Digital health technologies/interventions in smart ward development for elderly patients with diabetes: A perspective from China and beyond

Abstract

Diabetes is highly prevalent among the elderly worldwide, with the highest number of diabetes cases in China. Yet, the management of diabetes remains unsatisfactory. Recent advances in digital health technologies have facilitated the establishment of smart wards for diabetes patients. There is a lack of smart wards tailored specifically for older diabetes patients who encounter unique challenges in glycemic control and diabetes management, including an increased vulnerability to hypoglycemia, the presence of multiple chronic diseases, and cognitive decline. In this review, studies on digital health technologies for diabetes in China and beyond were summarized to elucidate how the adoption of digital health technologies, such as real-time continuous glucose monitoring, sensor-augmented pump technology, and their integration with 5^th generation networks, big data cloud storage, and hospital information systems, can address issues specifically related to elderly diabetes patients in hospital wards. Furthermore, the challenges and future directions for establishing and implementing smart wards for elderly diabetes patients are discussed, and these challenges may also be applicable to other countries worldwide, not just in China. Taken together, the smart wards may enhance clinical outcomes, address specific issues, and eventually improve patient-centered hospital care for elderly patients with diabetes.

Key Words: Diabetes; Elderly care; Digital health technology; Smart ward; Wearable devices; Continuous glucose monitoring; Sensor-augmented pump

Core Tip: Diabetes affects nearly a quarter of individuals aged 65 years and older worldwide, with China reporting the highest number of cases. The unique features of elderly diabetes patients underscore the need for improved management. Digital health technologies have facilitated the establishment of smart hospital wards for diabetes patients. However, there is limited research and review focusing on smart wards tailored for older diabetes patients. This review discusses the development of smart wards, addressing the issues specific to managing elderly diabetic patients, and suggests future research directions to enhance the care of elderly diabetes patients.

INTRODUCTION

Diabetes mellitus, predominantly type 2 diabetes mellitus (T2DM), is an ongoing public health concern globally, affecting approximately 10.5% of the adult population worldwide (aged 20-79 years) according to the International Diabetes Federation (IDF) Diabetes Atlas 2021. In China, the prevalence of diabetes mellitus has surged from approximately 0.7% in 1980 to as high as 12.4% in 2018, and both the disease and economic burdens are projected to increase during 2020-2030[1-3]. Currently, China is the global leader in the number of individuals affected by diabetes mellitus, with a total of 140 million diabetes patients, accounting for nearly a quarter of all cases worldwide[1,4]. Furthermore, the prediabetes population in China has surpassed the number of diabetes patients, with data indicating a prevalence of 35.7% and a total of nearly 400 million individuals[5]. Nevertheless, diabetes management in China is far from satisfactory. For instance, the awareness rate of diabetes, defined as the proportion of participants with physician-diagnosed diabetes among all participants diagnosed with diabetes in the study, was a mere 36.7%, and the treatment rate was only 32.9%[2]. In addition, among individuals with physician-diagnosed diabetes receiving treatment, the rate of blood sugar control meeting standards was 50.1%[2]. These figures suggest a low estimated prevalence of adequate treatment, along with low rates of awareness, treatment, and control in China[2].

With diabetes mellitus being an age-related chronic condition, the prevalence of diabetes in the elderly, typically defined as individuals aged 65 years or older, is notably high, with more than a quarter of elderly individuals affected by diabetes[6,7]. In addition, approximately half of elderly individuals have prediabetes[7]. The prevalence of these conditions among older adults is projected to escalate significantly in the forthcoming decades[7]. The highest number of diabetes cases in the elderly is reported in China, followed by the United States and India[6]. Moreover, coronavirus disease 2019 worsens diabetes and increases the risk of developing diabetic complications that can result in disability or premature death[8]. The increasing prevalence of diabetes, along with the morbidity and mortality associated with the disease and its complications, as well as specific features (i.e., susceptibility to hypoglycemia, multiple comorbidities, cognitive decline) in elderly diabetes patients underscore an urgent need to address the specific challenges in caring for this rapidly expanding subgroup of the diabetic population, including hospitalized patients with diabetes[9,10].

