Type 1 diabetes mellitus (T1DM), a chronic autoimmune condition characterised by the destruction of insulin-producing pancreatic beta cells, was historically viewed as a disease predominantly affecting children and adolescents. It was often associated with significant reductions in life expectancy due to the complications arising from inadequate blood glucose control. In the past, many individuals with T1DM faced a host of health challenges that limited their lifespan and quality of life.

In recent decades, however, advancements in diabetes management and medical care have fundamentally altered this narrative. Improvements in the development and accessibility of insulin analogues, the adoption of continuous glucose monitoring (CGM) systems, and better education on diabetes management have all contributed to increased life expectancy for people with T1DM. As a result, the number of older adults living with T1DM has risen. This trend highlights the significant progress made in diabetes care and underlines the need for a more focused approach to managing T1DM in aging populations.

Global Data Gaps and Increasing Prevalence

Despite the progress in diabetes management, comprehensive global data on T1DM among older adults remain limited. This lack of robust data hinders the ability to fully understand the burden of T1DM in aging populations. Reliable statistics on prevalence, mortality, and Disability Adjusted Life Years (DALYs) for individuals aged 65 and older are essential for guiding healthcare policies and resource allocation. However, most countries and regions lack consistent and detailed data in this regard.

A recent modelling study estimated that, globally, 3.7 million cases of T1DM went undiagnosed in 2021. The study also projected a 60–107% increase in T1DM diagnoses between 2021 and 2040. This anticipated rise reflects not only an increase in the global population but also improved survival rates among people with T1DM. As life expectancy improves due to advancements in medical care, the number of older adults living with T1DM is likely to continue growing. This highlights the urgency of addressing data gaps and adapting healthcare strategies to meet the needs of this demographic.

Challenges of Managing T1DM in Older Adults

The management of T1DM in older adults presents unique challenges that differ from those encountered in younger populations. Achieving optimal blood glucose control becomes increasingly difficult as individuals age. Several factors contribute to this complexity, including changes in metabolism, declining cognitive function, and the presence of comorbid conditions such as cardiovascular disease and renal impairment. These age-related factors complicate the dynamic adjustment of insulin doses, which depends on variables such as dietary intake, physical activity, and insulin sensitivity.

Healthcare providers often face a critical dilemma when managing blood glucose levels in older adults with T1DM. While hyperglycaemia (high blood sugar) increases the risk of long-term complications, hypoglycaemia (low blood sugar) poses immediate dangers, including unconsciousness, falls, cardiovascular events, and brain damage. As a result, doctors may prioritise avoiding hypoglycaemia, even if this means accepting higher blood glucose levels. This approach, while pragmatic, highlights the need for individualised glucose targets that balance safety and efficacy.

In addition, older adults may face challenges related to self-management of their condition. Declining physical dexterity, visual impairments, and cognitive decline can hinder their ability to administer insulin, monitor blood glucose levels, and follow dietary recommendations. These challenges emphasise the importance of caregiver support and personalised education programs to encourage older individuals with T1DM to manage their condition effectively.

The Role of Technology in Diabetes Management

Advances in diabetes technology have transformed the management of T1DM, offering new tools to help individuals achieve better glucose control. Devices such as continuous glucose monitors (CGMs) and insulin pumps have become increasingly common, providing real-time data and automated insulin delivery. These innovations have been shown to improve glycaemic outcomes and reduce the risk of complications.

For younger populations, hybrid closed-loop insulin delivery systems, often referred to as “artificial pancreas” systems, have demonstrated significant benefits in maintaining stable glucose levels. While evidence for their use in older adults is limited, these systems hold promise for addressing the challenges faced by this demographic. However, barriers such as cost, technological literacy, and the need for caregiver involvement may limit their adoption among older individuals.

Education and training are critical for maximising the benefits of these technologies. Older adults and their caregivers must receive clear and practical guidance on using CGMs and insulin pumps effectively. Additionally, healthcare providers must consider the unique needs and preferences of older patients when recommending technological solutions.

Environmental Factors and Their Impact on T1DM

Environmental factors, particularly extreme temperatures, play a significant role in the management of T1DM. Research has shown that both high and low temperatures are associated with increased diabetes-related complications and mortality, especially among older adults. Extreme heat can affect insulin storage, reducing its efficacy, while cold temperatures can impact blood glucose levels through changes in dietary habits, physical activity, and susceptibility to infections.

