Insulin Pump Use in the Elderly
A significant number of elderly people with diabetes have type 1 diabetes that was diagnosed in childhood or young adulthood. These patients are often suboptimally controlled with insulin injections, leading to microvascular complications of neuropathy, retinopathy and nephropathy, as well as macrovascular disease. The other, larger elderly group has type 2 diabetes, which increases in incidence with age, physical inactivity and weight gain (Franse et al., 2001). These factors are known to increase insulin resistance and impair ß-cell function, thus contributing to progression of this disease.
Treatment methods for diabetes in the elderly include lifestyle changes, dietary manipulation, weight management, oral agents and insulin, which is commonly given in the form of one or more daily injections. It is often difficult to mimic physiologic insulin delivery and dovetail insulin action to blood glucose. The result is suboptimal metabolic control and unpredictable glycemic excursions, even when a complex insulin regimen with multiple injections is employed. Lifestyle restrictions and curtailment of flexibility are additional drawbacks that may decrease treatment satisfaction.
Potential Benefits for the Elderly
A small but growing body of experience suggests that carefully selected elderly patients can benefit enormously from the advantages offered by the insulin pump. Case studies and anecdotal reports have been published demonstrating the feasibility of insulin pump use in patients in their seventh and eighth decades of life (Davidson, 1995; Farkas-Hirsch and Hirsch, 1994; Mecklenburg et al., 1982). Kamoi (2002) recently described good long-term quality of life in a brittle 72-year-old diabetic woman treated for 20 years with continuous subcutaneous insulin therapy who remained free of complications by maintaining excellent glycemic stability.
Our group has previously reported success in a small number of older subjects when switched from injections to pump therapy (Rizvi et al., 2001). They had long-standing type 1 diabetes with suboptimal glycemic control and presence of complications. Glycosylated hemoglobin was significantly better on the pump after more than a year of follow-up. Concurrent with improved metabolic control, there was a reduction in insulin requirements and decreased propensity to hypoglycemia in our study patients. In other words, pump therapy offered a more physiologic and effective use of available insulin.
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