Recent advancements have been made in the development of digital health technologies/interventions, 5^th generation (5G) networks, big data cloud storage, and artificial intelligence (AI). The integration of these digital health technologies into diabetes management has led to the development of smart hospital wards, revolutionizing patient care. In the context of diabetes management, the combination of real-time continuous glucose monitoring (CGM) and sensor-augmented pump (SAP) technology has been implemented in the creation of smart wards in some hospitals in China, leading to improvement of blood glucose management within the hospital setting. Additionally, SAP technology can customize insulin dosages based on individual blood glucose variations to achieve optimal glucose control[11,12]. This model can be expanded to establish smart wards tailored for elderly diabetes patients with unique characteristics, including a high susceptibility of hypoglycemia, cognitive decline, multiple diabetes complications, and concurrent chronic conditions (such as cardiovascular disease, hypertension, kidney disease, and retinopathy), necessitating a multidisciplinary approach for consultation and treatment[9]. While notable progress has been made in this field, challenges associated with the use of digital health technologies and interventions in smart wards, such as data security, privacy concerns, and technology-induced errors, remain. Further studies are needed in the future.

In this review, we collected studies focusing on the integration of digital health technologies in the development of smart hospital wards for managing elderly diabetes patients by conducting a literature search using the PubMed, Google Scholar, and Wanfang Med Online databases, as of December 31, 2024. Of these databases, Wanfang Med Online serves as a database for the Chinese medical literature, allowing for the capture of studies relevant to the Chinese population or those conducted in China, which may not be available in English-language databases. From the identified articles, we selected the original and most relevant studies for citation and discussion in this review, while excluding those that lacked relevance. Additionally, this review not only addresses current challenges but also proposes future research directions and implementation strategies for the care of elderly diabetes patients. Smart hospital wards may enhance clinical outcomes, address specific issues, and ultimately improve patient-centered hospital care for elderly patients with diabetes. Furthermore, the proposed future directions detailed in this review may assist clinical investigators in China and beyond when planning their clinical studies.

DIABETES IN THE ELDERLY AND MANAGEMENT CHALLENGES

Prevalence and features of diabetes in the elderly

The past fifty years have witnessed a rapid growth in the aging population, and the prevalence of T2DM, along with other age-related chronic medical conditions, has been on the rise. Currently, T2DM in the elderly (aged 65 years and above) accounts for approximately 50% of all diabetes mellitus cases worldwide[9]. In China, recent nationwide cross-sectional survey studies with a large representative sample size of adults (aged 18 years or older) - 170287 participants in 2013-2014 and 173642 participants in 2018-2019 - indicated that the prevalence of diabetes in 2018, based on the diagnostic criteria of the American Diabetes Association, was 12.4%, which is significantly higher than 10.9% reported in 2013 (P < 0.001) and greater than 10.5% of the global adult population (aged 20-79 years) as reported by the IDF Diabetes Atlas 2021[4]. In addition to the increasing trend in prevalence, China has the largest number of diabetes patients among all global cases of diabetes[2,5]. According to the IDF Diabetes Atlas 2019, the number of elderly diabetes patients in China was approximately 35.5 million, accounting for one-fourth of the global elderly diabetes patients (135.6 million)[6]. In the study by Sinclair et al[6], statistical charts and tables provide global and regional prevalence estimates as well as projections of diabetes in older individuals aged 65 and above. Notably, the prevalence of diabetes significantly increased with age (P < 0.001), being 5.0% for individuals aged 18-29 years and 27.3% for older adults aged 70 years or older in 2018[2].

Some features specifically associated with diabetes mellitus in the elderly are well recognized[9]. For instance, older adults with diabetes generally present a higher susceptibility to hypoglycemia compared to the younger patient population[9]. Additionally, older adults with diabetes may potentially have multiple comorbidities, such as cardiovascular disease, hypertension, and kidney disease, which complicate disease management and increase the risk of complications[9]. Age-related changes in metabolism, reduced physical activity, and cognitive decline can further exacerbate the challenges of diabetes management in the elderly[13,14]. These characteristics, along with others such as accentuated heterogeneity, increased reliance on care, and the impact of frailty, collectively contribute to the complexity and pose challenges in effectively managing diabetes in this specific age group of T2DM patients[9]. These challenges not only affect the patients themselves but also impact their families, outpatient clinics, and hospital wards.