The impact of temperature variations is particularly pronounced in low-income regions, where access to reliable refrigeration for insulin storage and adequate healthcare resources is limited. Addressing these challenges requires targeted public health interventions, such as ensuring access to temperature-controlled insulin storage and raising awareness about the effects of environmental factors on diabetes management.

Sociodemographic Inequalities in T1DM Burden

Sociodemographic factors significantly influence the burden of T1DM among older adults. High-income countries generally have better access to advanced diabetes care, including insulin analogues, CGMs, and educational resources. In contrast, low-income countries often face significant barriers to care, including limited access to insulin, a lack of blood glucose monitoring equipment, and inadequate healthcare infrastructure.

These disparities are reflected in DALYs, which measure the overall burden of disease in terms of years lost due to ill-health, disability, or premature death. While DALYs associated with T1DM have decreased more slowly than mortality rates, they remain disproportionately high in low-income regions. Addressing these inequalities requires concerted efforts to improve access to diabetes care in resource-poor settings. Initiatives such as subsidised insulin programs, community-based education campaigns, and the expansion of healthcare infrastructure can help reduce the global burden of T1DM.

Sex Differences in Disease Burden

Research has identified notable sex differences in the burden of T1DM among older adults. Men aged 65 and older generally experience a higher disease burden compared with women. This disparity may be partially explained by biological factors, such as differences in hormone levels and immune responses, which influence the onset and progression of T1DM. Additionally, lifestyle factors such as smoking and physical inactivity are more prevalent among men, contributing to their increased risk of complications.

Women, on the other hand, tend to engage more proactively in healthcare utilisation and disease management. Research suggests that women with T1DM are more likely to adhere to treatment plans, attend regular medical appointments, and monitor their blood glucose levels consistently. These behaviours may mitigate the risk of complications and improve overall outcomes. Addressing these sex-based disparities requires personalised interventions that consider the unique risks and behaviours of men and women with T1DM.

The Economic Burden of T1DM

The economic impact of T1DM is substantial, particularly for older adults who require ongoing medical care and support. The global economic burden of diabetes in adults is projected to reach £20 trillion by 2030, with significant costs associated with insulin, glucose monitoring devices, and hospitalisations for complications. Low and middle-income countries face the greatest challenges in meeting the demands of diabetes care, as limited resources and healthcare infrastructure constrain their ability to provide comprehensive support.

Policy makers must prioritise the allocation of resources to address the growing economic burden of T1DM. Strategies such as subsidising essential diabetes supplies, investing in healthcare infrastructure, and promoting cost-effective interventions can help reduce the financial strain on individuals and healthcare systems.

Future Directions and Research Needs

As the global population continues to age, the need for targeted research on T1DM in older adults becomes increasingly urgent. Current guidelines for managing T1DM often focus on younger populations, leaving significant gaps in the care of older individuals. Future research should explore evidence-based strategies for glycaemic control that address the unique challenges faced by older adults, including age-related physiological changes and comorbidities.

Innovative approaches to healthy aging and diabetes management are also needed. These may include the development of new technologies, such as simplified insulin delivery systems, and interventions to improve self-management skills among older adults. Additionally, research on the cost-effective delivery of care in low and middle-income countries can help address global disparities in T1DM outcomes.

Conclusion

The story of T1DM in older adults is one of significant progress and ongoing challenges. While advancements in medical care have extended life expectancy and improved outcomes for individuals with T1DM, the increasing prevalence of the disease among aging populations demands urgent attention. Policymakers, researchers, and healthcare providers must work collaboratively to address disparities, improve access to care, and develop targeted strategies for managing T1DM in older adults.

By prioritising the needs of this growing demographic, society can ensure that older individuals living with T1DM continue to benefit from the medical progress of recent decades. Through a combination of innovative research, equitable healthcare policies, and community support, the challenges of T1DM in aging populations can be met, improving the lives of millions worldwide.

Reference

Yang, K., Yang, X., Jin, C., Ding, S., Liu, T., Ma, B., Sun, H., Zhang, J., & Li, Y. (2024). Global burden of type 1 diabetes in adults aged 65 years and older, 1990-2019: population based study. BMJ (Clinical Research Ed.), 385, e078432. https://doi.org/10.1136/bmj-2023-078432