Running Head: INSULIN DELIVERY IN THE ELDERLY 1

Insulin Delivery in the Elderly Patient Population: Is the insulin pen safer for the elderly
compared to the traditional insulin syringe and vial?
Meaghan J. Kiley
University of New Hampshire
May 6, 2014













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Question: Is the insulin pen safer for the elderly compared to the traditional insulin
syringe and vial?
Population: Elderly diabetics
Intervention: Insulin administration via the insulin pen
Comparison: Insulin administration via syringe and vial
Outcome: The insulin pen is the safest method of insulin delivery for the elderly
Background and Rationale:
According to the American Diabetes Association, 10.9 million Americans age 65
years or older are living with diabetes mellitus. In relation to these statistics, increasing
age is a known risk factor for developing diabetes. Of the elderly diabetic population,
many require insulin therapy to manage their chronic condition. Due to diabetes
associated comorbidities in the elderly population such as dementia, vision loss,
neuropathies, and poor manual dexterity, elderly patients may be at increased risk for
hypoglycemia and dosing errors associated with the administration of insulin (Wright,
2010). These factors of aging can negatively impact the patients ability to self-inject
insulin, but also increase dependability on caregivers. For this population, simplifying the
administration on insulin can result in better management of diabetes and help the elderly
maintain their independence. Administering insulin via an insulin pen rather than the
traditional insulin syringe may provide a safer alternative for the elderly population.
Search Methods:
The University of New Hampshires online library database was used to conduct
research on insulin delivery devices, the insulin pen and insulin syringe. The health and
medical database, CINAHL, was selected to yield evidence-based articles appropriate to
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the search topic. Initially, the term insulin pen was searched via CINAHL, which
produced thirty results. To accurately refine the search, only linked full text articles that
were 10 years old or less were selected in the English language. Although this
contributed to a positive search result, the search terms needed to be more specific to the
target population. In attempt to generate results based on the elderly population, insulin
pen and elderly were entered into the database using the same criteria as the previous
search. This search term proved to be more concise and produced only two articles. The
same search method was used for the online database, MEDLINE, and resulted in articles
directed related to the comparison of insulin delivery devices.
For more general and statistical information regarding diabetes in the elderly
population, the online search engine, Google, was used. Reputable sources such as the
American Diabetes Association were also used to find statistics concerning the
prevalence of diabetes in senior citizens. The National Center for Biotechnology
Information was also used to obtain information regarding nursing implications and
patient education for insulin therapy.
Critical Appraisal of Evidence:
A Review of Insulin Pen Devices and Use in the Elderly Diabetic Population
In the review of insulin pen devices, Bradley Wright (2010) considers the various
insulin pen devices available today as well as the advantages the pen may have for the
elderly population. The review is comprehensive in the sense that it compares the insulin
pen device to the traditional insulin vial and syringe yet also considers dosing, ease of
use, and barriers associated with the insulin pen.
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The convenience of the insulin pen is discussed in comparison to the syringe and
concluded that it eliminates the need for elderly patients to draw up a dose from the vial.
Inaccurate dosing when drawing up insulin with the syringe can lead to complications
such as hypoglycemia or hyperglycemia. The insulin pen method reduces the amount of
steps when self-administering insulin and prevents the elderly from having to inject air
into the vial, drawing up the appropriate dose into the syringe with fine print measuring
increments, and visually validating the correct dose. In addition to the complexity of
insulin administration, visual impairment, joint immobility, and peripheral neuropathy in
elderly patients with diabetes may contribute to inaccurate dosing, and insulin pen
devices may be beneficial in terms of safety for elderly patients due to these visual of
physical disabilities (Wright, 2010 p. 55). The pen provides a larger visual display in
addition to some pens having an audible clicking feature that sounds with both dosage
selection and injection completion. Although the clicking feature would not help the
hearing impaired, it serves as an advantage to the visually impaired in addition to the
larger visual display.
Although Wright (2010) highlights the positives the pen has for the elderly, it
does not fail to mention barriers associated with straying away from the traditional
method of insulin administration. A large factor for all medical treatment is cost, and this
does address that concern. Although pen devices are commonly associated with a higher
cost per unit insulin in comparison to traditional vials and syringes, it is possible that
patients will have less insulin waste due to expiration of open vials (Wright, 2010). If the
pen is effective in providing accurate insulin dosing to the elderly, the pen may be linked
with overall lower diabetes-related costs due to preventing episodes of hypoglycemia or
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hyperglycemia. In addition to hypoglycemia cost savings, initiating therapy with a pen
device has shown significant reductions in hospital and outpatient costs when compared
to initiation with vials and syringes (Wright, 2010 p. 61).