Specific issues concerning diabetes management challenges in the elderly

The rapid growth and distinct characteristics of elderly diabetes patients present specific challenges in managing this patient population within traditional hospital settings. First, elderly individuals with diabetes are particularly prone to hypoglycemia, leading to greater complexities in antihyperglycemic treatment and glycemic control compared to younger adults[7,15,16]. The age-related decline in physical function and cognition has been linked to susceptibility to hypoglycemia[13,14]. Moreover, the increased risk of hypoglycemia in the elderly is attributed to disrupted hormone regulation and counter-regulation, as well as impaired liver and kidney function. The higher susceptibility to hypoglycemia, compounded by the presence of comorbidities, may complicate blood sugar management in elderly patients with diabetes. Notably, even well-managed elderly patients with T2DM experience significant fluctuations in blood sugar levels; approximately 40% of these patients experience asymptomatic hypoglycemia, while 50% encounter transient hyperglycemia. Besides medication-related factors, blood sugar fluctuations are influenced by insulin and cortisol secretion, sleep patterns, variations in nocturnal blood pressure, and meal timing. Additionally, unstable blood sugar levels have been linked to elevated mortality rates and the onset of chronic complications in diabetes patients[9]. It also has been noted that these fluctuations in blood sugar levels may disrupt the brain’s functional architecture and impair cognition[17,18]. As such, this can exacerbate the condition of elderly diabetes patients with comorbid Alzheimer’s disease. Second, elderly patients with diabetes commonly exhibit multiple chronic diseases and comorbidities, including cardiovascular disease, hypertension, kidney disease, retinopathy, cognitive decline, or Alzheimer’s disease, all of which are potentially linked to prolonged exposure to elevated and uncontrolled blood glucose levels. Third, elderly diabetes patients are at a higher risk of developing cognition impairment from subtle executive dysfunction to memory loss and overt dementia[19,20]. The diabetes-associated cognitive impairment in elderly diabetes patients such as memory impairment and other manifestations associated with age-related cognitive decline can diminish their medication adherence, notably in the context of managing multiple oral medications and subcutaneous insulin injections for glycemic regulation. This scenario may increase their susceptibility to drug interactions, potentially resulting in compromised drug effectiveness or adverse reactions. Finally, the current limited public health education resources and inadequate social support, especially in developing nations, can pose challenges for elderly patients and potentially hinder effective disease management.

To address the challenges of diabetes management in the elderly, it is crucial to establish a scientific and effective management model and approach. Fortunately, the emergence of digital health technologies and interventions, along with the progress of 5G networks, can facilitate the development of smart hospital wards to enhance care for elderly diabetes patients.

SMART WARDS FOR DIABETES PATIENTS EMPOWERED BY DIGITAL HEALTH TECHNOLOGIES/INTERVENTIONS AND 5G NETWORKS AS WELL AS CLINICAL BENEFITS

In the past decade, there have been substantial advancements in the use of digital health technologies and 5G networks to enhance clinical outcomes for diabetes patients. These technologies include mobile health applications (apps), wearable devices, remote monitoring platforms, AI, health chatbots, and virtual assistants. Currently, there is a limited number of studies evaluating the clinical benefits of these digital health technologies and interventions among the elderly patient population in both outpatient and inpatient settings. Building on the findings in patients with T1DM or T2DM, some strategies can be extended to elderly diabetes patients for the development of smart wards (Figure 1), which are discussed in this section of the review.

Figure 1 Key features of smart wards for patients with diabetes. Smart wards designed for diabetes patients exhibit key features that enhance diabetes management. Pump integration enables real-time visualization of blood glucose and insulin infusion data, thus improving decision-making efficiency, reducing response times, and facilitating rapid blood glucose control. A centralized display of abnormal alarms assists healthcare providers in ensuring timely and effective blood glucose management. Synchronous and standardized management supports remote system oversight for diabetes care. Additionally, comprehensive data analysis generates multidimensional reports to enhance management, while localized data storage improves data security.

Digital health technologies/interventions, 5G networks, and other accessible technologies for the management of diabetes patients

Mobile health apps for diabetes: Apps are computer programs specifically designed to operate on mobile devices such as smartphones, tablets, and other portable technology[21]. Mobile health apps have been developed to assist patients with diabetes, including those with T1DM or T2DM, in enhancing their care. These innovative technologies have emerged as transformative tools that aid in the demanding task of diabetes self-management. Individuals with diabetes who have access to mobile technology are increasingly utilizing these apps to improve blood glucose control and receive support, often in collaboration with their healthcare providers in both outpatient and inpatient settings. Currently, diabetes-related apps offer various functionalities[21-23]: (1) Instant access to diabetes management information, including resources from medical institutions and knowledge about diabetes; (2) Health assessment reminders that alert users and provide health instructions by identifying risk factors; (3) Diabetes diaries for recording diverse data to stimulate reflection and facilitate discussions between patients and healthcare providers; and (4) Online consultation and communication features that deliver personalized health information through interactive question-and-answer sessions to address queries and provide tailored health guidance to patients with diabetes[23].

