The papers in this edition of International Diabetes Nursing raise some important issues that arise when developing care with and providing care for older people with diabetes. The population is ageing and older age is associated with physiological changes that increase the risk of diabetes.
Older age generally refers to people aged 65 and older; but chronological age is not a good basis for planning care for individuals. General and diabetes care and education must be personalised with the individual and sometimes their families. Older people have significantly different health care needs from their younger counterparts. Most older people are self-caring and live independently in the community, with and without some support. A smaller proportion is vulnerable and require a great deal of support and live in care homes.
Most have T2DM; but people with type 1 are surviving to older age and have long duration of diabetes. Type 1 can be diagnosed in older age. The type of older age the individual will experience depends on their genetic makeup and lifestyle. A healthy lifestyle can mitigate some of their adverse genetic inheritance.
Long duration of diabetes plays a significant role in health status, along with genetics and metabolic control. Risk of complications and polypharmacy increase with increasing age and diabetes duration and are key risks for admission to a care home and mortality. Twenty to 25% of care home residents have diagnosed diabetes and a further ∼20% are undiagnosed but at risk. Some 20% of hospital beds are occupied by people >70 years and many of these have diabetes.
Continuing to focus on tight blood glucose control may be unsafe for older people and put them at risk of hypoglycaemia and related risks. However, hyperglycaemia also has adverse consequences. The challenge is to balance benefits of care options within the individual's likely life expectancy with the risks, and to preserve autonomy and social connections for as long as possible. It is also important to consider the benefits of including a palliative approach to managing pain and discomfort with usual diabetes care. Early initiation of palliative care improves comfort, quality of life and life expectancy.
Older people are entitled to appropriate diabetes education. However, the teaching strategies must suit the individual's learning style and be offered when the blood glucose is in an appropriate range given both high and low blood glucose affect short-term cognition. In addition, written and electronic information must meet health literacy and design standards.
Several guidelines and position statements concerning care of older people were published in the past few years, for example The McKellar Guidelines, The International Diabetes Federation (IDF) and National Institute of Clinical Excellence (NICE) Guidelines and the American Diabetes Association Position Statements and Standards of care. These are all important guidelines; however, most do not include key issues relevant to older people such as pain management, falls and the need for general health care such as vaccinations and screening.
The papers in this special edition of IDN focusing on older people with diabetes make a number of key points including the
need to plan for older age when young to achieve a healthy older age
importance of valuing older age as a life stage
association with morbidity and mortality and the value of proactively planning for palliative and end of life
importance of employing knowledgeable staff in care home and supporting their role with relevant policies and processes
risks and benefits of medicines and the importance of pharmacovigilance
important role of primary care to helping older people achieve a productive and quality old age.
I commend these papers to our readers and hope they will help them plan care with and advocate for older people with diabetes in all care settings where they work.