Time to take stock of our care of older people with diabetes

The NSF for Diabetes Delivery Strategy published earlier this year does not specifically mention elderly people in the 12 standards, although it does state that all adults with diabetes should receive high-quality care throughout their lifetime (DoH, 2003). One could argue that elderly people with diabetes are a special case and should be considered as such, in the same way that children and pregnant women have been highlighted.

A formidable task for healthcare professionals and carers
The prevalence of type 2 diabetes is estimated to be as high as 6% in the over 65-year-old age group. Estimates of the number of elderly people with diabetes in care homes ranges from 7–25% in England (Bartlett, 2001). This is coupled with the fact that there is a lack of diabetes training and awareness among care home staff.

In addition, many more elderly people with type 2 diabetes are being transferred to insulin therapy in an attempt to optimise metabolic control in line with Standard 4. This in itself may highlight both practical and cognitive problems. Moreover, there may be difficulties involving multiple pathology and polypharmacy, not to mention social isolation, limited mobility and a lack of resources to deal with it all successfully. Caring for the elderly person with diabetes is complicated, challenging and requires time and patience to achieve positive results.

How can we improve the situation?
We must think of new and innovative ways of working and push the boundaries further than they have been pushed before. This requires a team approach by all agencies involved, in order to make the most effective use of the available resources. Indeed, there are examples of innovative ways of working throughout the UK. For example, Derby’s diabetes team carried out complete assessments of elderly people in care homes and produced individualised plans of care for each (Kirkland, 2000). Bridlington used a diabetes support worker to carry out annual reviews/assessments on elderly patients either in their own homes or in care homes (Smith, 2001).

Support workers
The idea of using support workers to take on roles which were previously carried out by specialist nurses (and now often done by district nurses) is an interesting one. With the increasing number of elderly people transferring to insulin therapy, the numbers of people who require the assistance of district nurses, to carry out blood glucose testing or to administer insulin, is bound to increase. 

Although many of our elderly patients may cope initially, as they get older they may require help especially when they live alone. A visit to give twice-daily insulin injections can be very time-consuming, particularly if there are a number of dependent insulin-treated patients on the nurse’s caseload.

If we can teach relatives to carry out blood glucose testing and administer insulin injections, why can we not teach care workers to do the same? With appropriate training and assessment, care workers and nursing auxiliaries could be taught these skills, which would lead to them feeling more involved with the care of the patient and add to their knowledge of diabetes.

Conclusion
The NSF highlights the need for staff to be trained in the care of people with diabetes and this includes all of those involved. Diabetes care is moving on; it is time to break new ground, take stock of what we are doing, look at where we are going and what we need to do to get there.