As discussed earlier in this review, elderly patients with diabetes are at a higher risk of hypoglycemia, mainly due to decreases in appetite, nutritional intake, as well as reduced liver function. Some mobile health apps may be clinically beneficial to patients with diabetes by increasing their awareness of hypoglycemia and its prevention as well as reducing the frequency of hypoglycemia[24,25]. This is particularly helpful for elderly diabetes patients undergoing insulin treatment that requires multiple daily doses. For instance, a pilot clinical study demonstrated a significant reduction in hypoglycemic symptoms and increased awareness of hypoglycemia and its prevention among patients with T1DM through app utilization[24]. In addition, Sun and colleagues conducted a systematic review to assess the impact of smartphone-based apps on glycemic control in patients with T1DM[25]. The analysis revealed that the main functions of smartphone-based apps included recording blood glucose levels, calculating carbohydrate values, improving patients’ blood glucose levels, and monitoring compliance with antidiabetic medications. These functions were effective in enhancing patients’ blood glucose levels and promoting adherence to antidiabetic medications[25]. However, some individuals faced challenges with app usability and time constraints. Therefore, the future development of user-friendly apps tailored for elderly patients is essential.

Wearable health devices for diabetes patients: Wearable devices, such as fitness trackers and smartwatches, utilize sensor-based technology to collect and transmit data to a receiver or smartphone app[26]. These wearable health devices can assist individuals in adapting their lifestyles, setting goals, receiving feedback, and engaging in social activities. Currently, various wearable devices for diabetes patients that utilize specialized smart sensors have been developed and are widely used to enhance diabetes management[27-29].

(1) Real-time CGM systems. Real-time CGM systems continuously monitor interstitial fluid glucose levels and offer real-time data[27]. The wearable CGM device can visually represent blood glucose fluctuations and the impact of factors like diet, exercise, medication, and emotions[26]. Therefore, the real-time data from these devices allow healthcare providers to adjust treatment plans and lifestyle recommendations for patients with diabetes based on individual blood glucose patterns and key factors affecting glucose levels, such as dietary intake, physical activity, the timing and dosage of diabetes medications, stress, and side effects from other medications. For example, Yang et al[30] conducted a 72-hour dynamic blood glucose monitoring in diabetes patients using CGM. By analyzing fluctuations in blood glucose levels and the impact of key factors, the researchers were able to carry out personalized diabetes education[30]. This study demonstrated a positive impact on enhancing patients’ blood glucose control and lipid levels as well as improvements in their self-management capabilities, including diet, exercise, blood glucose testing, adherence to diabetes medications, and foot care[30];

(2) Insulin pumps and insulin pens. Insulin pumps, technically referred to as continuous subcutaneous insulin infusion devices, administer insulin from an externally worn pump at programmed rates[31]. Meanwhile, insulin pens are wearable digital devices that track insulin doses, injection times, and blood glucose levels[28]. These wearable devices can sync data with smartphone apps to provide information about insulin usage and help individuals adhere to their insulin treatment[28]. As insulin pumps can be programmed to deliver basal insulin continuously and allow for additional insulin doses to be administered before meals (bolus doses), these wearable devices offer more flexibility in insulin dosing and can help improve blood sugar control for individuals with diabetes[31];

And (3) CGM coupled with insulin pumps. The combination of real-time CGM and insulin pumps can assist diabetes patients requiring insulin treatment in order to better manage their blood sugar levels by adjusting the insulin doses as needed[29,32]. Gubitosi-Klug et al[33] have reported that in older adults suffering from long-term T1DM, the regular use of CGM and insulin pumps was linked to reduced hypoglycemic events, fewer hyperglycemic excursions, and lower A1C levels. Although the evidence for the clinical benefits of CGM and insulin pump use in the management of diabetes in elderly patients is mainly derived from T1DM, the clinical advantages of CGM have been demonstrated for individuals with T2DM who use insulin and are expanding[34]. The recent advancement involves combining CGM and a SAP with algorithms to enable automated insulin delivery (AID) based on real-time glucose readings, also known as an artificial pancreas or closed-loop system[29,32]. Currently, three hybrid closed-loop systems commercially available for patients with T1DM are the Medtronic MiniMed^TM 770G system, the Tandem t: Slim X2 Insulin Pump with Control-IQ Technology system, and the Abbott FreeStyle Libre with the Libre 2 system[32]. These systems enable T1DM patients to better manage diabetes in their day-to-day life. The Medtronic and Tandem systems automatically adjust insulin delivery, while the Abbott system requires compatible insulin delivery devices for hybrid functionality. Additionally, there are differences in the age groups for which each system is approved: Medtronic is approved for ages 2 and older, Tandem for ages 6 and older, and FreeStyle Libre 2 for ages 4 and older. However, data derived from the inpatient setting are limited. Several studies in the inpatient setting have shown the benefits of glycemic control with a hybrid closed-loop system using different algorithms[35,36]. In a pilot clinical trial involving patients with T2DM, the patient group using a closed-loop system achieved a significantly higher percentage of glucose levels within the target range (5.6-10 mmol/L/100-180 mg/dL) compared to the control group (65.8% vs 41.5%; P < 0.001)[35]. Another clinical trial involving patients on enteral or parenteral nutrition requiring subcutaneous insulin therapy revealed a notably higher proportion of time within the target range in patients using the closed-loop system (68.4% vs 36.4%)[36]. The SAP technology that integrates subcutaneous insulin infusion and real-time CGM offers many clinical advantages, including lowering glycated hemoglobin levels[12], early intervention to reduce the incidence of hypo- and hyperglycemia[37], improving the time required to reach predefined glycemic targets[11], shortening the time required to reach predefined glycemic targets by 2.6 days, thereby reducing the hospital stay[11], and enhancing treatment satisfaction and quality of life[38].

