Does one size fit all? The needs of the older person with diabetes

Our population is ageing, and for many of us, caring for people with diabetes over 85 years of age is commonplace. While all are individuals, experience has shown that the older age group have some additional needs that must be included in care planning.

The older person with diabetes is likely to have associated comorbidities as well as cognitive deficits and disabilities (Finucane and Sinclair, 2001). They may also be socially isolated and limited in their range of foods due to finance or capability. Some may reside in nursing or residential homes, and may not be diagnosed with diabetes, but may be treated for urinary tract infections, evidenced by nocturia. 

Although increasing age brings increasing incidence of diabetes (Finucane and Sinclair, 2001), screening programmes are absent, and access to basic diabetes care when diagnosed, such as annual reviews, can often be limited. This can be considered neglect of care, with the opportunity to improve quality of life and patient satisfaction deliberately denied. It can often be associated with adult protection issues and institutional abuse. Certainly in our diabetes team we are much more aware of this than 2 years ago, which may be because we are now looking for it. 

Whatever the prompt, we have individuals sent in from nursing and residential homes with low or high blood glucose levels, who should have been referred to us for phone advice much earlier, thus preventing the distress of an ambulance journey into the accident and emergency department, and often an avoidable admission. When this happens, we report the care home through adult protection, and this workload is unfortunately increasing.

There are, however, some excellent initiatives that could raise collective awareness of this group’s needs, and also improve their diabetes care and management. Last year, the Institute of Diabetes in the Older Person (IDOP) was launched, led by Professor Alan Sinclair, and including clinicians from primary and secondary care, to develop initiatives designed to improve quality of care in this age group. Board members will be expected to lead on national and local initiatives to deliver this outcome.

There is an Older People with Diabetes Project Steering Group, of which I am a member, supported by NHS Diabetes, whose membership includes the Department of Health (DH), Diabetes UK, the IDOP and Age Concern. The aim of this group is to improve the quality of care for all older people with diabetes across different settings, including inpatients, care homes and in the community. The objectives include:

• Identification of existing inequalities in clinical and social environments.
• Promotion of examples of best practice.
• Provision of a simple cognitive assessment tool.
• Development of an audit tool for residents of care homes in collaboration with Diabetes UK.
• Piloting an audit of a diabetes-specific health inequality tool to be developed by IDOP.

Concurrently, pathways of care for the older adult with diabetes are being developed by the DH, and these have been reviewed and influenced by the steering group. They span screening to management and aim to produce a route for care that can be used by clinicians and commissioners when developing services to meet our population’s needs.

These and other emerging initiatives demonstrate that one size does not fit all, but that, at last, the often complex needs of older people with diabetes have a chance to be recognised and, hopefully, met when we plan services and care for this population. These and other specific issues are discussed in the accompanying article by Joy Williams, where she considers what care is needed, and what care is in currently received by older people with diabetes.