On the other hand, this review also had its imperfections. Although some barriers
were addressed the review failed to mention that switching from the traditional vial and
syringe would require additional patient education. There is a reduction of administration
steps associated with the use of the pen, but there would be new steps that elderly patients
would have to learn to safely transition to using an insulin pen. For example, insulin pen
devices require an air shot or safety shot to prime the device before administration.
Failure to include this step in the process of insulin administration could result in the
injection of air or inaccurate dosage delivery. New pen users may also not know that the
needle cannot be pulled out of the subcutaneous tissue directly after injection like the
traditional syringe can. To ensure the full dose of insulin has been delivered, the pen must
remain in the subcutaneous tissue for an extra five to ten seconds following the dose
release. Finally, not all elderly diabetics on insulin would be candidates for the pen due to
some forms of insulin not being available in the pen device.
Insulin Devices: Addressing Barriers to Insulin Therapy With the Ideal Pen
This article addresses many of the mechanical barriers associated with the
administration of insulin via a syringe and a vial. The advancement of insulin delivery
proves to be effective in addressing mechanical barriers and can specifically meet the
needs of some patient populations such as elderly diabetics suffering from visual or
manual dexterity disabilities. This article suggests that many barriers associated with
insulin therapy are related to the method of administration, the traditional syringe and
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vial. Correctly holding the syringe or having precise visual acuity is necessary to
accurately self-administer insulin via the traditional route. However, visual impairment
and decreased manual dexterity are common secondary to diabetes in the elderly
population.
According to Spollett (2008), visual impairment is estimated to affect at least 16%
of patients with diabetes older than age 65 years and 27% of patients by age 75. In
addition, at least 50% of patients with type 2 diabetes have limited joint mobility in their
hands and 25% have symptomatic peripheral neuropathy. The simplification of insulin
administration with the pen would aid the elderly who have visual or tactile disabilities to
effectively manage their diabetes. Results after testing 86 insulin-nave visually impaired
patients with diabetes revealed that the clear dose scale, audible clicks while the dialing
of the dose, a large dose delivery button, the ability to handle the device are extremely
important features in an insulin delivery device. A device such as the pen, which will
simplify the accuracy of insulin delivery, can overall improve patient ability to set and
deliver the correct dose of insulin over and over again (Spollett, 2008).
When recommending an injection method for elderly patients, the ease of use is
important to consider because inaccurate dosing that can result in hypoglycemia. A 12-
week study, consisting of patients age 60 and above, assessed elderly diabetics and their
ability to use a syringe and a vial verses an insulin pen. Participants were randomly
assigned to one of the insulin administration methods for a period of six weeks and were
then required to switch methods. In total, 90% of patients found the insulin pen easy to
understand and preferred it for future treatment because it was faster and easier to use
compared with the conventional syringe and vial method (Spollett, 2008 p. 960).
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A major benefit of this article was the investigation of three insulin pens: the
SoloStar device, FlexPen, and the Lilly Disposable pen. All 510 patients trialing these
pens were assessed on their ability to correctly complete a four-step process for each of
the pens. The steps included: getting the pen started and removing the cap, attaching the
needle, setting and delivering a safety dose, and finally dialing a dose of 40 units and
administering that dose. The population of patients aged 60 or older preferred the
SoloStar and FlexPen and successfully completed the steps despite visual and dexterity
impairments. Although this article revealed that the insulin pen is an effective and safe
method of delivery for the elderly, it failed to address other barriers as to why the pen
may not work for some of the elderly population.
Evolving Trends in Insulin Delivery: In Pursuit of Improvements in Diabetes
Management
This article emphasizes the challenges associated with the conventional method of
insulin delivery and describes how newer insulin delivery methods aim to overcome
barriers for diabetics requiring insulin. It explains that the traditional insulin syringe and
vial method is a major result in reduced patient adherence to treatment. Suggesting an
alternative approach for the delivery of insulin can decrease patient burden and
inconvenience, while also improving medication adherence and ultimately patient
satisfaction (Akhrass, 2010).
Because the vial and syringe can be a daunting method of insulin delivery,
evidence suggests that patient preference in alternative ways of administering insulin can
result in reduced anxiety about insulin injections and reduced fear of hypoglycemic
episodes. Innovative delivery systems such as the insulin pen, can improve medication
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adherence ultimately leading to better glycemic control, patient satisfaction, and
improved health-related quality of life (Akhrass, 2010). For the elderly population with
additional health conditions, reducing anxiety related to their diabetes should be a main
goal to help prevent episodes of hypoglycemia. The insulin pen has many benefits that
can help the elderly population achieve this goal.