Recently, significant progress has been made in the development of advanced insulin delivery systems for diabetes management, including both T1DM and T2DM. One notable system is the Omnipod 5 AID system (Insulet Corporation), the first and only AID system approved by the US Federal Drug Administration in August 2024 for individuals with T2DM requiring insulin treatment. Unlike hybrid closed-loop systems, the Omnipod 5 has achieved fully AID, making it easier for elderly patients with T2DM to manage their insulin and maintain their glucose levels within the target range[39]. The system also features a tubeless design that allows for greater freedom of movement, as well as an intuitive interface that enhances user-friendliness for older individuals. Currently, hybrid closed-loop systems are utilized for patients with T1DM or T2DM requiring insulin in China[40]. Although AID systems are not yet available in China, it is projected that they will be accessible in the near future.

The 5G networks, big data cloud storage, and AI: In China, there are approximately 1.6 million 5G base stations, with smart 5G apps spanning various fields, including the medical care system. The 5G networks have been implemented in the healthcare system in China, and the extensive coverage of 5G networks has led to a profound transformation in connectivity and data transmission capabilities within healthcare settings[41,42]. The 5G networks allow for real-time access to medical information, teleconsultations, tele-referrals, and other healthcare services, and 5G-empowered hospitals may fundamentally change how the healthcare system operates[41]. In the context of diabetes management, 5G networks can facilitate seamless communication among devices, healthcare professionals, and patients, thus enabling real-time data sharing and exchange as well as remote monitoring on a unified platform.

By integrating 5G networks with big data cloud storage and AI, comprehensive smart hospitals in China can cover various areas of the healthcare system, including outpatient and inpatient settings. For example, the implementation of 5G networks together with AI and big data cloud storage facilitates real-time data sharing for prompt evaluation, monitoring, potential diagnosis, and timely treatment initiation, with the data being simultaneously transmitted to the hospital system[41]. Recently, the Guangdong Second Provincial General Hospital (Guangzhou, Guangdong, China) established a 5G-powered smart hospital, where if a consultation and decision-making process is required, a multidisciplinary team of medical experts can promptly arrive within minutes[41,43]. We propose that this establishment could be particularly beneficial for elderly diabetes patients who frequently experience multiple complications and concurrent chronic diseases (e.g., cardiovascular disease, hypertension, kidney disease, and retinopathy), necessitating consultation and treatment through a multidisciplinary approach[41].

Smart wards for diabetes patients through integrating digital health technologies/interventions, 5G networks, and other accessible technologies

In traditional hospital wards for patients with diabetes, blood glucose management typically involves bedside point-of-care testing using fingertip blood glucose testing. However, this conventional approach is cumbersome, increases patient discomfort, is prone to manual data recording errors, and consumes valuable medical staff resources. The wearable devices for diabetes patients (such as CGM and insulin pumps), 5G networks, and other digital health technologies and interventions have paved the way for more efficient healthcare delivery, including the implementation of smart wards tailored to meet the needs of diabetes patients. Smart diabetes wards are developed based on innovative technologies such as wearable devices for diabetes (e.g., CGM and insulin pumps), 5G networks, and other digital health interventions, enabling physicians, nurses, patients, and family caregivers to simultaneously access blood glucose information, leading to efficient blood glucose management.

During the hospitalization of diabetes patients, SAP therapy enables real-time monitoring of the patient’s blood glucose changes, facilitating the identification of existing issues and adjustment of treatment plans, thereby achieving an “information-insight-decision” approach for blood glucose management[44,45]. For instance, some diabetes patients are susceptible to hypoglycemia due to the gradual recovery of insulin function during treatment. SAP therapy has demonstrated effective reduction of hypoglycemia and clinical benefits for both adult and pediatric patients[44-46]. In China, the use of smart technology in the inpatient setting has been initiated to enhance the management of patients with diabetes[47]. With the availability of SAP and other smart devices, the abnormally high/Low blood sugar alert functions can issue warnings before the patient exhibits symptoms. Moreover, real-time visualization of blood sugar levels and adjustment of blood sugar levels are other advantages of SAP. The blood glucose changes and insulin infusion status are simultaneously displayed on the same screen, enabling healthcare providers to adjust the insulin doses for patients in different time periods based on this information. The healthcare providers can also visually observe the blood glucose changes after adjusting the treatment, indicating whether the current insulin dosage is appropriate. In contrast, healthcare professionals previously had to manually record blood glucose and insulin dose data, which was inconvenient and challenging to trace in the information system. The introduction of SAP therapy has addressed these issues, providing physicians with clear dynamic changes in the patients’ blood glucose levels and enabling the downloading and storage of relevant data from the backend for retrospective research, benefiting both clinical practice and research.

