To Whom it may concern

THE BENEFITS OF USING INTERMITTENT REAL-TIME CONTINUOUS GLUCOSE MONITORING IN INSULIN TREATED FRAIL ELDERLY ADULTS

The update of NICE Guidance in June 2022 including a recommendation to offer
“intermittently scanned continuous glucose monitors (isCGM) to adults with insulin-treated
type 2 diabetes who would otherwise need help from a care worker or healthcare
professional to monitor their blood glucose” (recommendation 1.6.18). It also suggests
considering “real-time continuous glucose monitoring (rtCGM) as an alternative to isCGM for
adults with insulin-treated type 2 diabetes if it is available for the same or lower cost”
(recommendation 1.6.19).

THE GOLDILOCKS ZONE

The inclusion of this population marks a significant upgrade in access compared to previous
recommendations. It is likely that this is an acknowledgement of the need to maintain the
glucose in the “Goldilocks zone” of not too high, avoiding with cognitive decline,
hospitalisations, urinary incontinence and reduced quality of life; and not too low, triggering
falls, progression of frailty and approximately doubling the risk of dementia if they are
recurrent.

For the older population, the use of rtCGM is preferred, providing it can be remotely
accessed by the carers who support the individual as it can glucose trends in real-time by
providing glucose readings every five minutes and thus giving advanced warning of
impending likely hypoglycaemia. In older adults the use of 10 days compared to using a
blood glucose meter (BGM), demonstrated both improved glycaemic control and a low
frequency of hypoglycaemia.

BENEFITS OF NEEDLE-FREE NON INVASIVE SKIN PATCHES FOR INTERMITTENT CONTINUOUS GLUCOSE MONITORING

When choosing a device for this population there are additional concerns. Enhancing skin
health and preventing skin barrier function damage are integral parts of maintaining the
health of an older adult living with diabetes. In older age the skin is more vulnerable,
rendering individuals more susceptible to skin injury (skin frailty). The International Skin Tear
Advisory Panel (ISTAP) based on over a decade of work, has identified the key indicators in
prevention and management of skin problems, specifically recommending minimisation of
any skin breaks, skin tears, pressure injuries/ulcers, moisture-associated skin damage
(MASD), and skin changes at end of life. Frail older adults are at particular risk of puncture
wounds having protracted healing term, and therefore should be avoided when alternatives
are available.

As such the opportunity to monitor glycaemia remotely for older adults without causing an,
albeit small, puncture wound is an attractive option. Further, by pre-emptively identifying
hypoglycaemia, without causing puncture wounds, we could achieve the goal of the NG28
recommendations; to improve clinical outcomes in frail older adults, help them maintain
their independence for longer and reduce the risk of hypoglycaemia related hospital
admissions and thus indirect cost of diabetes in older adults.

Yours sincerely,
Pr. David Strain

Professor Strain Article PDF