Characteristics that make the pen ideal include its convenience and ease of use
that are accommodating to a patients lifestyle. A randomized, crossover study was
conducted at 50 different physician offices in the United States. Questionnaires were
distributed to patients and included the Insulin Device Preference Questionnaire. Results
revealed that 72% preferred the use of the insulin pen, while a mere 22% preferred the
vial and syringe method (Akhrass, 2010 p. 119).
This article was inclusive of additional modes of insulin delivery that included the
insulin injection port, insulin infusion pump, transdermal insulin patch, and inhalable
insulin. Although these additional modes of delivery can be beneficial to the diabetic
population, it was not beneficial to the question at hand. Unlike the other articles, this
article was brief in explaining the advantages of the insulin pen. However, it did
recognize that the insulin pen is a safe method of administration that is associated with
convenience, ease of use, and reduced hypoglycemic events. In addition, the article failed
to elaborate how an alternative to the syringe and vial are beneficial to the elderly
population specifically.
Evidence Synthesis
After the careful review and appraisal of the articles researched, it is evident that
the insulin pen provides optimal patient preference, convenience, and safety in the
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administration of insulin. The features associated with the insulin pen are particularly
advantageous to the elderly with additional health conditions, some secondary to
diabetes. The insulin pen provides tactile and visual aids that can improve the ease of
insulin administration for the elderly as well as the accurate dose. Reading the fine print
on an insulin syringe, drawing up insulin from the vial, and properly storing insulin are
tedious steps the elderly do not have to take. The advancement and options associated
with insulin therapy should be discussed with diabetics of all ages to improve and
maintain medication adherence.
Particularly for the elderly, it is vital that the insulin pen can help maintain their
autonomy. Even with visual and physical disabilities, many diabetics in their senior years
can safely and successfully use the pen. An older adult with diabetes, who also has
Parkinsons disease, may have hand tremors that can interfere with their ability to
complete the several steps of delivering insulin with a syringe and vial. However, a larger
device such as the pen that is easier to hold may allow them to administer their insulin
independently. As a result, the use of the insulin pen in comparison to the traditional
syringe and vial is an ideal technique of insulin delivery, especially in the elderly
population.
Clinical Recommendations
Based on the evidence that the insulin pen is a safe, effective, and convenient
method for receiving insulin therapy the use of the pen should be encouraged over the
syringe and vial. Recommending the insulin pen to the elderly, can improve accuracy of
dosing and pharmacological adherence. The pen should be particulary recommended to
diabetic patients with visual and physical disabilities for ease of use and preservation of
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autonomy. For elderly patients who have been long time users of the syringe and vial,
there may be several barriers associated with changing methods of insulin administration.
Nurses can assess those barriers and concerns to help determine if the patient would
benefit from a different mode of insulin therapy.
Patients must choose the insulin delivery method that best fits their needs and
lifestyle, but nurses can intervene to help patients identify to the insulin therapy that suits
them. Nurses can address concerns regarding insulin therapy in addition to exploring
barriers to the use of the pen. Patient barriers typically fall under a number of definable
categories: denial of the need for insulin; misconceptions about insulin; fear of injections,
weight gain, and hypoglycemia; and complexities of insulin use. By following a
systematic approach, patient obstacles can be identified, clarified, and overcome
(Levich, 2011). Overall, nurses play a large role in educating patients about insulin
administration methods and should encourage the elderly to use the insulin pen for
ultimate safety, ease of use, and satisfaction.









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References
Akhrass, F., Skinner, N., Boswell, K., & Travis, L. B. (2010). Evolving trends in insulin
delivery: In pursuit of improvements in diabetes management. American Health &
Drug Benefits, 3(2), 117-122. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2010632694&sit
e=ehost-live
Diabetes Basics - American Diabetes Association. (n.d.). American Diabetes Association.
Retrieved May 4, 2014, from http://www.diabetes.org/diabetes-basics/?loc=db-
slabnav
Levich, B. (2011, February 20). Abstract. National Center for Biotechnology
Information. Retrieved May 4, 2014, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065562/
Spollett, G. (2008). Pharmacy update. insulin devices: Addressing barriers to insulin
therapy with the ideal pen. Diabetes Educator, 34(6), 957. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2010145569&sit
e=ehost-live
Wright, B., M., Bellone, J., M., & McCoy, E., K. (2010). A review of insulin pen devices
and use in the elderly diabetic population. Clinical Medicine Insights:
Endocrinology & Diabetes, 3, 53-63. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=2010940551&sit
e=ehost-live
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