Use of Automated Clinical Decision Support (CDS) to Effect Glycemic Control in Elderly Patients with T1D

Older adults with T1D can require additional support to achieve glycemic goals as they may have cognitive impairment and be at high risk for hypoglycemia. The Technological Advances in Glucose Management in Older Adults trial (TANGO) is a RCT comparing risk of hypoglycemia (primary outcome: time glucose <70 mg/dl per day) in patients older than 65 yo managed with pump or pen, randomized to receive CGM with automated CDS (intervention; INT) or equal clinical attention (control; CON). Patients are randomized after a 2-week period confirming ability to use CGM (2 successful insertions; Dexcom CGM) and baseline hypoglycemia (2 incidence of CGM < 70 mg/dL for 20 minutes). Sixteen subjects have been enrolled (median [IQR] age 70 [68 73] yo), all 16 eligible for randomization (9 pump and 4 pen patients randomized to INT; 3 to CON). Insulin delivery, meal, and activity (FitBit) data are obtained daily from the cloud (glooko; see Figure) and an explicit CDS algorithm is used to review the data and recommend changes in CIR, ISF, and basal rates (pump patients), or long and short acting insulin doses (pen patients). CDS has reviewed 1194 days of patient data and generated 15 recommendations (average 1 every 79.6 days), all approved or modified. We conclude that hypoglycemia is common in this population and that patients can be managed with the aid of an automated CDS algorithm reviewing data at the end of each day.