By combining real-time CGM and SAPs as well as integrating them with 5G networks, big data cloud storage, and hospital information systems, numerous hospitals in China have established smart diabetes wards or initiated such efforts[47]. The smart wards include not only the intelligent transformation of hardware facilities but also the intelligent upgrade of software systems, such as electronic health records, clinical decision support systems, etc. The main component of the smart ward project is the smart blood glucose management workstation. The key features of current smart wards for diabetes patients are as follows: (1) Pump integration and simultaneous presentation. By integrating blood glucose monitoring information and insulin infusion data through the insulin pump and synchronously transmitting it to the blood glucose management workstation, mobile ward terminal, patient education platform, etc., department physicians and nurses can promptly visualize the patient’s blood glucose fluctuations and corresponding insulin infusion details. The simultaneous presentation of pump information provides a clear overview of the treatment plans and effects. Pump integration reduces the response time, improves decision-making efficiency, and facilitates rapid blood glucose control; (2) Centralized display of abnormal alarms with classified processing: Any blood glucose or insulin infusion abnormalities can be centrally displayed at the workstation, assisting healthcare providers in enhancing the safety and effectiveness of blood glucose management; (3) Synchronous and standardized professional management of blood glucose monitoring and treatment: Patients in various conditions can receive timely diabetes professional remote system management, including personalized diabetes education, monitoring, formulation, and adjustment of treatment plans. Information solutions facilitate more convenient cross-departmental management; (4) Comprehensive data analysis and unified equipment management: The workstation generates multidimensional reports through data analysis to meet the needs of disease management, equipment management, departmental management, etc., thus enhancing the efficiency of in-hospital blood glucose management; and (5) Localized data storage paths ensure data security, enhancing the safety of blood glucose management (Figure 1). Apparently, the smart diabetes wards adopt a collaborative medical and nursing management approach to provide real-time health guidance and precise adjustment of blood sugar reduction plans for diabetes patients.

Enhancements in hospital care for elderly patients with diabetes in China through initiating the construction of smart wards for managing elderly diabetes patients

Although smart wards for diabetes patients have been established in various hospitals across China, there is currently a lack of hospital wards specifically tailored for older diabetes patients. Elderly diabetes patients face unique challenges compared to younger adult patients in terms of glycemic control and diabetes management, including increased susceptibility to hypoglycemia during antidiabetic treatment, the presence of multiple chronic diseases, and potential cognitive decline. Designing smart hospital wards for this vulnerable patient population must consider these specific issues.

Building upon existing research findings globally and in China, particularly in the general patient population with T1DM or T2DM, strategies such as integrating real-time CGM and SAPs as well as 5G networks, hospital information systems, etc., can be implemented in the development of smart wards for elderly diabetes patients to address their specific issues. The challenges in managing elderly patients with diabetes and potential resolutions through the development of smart wards are summarized in Table 1. These specialized hospital wards should be equipped with hardware and software, with a smart blood glucose management workstation as the central component. The SAP combines CGM with insulin delivery to provide real-time glucose readings and adjusts insulin delivery accordingly, aiding diabetes patients in maintaining stable blood glucose levels and improving overall diabetes management. The mobile ward terminal allows medical staff to access patient information, review test results, input notes, and communicate with other healthcare providers, thus enhancing efficiency and accuracy in patient care through rapid data access and improved team communication.

Table 1 Challenges in the management of elderly patients with diabetes and potential resolutions through the development of smart wards.

