Guidelines to improve the care of older people with diabetes

The care of older people is often in the news, usually associated with harrowing stories of neglect and lack of compassion and dignity.  As a nation we are living longer, which means that there will be a greater number of older people with diabetes requiring care. It goes without saying that these older people deserve the same compassionate, individualised care as their younger counterparts. 

Increasing age can bring increased dependence and physical or mental decline so diabetes services, as any other service, will require flexibility and focus to meet a potentially complex range of needs. Coordination across organisational boundaries, robust communication and defined accountability will be paramount in order to prevent duplication of services, all of which will be challenging within limited resources.

Guidelines for the care of older people with diabetes
The specific needs of older people with diabetes and the financial impact of this increasing diabetes population is acknowledged by the Institute of Diabetes for Older People (IDOP), which has recently launched the European Diabetes Working Party for Older People 2011 clinical guidelines for type 2 diabetes mellitus. These guidelines provide an evidence-based review of treatment, with a user-friendly set of recommendations and guidance in 18 clinical areas. Their detailed summary identifies best practice and addresses the gap in existing guidelines which do not focus on the needs of older people (Sinclair et al, 2011). 

The guidelines also highlight how the current European Union spending of €80 billion is expected to soar to €94 billion within 7 years to cope with the predicted 66.5 million people with diabetes, more than half being over 60 years of age. Talking about the need for improvement in the care of older people with diabetes, Professor Alan Sinclair, Director of IDOP, stated that: 

“If nothing is done now to improve the care of older people with type 2 diabetes, the effect on patients and the NHS could be catastrophic – the impending diabetes time bomb could potentially bankrupt the already stretched service”

Hypoglycaemia is greatly feared by many people with diabetes. Hypoglycaemic episodes are much harder to manage when an individual does not have early warning signs, as there will be little time to treat and prevent a hypoglycaemic event. This increases the individual’s risk of falls and collapse. The older person with diabetes is more likely to have fewer warning signs, which can sometimes be due to duration of their diabetes, or can be due to persistently low blood glucose. Persistently low blood glucose can be attributed to the overzealous adherence of Quality and Outcomes Framework targets, rather than an individualised approach to treatment, which seeks to improve quality of life without compromising patient safety. 

Cognitive deterioration in older people can also prevent the recognition of hypoglycaemia due to lack of understanding and confusion and failure to communicate with the healthcare professional.  Changes in diet, routine and medication, which can happen when a person is admitted to hospital, can also complicate the recognition of hypoglycaemia.

The accompanying article demonstrates how hospital hypoglycaemia protocols alone do not ensure that recommended treatment of hypoglycaemia is implemented and that case-based education should be included in the training of healthcare professionals. Although this audit was carried out in a South Australian hospital, the principles and learning point that it raises can be applied to UK practice.