OLDER PEOPLE WITH DIABETES #ATTD23/24 

Last year in 2023, I was proud as a 73-year-old diagnosed in September 1954 to be able to represent the older person with diabetes when I attended #ATTD2023, the 'Advanced Technologies & Treatments for Diabetics' conference in Berlin, as part of the #dedoc° voices scholarship programme. This year I was fortunate to be selected again in March 2024 to attend #ATTD2024 this time in Florence.

During the first conference, I soon discovered that a conference 'in person' was a different affair from my previous virtual attendances. It is full-on from start to finish. There is so much to see & do. But I eyed up the session offerings eagerly, hoping to attend those that were of interest.

One session stood out in 2023 'Technology for the Healthy Aging of Older People with Diabetes'. That for me was a must. Chaired by Pratik Choudhary. With guest speakers Medha Munshi, Tali Cukierman-Yaffe, Richard Pratley & David O'Neal.

Professor Tali Cukierman-Yaffe, talked about how as the population ages, the number of people living with diabetes is also increasing, the majority of with type 2 (90%). However, with the improvement of care and modern diabetes technology, more people with type 1 are reaching their third age.

We heard and I took on board how diabetes is challenging as it is a disease of accelerated ageing that shares mechanisms with physiological aging. Older adults may have difficulty managing their condition due to cognitive and physical decline, and multiple chronic conditions. It is now well recognised that people with diabetes have an increased risk for cognitive dysfunction and disability.

As a fairly healthy type 1 with only minor diabetes complications, this session had hit hard making me anxious with all the talk about comorbidities. The so-called geriatric syndrome, that occurs at higher frequency in older adults with diabetes, such as cognitive dysfunction, depression, physical disability, and polypharmacy. Conditions which affect a person's ability to take care of themselves. To be honest I'd not thought about what could happen during my journey as an older person with diabetes. It is only recently that I have been able to revisit these sessions from last year. However, it has given me the resolve to continue to look after my diabetes to try to avoid any future problems in these areas.

Professor Medha Munshi had spoken about homeostasis a progressive constriction of the homeostatic reserve. "This allows us to maintain homeostasis in the presence of environmental, physiological and emotional stress and there is a limit beyond which if the stress is beyond that, then the body is unable to restore homeostasis. This limit narrows with ageing. A stressor of a certain magnitude could be an infection, a hypoglycaemic disorder, side effects of medication, etc. If it happens at a younger age, the body can rebound from the stress. But, if it happens at an older age it might lead to poor outcomes and then for example older patients going from infection to kidney failure, from pressure ulcers to falls, and ending up in a nursing home."

Data shown in a session by Professor Tali Cukierman-Yaffe showed that in a trial of 130 older people with diabetes who were connected to CGMs & movement monitors showed that during hyperglycaemia, with increasing glucose levels, there was an increase in indices related to gait instability. The individual's Y axis (forward movement) was accelerated. Maybe this explains the higher risk of falls ending up in hospital and then a care home?

This scares me, the possibility of ending up in a nursing or residential care home and losing my personal control over my diabetes and even having my technology taken away from me. Someone else controlling my insulin needs or the content and timing of my meals. Too often I have seen this happen to a family member in a nursing home, insulin given, meal late or not eaten because there was no one to help with feeding. Resulting in hypoglycaemia. I am therefore very concerned about those untrained staff in residential care homes.

During my journey with diabetes, I have always managed my diabetes. Insulin dosing, carb counting etc. With very little input from healthcare professionals. Perhaps, I have not always done things by the book but it was always my choice. That ultimately has brought me to where I am now.

Professor Tali Cukierman-Yaffe also showed that there is also evidence that both hypo and hyperglycaemia may have deleterious effects in older people with diabetes. Speaking about the acute or subacute consequences of hyperglycaemia include dehydration and hypotension, impaired balance with falls and fractures, polyuria incontinence infection, slow wound healing, electrolyte disturbances, impaired cognition, sleep disturbance, and if severe can be life-threatening. Older people are more prone to hypoglycaemia and have more hypos than younger patients. The autonomic symptoms occur at a lower glucose threshold in older people than younger generation. And when they happen, there is a longer reaction time. So, it takes them longer to react to hypoglycaemia.

This year my interest was piqued during ATTD2024 by Professor Alan Sinclair who shared a slide that he had worked on for the International Diabetes Federation Atlas 9th edition. Showing that it is estimated that the 536.6 million people worldwide with diabetes will grow to 783.2 million by 2045. The IDF slide showed global diabetes rates in older people and it stated that the predicted rise of diabetes in ageing populations globally over the next 20 years shows an increase in overall prevalence of about 20%. Prof. Sinclair said, "It can be seen essentially as a global pandemic affecting every continent, causing a tremendous burden of personal & socio-economic impact for the future."

He continued to give an excellent talk about the emerging topic of 'Sarcopenia, Frailty & Diabetes'. He explained that all 3 conditions have many features in common. Highlighting that insulin resistance, is an intrinsic feature of aging muscle development of sarcopenia. The conclusion from his talk: There should be a multi-domain individualised management plan for the treatment of diabetes, this is particularly so for diabetes complicated by frailty with or without sarcopenia.

The role of medical technology in diabetes self-management is continuing at a pace. Hybrid Closed loops (HCL) are being rolled out following in the footsteps of the DIY Automated Insulin Delivery (AID) pump algorithms. There is peer pressure now to give CGMs to all of those with diabetes not just type 1s'. Using a CGM instead of finger pricking gives better control. To me a finger prick is like a photograph. One moment in time but CGM data is like a 24-hour video. CGM can allow monitoring on a remote PC or phone by a relative anywhere in the world. Smart pens, insulin pumps & Hybrid Closed Loops could also be beneficial for older people with diabetes. I know this from personal experience.

However, the technology itself, CGMs, pumps, etc need to evolve for the elderly person with diabetes or any person with sensory impairment or reduced dexterity. So that they can start or continue to use the latest tech.

I recently asked the diabetes community to make suggestions on what they would like to see for older people with diabetes. These suggestions have been sent to Dr Giuseppe Maltese with whom I have been collaborating with for a manuscript. Some examples are:

• Braille on buttons
• Talking tech most likely via phone apps. Choice of voices Male or female.
• Warning tones that can be adjusted as some are too high-pitched
• Zoomable bright screens
• Displays that can be read outdoors in sunlight with fonts whose size & colours can be adjusted including high-contrast text
• Alarms via phone apps could be visually colour coded for importance eg: red, amber & green. Useful for HCL systems.
• One-handed applicator for CGM, & infusion devices that don't have to be pushed very hard to activate.
• Pump refilling devices to aid those with reduced dexterity
• Remote control of the pump, dosing etc
• Voice commands for dosing or carb input

I'm sure you could think of many more. Manufacturers should be considering these changes now as more older people are using this technology - this unfortunately will take time as the development of new devices can take years to come to fruition.

My thanks to dedoc.org for allowing me to become a #dedoc° voice and allowing me to attend conferences where I have been able to attend lectures on equal footing with medical professionals. Enabling me to #payitforward to the diabetes community.

Watch out for my blog about my attendance at the Diabetes UK Professional Care Conference in London and how it spurred me on to try to get changes to the care given to older people with diabetes in nursing and residential care homes in the UK.

DISCLOSURE: dedoc.org paid for my hotel & travel costs plus granted me complimentary registration to both conferences. In return #dedoc° voices agree to #topayitforward to their communities in various ways.