Challenges in managing elderly diabetes patients	Resolutions through development of smart wards
High susceptibility to hypoglycemia. Elderly diabetes patients are highly susceptible to hypoglycemia during antihyperglycemic treatment; High susceptibility to hypoglycemia increases complexities in glycemic control	Integration of wearable devices with smart sensors, mainly CGM and SAPs, into the development of smart wards for diabetes in the elderly
Multiple chronic diseases and comorbidities. The chronic diseases and comorbidities commonly found in diabetes patients: (1) Cardiovascular disease; (2) Hypertension; (3) Kidney disease; (4) Retinopathy; and (5) Neuropathy	Integration of 5G networks, big data cloud storage, and AI into the development of smart wards for elderly diabetes patients, allowing simultaneous transmission of data to the hospital information system and enabling real-time data sharing for prompt evaluation, monitoring, potential diagnosis, and timely treatment initiation. In patients with multiple chronic diseases requiring consultation and decision-making, a multidisciplinary team of medical experts can promptly convene within minutes
Cognitive impairments: Various degrees of cognitive impairments observed in elderly diabetes patients: (1) Subtle executive dysfunction; (2) Memory loss; and (3) Overt dementia	Integration of 5G networks for real-time monitoring, prompt evaluation, and timely initiation of treatment for patients in need
Limited access to health education resources: (1) Digital health apps; (2) Health chatbots; and (3) Virtual assistants	Incorporation of elderly-friendly diabetes apps, health chatbots, and visual assistants designed specifically for the older patient population

AI: Artificial intelligence; CGM: Continuous glucose monitoring; SAP: Sensor-augmented pump: 5G: 5^th generation.

Regarding the blood glucose control target ranges set for elderly patients with diabetes, the expert consensus on the construction and application of the hospital blood glucose management information system in China suggests tailoring different targets to individual patients for a more precise and personalized management approach[48]. For older patients aged above 75 years, following less strict and individualized blood glucose control targets is recommended. Additionally, for elderly patients with advanced diabetes-associated complications, life-limiting comorbid conditions, or cognitive impairments, it is recommended in major guidelines, such as the Standards of Care in Diabetes by the American Diabetes Association, to establish less intensive glycemic targets[7]. When providing palliative and end-of-life care for older patients with diabetes, the primary focus should be on preventing hypoglycemia and symptomatic hyperglycemia while easing the burdens associated with glycemic control[7].

CHALLENGES AND FUTURE DIRECTIONS

Although smart wards for elderly patients with diabetes offer promising clinical benefits, as discussed in this review article, several ongoing challenges persist in the use of digital health technologies and interventions for the development and implementation of such smart wards in clinical settings. These challenges may also be applicable to other countries worldwide, not just in China. Additionally, there are potential risks associated with the use of digital health technology in managing elderly diabetes patients in hospital settings, such as data security and privacy concerns as well as technology-induced errors potentially leading to incorrect treatment decisions[49-51]. Further studies are needed to ensure the safe and effective use of digital health technologies in managing elderly diabetes patients.

Ethical challenges and future directions

First, given the vulnerability of digital systems to breaches and unauthorized access, ensuring patient data security and privacy remains a critical challenge. Recently, it has been reported that the widespread integration of digital technologies in the healthcare sector in the digital era raises concerns regarding patient data security and privacy[52,53]. The utilization of digital health technologies introduces potential risks and vulnerabilities, including data breaches, unauthorized access, ransomware attacks, and the potential misuse of patient data[53,54]. To address this critical issue and to protect patient data effectively in the face of digital system vulnerabilities, we propose the following specific, robust, ethical frameworks and stringent data protection measures[55-57]: (1) Encryption: Utilize robust encryption methods to secure patient data; (2) Multi-factor authentication: Implement multi-factor authentication to add an extra layer of security for accessing patient data; (3) Data backup and recovery: Implement routine data backups and establish a robust data recovery plan in case of breaches; (4) Secure communication channels[58]: Use encrypted emails and secure messaging platforms to transmit patient information; and (5) Security audits: Conduct security audits without prior notification to ensure compliance with global and national privacy laws and regulations, such as the Health Insurance Portability and Accountability Act and the General Data Protection Regulation, for the ethical and legal handling of patient data[59]. Second, it is essential to obtain informed consent for using digital health technologies in smart wards, ensuring that patients understand how their data will be used and can make informed decisions about its collection and sharing. Third, patient autonomy as a key ethical principle must be carefully considered by respecting patients’ independence and self-determination to make choices based on their values, beliefs, and preferences, ensuring patients’ right to opt out of continuous monitoring systems[60-62]. The implementation of fully digital smart hospital wards may elicit varied responses from patients[63]. While some patients may appreciate continuous monitoring in the smart hospital wards as a means of enhancing their care, others may view it as excessively intrusive and may choose not to participate. Adhering to ethical considerations and patient-centered care principles, it is essential to offer options to patients. Conducting comprehensive reviews of patient opinions is crucial to ensure that their autonomy is upheld in the healthcare decision-making process[63]. Patients who express reluctance should have the opportunity to opt out. Therefore, given the intricacy of digital technologies in smart wards and the ethical challenges, there is a need for the development of comprehensive training programs for patients and healthcare staff to ensure that both are adequately prepared to use and benefit from new technologies.

