Seeing the Road Ahead—The Need to Address Accessibility of Diabetes Technology

Closed-loop automated insulin delivery (AID) systems significantly improve glycemic control in people with type 1 diabetes mellitus (DM). ¹ The American Diabetes Association (ADA) considers AID systems standard of care as they are associated with superior glycemic control compared with traditional sensor-augmented pump therapy. ^2,3 Yet despite the high prevalence of DM among older adults—29.2% of Americans aged 65 years or older are affected—their participation in clinical trials has been limited, ⁴ and this discrepancy increases among those with cognitive or functional impairments. ⁵ Such low participation rates are concerning, particularly because older adults are more susceptible to hypoglycemia, ⁶ and they face unique age-related challenges in managing their DM. ^4,5

AID systems are often inaccessible to older adults ⁷ because of insurance coverage, high costs, and insufficient training. ⁸ Many older adults with DM also develop disabilities, including visual impairment, that may hinder their ability to use these devices, ^{9 –18} and health care providers vary in their knowledge and comfort regarding the use of diabetes technology in older adults. ⁵ Hybrid closed-loop systems such as the Omnipod 5 and MiniMed 780 G systems improve glycemic control, time in range, and the psychosocial aspects of diabetes management in older adults, ^{7,19 –23} but there is limited research on their accessibility and use during the performance of daily activities such as driving and navigation. This commentary analyzes a study on diabetes technology use in older adults while driving and explores its broader implications for device accessibility among older adults with visual impairments and other disabilities.

In this issue of Diabetes Technology and Therapeutics, Trawley et al. evaluated the impact of closed-loop AID systems versus sensor-augmented therapy on glycemic control and road safety in older drivers with type 1 diabetes. ²⁴ This is the first randomized trial to assess the impact of diabetes technology on glycemic control while driving. The trial assessed 1894 driving trips by eight adults aged 60 years and older using vehicle logging devices to synchronize continuous glucose monitor (CGM) data with trip information. The authors found that AID systems significantly increased the time spent within the target glucose range (5.0–10.0 mmol/L) and reduced hyperglycemia (glucose levels >16.7 mmol/L) without increasing the incidence of hypoglycemia (<3.9 mmol/L). Compared with sensor-augmented pumps, AID devices led to a greater time in range (100% vs. 81%, P = 0.033). These findings suggest that AID systems can enhance driving safety by maintaining euglycemia more effectively than traditional sensor-augmented pump therapy.

The study’s strengths lie in its focus on an underrepresented population—older adults—performing a novel activity—driving. Given that older adults are particularly vulnerable to the dangers of driving with dysglycemia, the study’s results may help older adults mitigate risks associated with driving while also maintaining their independence. This research also challenges the misconception that diabetes technology is unsuitable for older adults, and it supports existing evidence that diabetes technology lowers HbA1c, improves glucose control, and reduces hypoglycemia in this population. ²⁵

The ADA Standards of Care recommend offering AID systems to all capable users, but eligible older adults may not receive AID systems because health care providers may underestimate their ability to manage this technology. ²⁶ The study by Trawley et al. provides valuable data that could encourage providers to recommend these technologies more frequently, but the authors of the study stated that they “did not include frail adults” or adults with disabilities, which represent a significant portion of the aging population. All participants were already pump users, which likely exclude individuals with socioeconomic barriers or physical/mental limitations that make using the pump difficult. While the authors acknowledge the need to include more vulnerable groups in future research, they did not directly address disability. Considering that diminishing dexterity, visual impairment, hearing loss, and cognitive decline among older adults are barriers to effectively using diabetes technology, ²⁵ future studies must consider these factors when assessing diabetes technology within this cohort.

Visual impairment is an important age-related disability that disproportionately affects older adults with type 1 DM. As of 2021, more than one in four U.S. adults aged 71 and older had significant vision impairments. ²⁷ An estimated 93 million people worldwide live with diabetic retinopathy (DR), including 17 million with proliferative DR and 28 million with vision-threatening DR, ²⁸ yet the use of diabetes technology among blind and visually impaired people has been understudied. ¹² For the purposes of this commentary, “blind” refers to the legal definition of blindness, which is a diagnosed visual acuity of 20/200 or worse with the best possible correction or a visual field of 20 degrees or less. Similarly, “visually impaired” refers to someone with a visual acuity of 20/70 or worse, with the best possible correction. Like what we see with older adults, visually impaired people are often excluded from diabetes technology research. ^16,29

Alexa technology and other audio and voice command features have significantly increased CGM accessibility. ¹⁸ In a recent analysis, CGMs lowered HbA1c, increased time in range, and significantly reduced severe hypoglycemia in blind and visually impaired individuals. ³⁰ Blind survey respondents also stated that accessible diabetes technology could increase independence, improve glycemic control, decrease safety concerns, and boost confidence. ¹⁸ These findings complement results of the study by Trawley et al. by highlighting the potential benefits of diabetes technology for understudied populations. We acknowledge that, since adults who are legally blind cannot drive, results of the study by Trawley et al. cannot be directly extrapolated to older adults who are blind. However, study by Trawley et al. offers a valuable framework to study the effectiveness of diabetes technology for visually impaired adults who may still be able to drive with accommodations, as well as blind adults performing other navigational tasks besides driving.

Despite recent recommendations by societies and progress by physicians and insurers, accessibility issues remain. While some devices such as the Prodigy Voice ⁹ have fully audible talking meters and tactile features, insulin pumps lack meaningful tactile or auditory feedback. ¹⁸ Pumps are difficult to set up, and complex battery and insulin reservoir systems require visual assistance. ³¹ Moreover, providers are often unaware of accessibility to patients, and there are no clinical guidelines for managing diabetes in patients who are visually impaired. ¹¹ Bias can further worsen accessibility issues because providers may underestimate the abilities of blind patients. ³² According to a study from the Canadian National Institute of the Blind, 20% of individuals were advised against using insulin pumps due to a perceived lack of competence and 86% were unaware of any insulin pumps that were accessible to them. ¹⁸ Active partnerships between providers, blind individuals, and advocacy organizations could reduce these disparities and improve diabetes care.

In conclusion, study by Trawley et al., together with other research in this area, underscores the potential benefit of diabetes technology use in older adults. Recent studies challenge the assumption that diabetes technology is too complex or unsafe for older adults and suggests that device use can improve quality of life while maintaining an acceptable safety profile. Future studies should investigate the usability of technology for older adults with disabilities and better identify provider biases that may hinder access for these patients. Doing so will help ensure that all individuals, regardless of age or ability, can optimally benefit from diabetes technology.