Who are the elderly? Although we would hesitate to label someone of 65 years old as elderly these days, often the figures quoted for diabetes for statistical purposes do exactly that. We know that the prevalence of diabetes increases as we get older, and it can be as high as 10% in the over 65 year olds (Croxson et al, 1991), thus representing a formidable challenge for healthcare professionals. The implications for diabetes care in such a large group of people raise a number of issues.
The elderly have special needs
The NSF for older people aims to eliminate age discrimination, provide person-centred care, promote older people’s health and independence and fit services around their needs (DoH, 2001). However, there was no specific reference to older people in the diabetes NSF, unlike children and adolescents, who are seen as a special group. I would argue that the older person with diabetes also falls into this category. Elderly people have very specific problems and needs. There is seldom just one chronic illness for an elderly person to cope with, but many. These are often accompanied by incapacitating disabilities and there are numerous drugs required to deal with each health problem. I would also argue that many elderly people take just as long, if not longer, to educate about their diabetes, than children. But unlike children, they require a slower pace and do not always have someone to look after their interests. Many elderly people live alone, are housebound and their nearest relative (if they have any) may live many miles away. Add depression to the list (which is high among people with diabetes (Meakin, 1999) and also the elderly) and you have a complex web of problems which require very specialist interventions.
In comparison, there are those elderly people who live permanently in residential accommodation where the knowledge of diabetes among their carers is poor (DoH, 2001). The DoH report also highlighted the poor communication between staff in the homes, social services and diabetes care teams and other NHS teams. Diabetes assessments and reviews of the elderly may be haphazard or non-existent, particularly if they are unable to attend hospital or practice follow-up appointments. Forbes et al (2002) highlighted how little was known about older people with diabetes, so this surely is an indication for action.
What do we need?
One of the main problems is lack of available manpower to put the required wheels in motion. However, we need to first identify the extent of the problem in our own areas, but who is going to do this? There is already a shortfall of consultants, DSNs, dietitians and podiatrists (Wincour, 2001) and those that do exist are already stretched to capacity. So how do we fit systematic care of the elderly with all their complex issues into such an equation? Surely this group of people require a DSN of their own? Unfortunately, it will fall on existing staff to highlight the problem, carry out the research to prove a need and formulate the results. However, having brought the problem to the fore, it would be a backward-thinking trust who ignored such highly–relevant research. Having proved a need, a business case for a DSN for the elderly should be submitted.
Grey power
I was at a meeting recently where plans to close a local hospital that only accommodated elderly people were being presented to the public. There was one elderly gentleman present who conveyed very articulately that he felt old people were a special case and require specialist treatment and nursing and this, he felt, could not be obtained in a general hospital.
He was fighting for what he believed were his rights and indeed the rights of all old people. Many would not have been so brave, so it is up to the healthcare professionals, you and I, to speak up for those who are not in a position to know what is rightfully theirs. From the research already done, we know that diabetes care for elderly people is substandard and this clearly needs to be addressed with some urgency. A DSN for elderly people may go some way to improving the situation.
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