CHALLENGES IN THE USE OF DIGITAL TECHNOLOGIES AND FUTURE DIRECTIONS

Elderly patients with diabetes may face challenges when using wearable devices and mobile health apps due to their unfamiliarity with technology. To address this challenge, we propose several strategies, including: (1) User-friendly design, such as a larger display, intuitive interface, and clear instructions; (2) Training and support for elderly patients, their family members, or caregivers through one-on-one tutorials or instructional videos; and (3) Community education programs focused on wearable technology and mobile health apps. By implementing these strategies, elderly diabetes patients may feel more comfortable and become familiar with using wearable devices and mobile health apps.

Challenge in interoperability and future directions

There is currently a potential challenge in the interoperability of new digital health technologies and interventions used in the development of smart hospital wards for older diabetes patients (e.g., CGM, SAP), 5G networks, and existing hospital information systems. Addressing this barrier is crucial to efficiently and safely access, exchange, and cooperatively use data to provide timely and seamless integration as well as efficient and secure data exchange. To overcome this challenge, it is necessary to enhance awareness and foster cooperation among all stakeholders, including companies in the digital health technology industry, participating hospitals, policymakers, and others[64-66]. This collaborative effort may ultimately improve patient outcomes.

Challenges in standardizing digital technologies and protocols and future directions

Other challenges may arise from discrepancies in technical access standards and protocols among hospitals across the nation. To address the issue of varying standards in creating smart wards and protocols for managing patients nationwide, the following several key strategies should be implemented[67-71]: (1) The development of national guidelines for the standardization of the design, implementation, and operation of smart wards is essential to ensure uniformity across various regions; (2) Providing training and educational programs for healthcare providers on the use of smart technologies would be helpful to reduce the differences; (3) The establishment of quality assurance programs and regular audits is necessary to monitor smart ward performance and to ensure compliance with set standards; and (4) Regulatory oversight should be implemented to enforce adherence to national standards and guidelines for smart ward development and operation. By taking the above proposed measures, healthcare systems can strive towards delivering consistent, high-quality in-hospital care for elderly diabetes patients in smart wards nationwide.

After the establishment of smart hospital wards for older diabetes patients, it is also important to ensure long-term sustainability. Strategies for future considerations may include the following[72-74]: (1) Implementing cost-sharing models with healthcare providers, insurers, or technology vendors to distribute financial responsibilities; (2) Establishing a schedule for regular maintenance of technological infrastructure; (3) Implementing a schedule for updates of technological infrastructure and software; and (4) Incorporating patient feedback mechanisms to continually adapt and improve the technology based on user experience, especially considering the specific needs of elderly patients. By adopting these strategies, healthcare facilities may improve the long-term sustainability of smart wards, ensuring ongoing efficiency, effectiveness, and innovation in patient care delivery.

For a specific subset of older patients, such as those receiving palliative care, whether with or without hospice services, there may be a need for an approach that prioritizes comfort and symptom management rather than strict control of metabolic parameters, such as blood glucose levels[7]. Although real-time CGM has advantages over traditional point-of-care glucose monitoring in reducing the incidence of hypoglycemia in diabetes patients, including the elderly, the use of CGM is currently not recommended for the intensive care unit mainly due to accuracy concerns[75]. Therefore, there is a need to enhance the accuracy of noninvasive glucose monitoring methods. Recently, several new technologies for noninvasive glucose detection have been developed. For instance, studies have demonstrated that terahertz spectroscopy can be used to effectively detect glucose concentrations[76,77]. The noninvasive nature of terahertz spectroscopy, along with its improved accuracy, presents promising opportunities for blood glucose monitoring in clinical settings. Additionally, CGM is still costly in China, representing one of the barriers for its use after transitioning from hospital care to outpatient management.

CONCLUSION

In conclusion, the high prevalence of diabetes mellitus among the elderly, along with the unique challenges relative to younger adults, underscores the need for improved diabetes management in older individuals. This review has focused on enhancing inpatient care by integrating digital health technologies like CGM and SAPs with 5G networks in the construction of smart wards. While progress has been made with the construction and implementation of smart diabetes wards in China, there remains a gap in tailored care with smart wards for older individuals. Recognizing the distinct challenges of glycemic control, comorbidities, and cognitive decline among elderly diabetes patients is essential for developing effective smart diabetes wards. Establishing smart hospital wards for this vulnerable population could provide an innovative platform to address these concerns and enhance patient outcomes. Therefore, the insights from this review offer a promising approach to meet the specific needs of elderly diabetes patients and may guide the formulation of innovative strategies to transform diabetes care for the growing aging population in China and beyond.