± 11% to 20% ± 9%; P < 0.001) at 3 months. Conclusion: In this real-world data most of the older patients with T1D initiating CLC were prior pump and CGM users. Initiation of CLC improved glycemic control and reduced time spent in hypoglycemia compared with prior therapy.

Impact of Isolation during the COVID-19 Pandemic on the Care of Older Adults with Type 1 Diabetes: A Qualitative Study

Background: Older adults with type 1 diabetes (T1D) face unique challenges, especially when their support structure is disrupted, as happened during the Covid-19 lockdown. We evaluated the clinical and psychological impact of this imposed isolation on the older population with T1D. Methods: We conducted semi-structured interviews with older adults with T1D who were part of an ongoing study, which was paused from March - August 2020. The interviews were performed between May - August 2020, and were transcribed, coded, and analyzed using content analysis to derive theme. A multidisciplinary team of 12 individuals coded the interviews to identify the themes and included geriatricians, endocrinologists, a nurse educator, infomaticists, an economist, a methodologist, and research assistants. Results: We have analyzed 12/35 interviews at this time;mean age 74±4 years, 50% female, 92% non-Hispanic white, mean duration of diabetes 37±18 years, and A1C 7.3±0.7%. Three main themes have emerged. The challenges related to diabetes care included fear of hypoglycemia, interruption in supply chain related to diabetes technology (insulin pump and continuous glucose monitoring (CGM) supplies), use of telehealth, diabetes-related distress, and adapting to new routines in self-care (diet and exercise). Challenges related to the Covid-19 pandemic included fear of getting Covid-19 infection, and a lack of reliable information on pandemic. The challenges related to psychological well-being included a feeling of isolation, loneliness, inability to spend time with family and friends, lack of in-person communication, and lack of recreational activity. Conclusion: The results of this qualitative study help to understand critical areas of need when social support structures are unavailable to older adults with T1D. Our results will help develop intervention strategies to overcome barriers in maintaining support for this vulnerable population.