Quality Standards for Diabetes Care Toolkit

Older adults and residential care

The definition of an ‘older adult’ is not clear as it can be based on chronological or functional age. ‘Older adults’ may be those over the age of 65 but this can be further broken down into the ‘young old’ under 75 and the ‘old old’ over 75. Additionally a distinction may be made between ‘healthy’ older adults (those who are aging but are in sound physical and mental health) and ‘frail’ older adults (those with comorbidities or physical, mental or emotional disability which compromises management of diabetes)’ (Australian Diabetes Educators Association 2003).
The Ministry of Health has produced the Health of Older People Strategy (2002). This document sets out the vision and eight objectives for the care of older adults aged 65 and over.
Guidelines for care of the older adult with diabetes are important because older people are more likely to have comorbidities which complicate management of diabetes (Australian Diabetes Educators Association 2003) and available guidelines often make little or no reference to this age group (Australian Diabetes Educators Association 2003; International Diabetes Federation 2013). Several organisations have developed diabetes guidelines specific to, or including, older adults (see below). The overriding message related to care of the older adult with diabetes is treat the patient not the HbA1c (McLaren et al 2013).

Older adults

A statement released by the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes (Sinclair et al 2012) provides consensus statements across eight domains covering glucose targets, influence of comorbidities, patient safety, hypoglycaemia, therapy, diabetes in care homes, diabetes education and family/whānau/carer perspectives pertinent to those aged 70 and over.
The American Diabetes Association (ADA) includes a section on older adults in its annual Standards of Medical Care in Diabetes – 2014 (American Diabetes Association 2014b). This section provides recommendations and a framework for considering treatment goals for glycaemia, blood pressure and dyslipidaemia in older adults with diabetes.
The International Diabetes Federation (IDF) (2013) guidelines for managing older people with type 2 diabetes provides extra detail for consideration when working with this group of people. The guidelines are designed for those aged 70+ and are also considered applicable for those with type 1 diabetes. The guidelines are based on expert consensus and clinical expertise but may not be useful for all older adult populations in New Zealand because of a lack of consideration for the needs of Māori and Pacific peoples. However the key message that older people are highly individual and their needs can differ dramatically is pertinent to New Zealand.
The Australian Diabetes Educators Association (2003) provides best practice standards for the diagnosis and care of older people in Australia with diabetes.
A New Zealand position statement produced by the New Zealand Medical Association (NZMA nd) provides 17 principles specific to care of older adults.

Residential care

Residential care includes long term care provided by rest homes, continuing care (hospital), dementia care units and specialised hospital care units (psycho-geriatric care) for individuals aged over 65; or aged between 50 and 64, unmarried and with no dependent children (Ministry of Health 2014). Younger persons may also be receiving care in residential facilities via disability services.
Older adults in residential care – the consensus statement from the International Association of Gerontology and Geriatrics (IAGG), the European Diabetes Working Party for Older People (EDWPOP), and the International Task Force of Experts in Diabetes (Sinclair et al 2012) pertinent to caring for individuals with diabetes in residential care suggests major aims for care for these individuals should be individualised care, prevention of hypoglycaemia, avoidance of acute metabolic complications, reducing risk of infection, prevention of hospitalisation and introduction of timely end-of-life care.
For examples of guidelines specific to care of older adults with diabetes in residential care refer to:

New Zealand residential care – Diabetes care for aged residential care facilities in Hawkes Bay (Diabetes Clinical Advisory Group 2012)

www.healthhb.co.nz/wp-content/uploads/2012/11/Diabetes-Care-for-Aged-Residential-Care-Facilities-in-Hawkes-Bay-2012-Reference-Book.pdf.

United Kingdom residential care – Good clinical practice guidelines for care home residents with diabetes (Diabetes UK 2010)

www.diabetes.org.uk/Documents/About%20Us/Our%20views/Care%20recs/Care-homes-0110.pdf.

Canadian residential care – Diabetes guidelines for elderly residents in long term care (LTC) facilities and the frail elderly (Diabetes Care Program of Nova Scotia 2010)

http://diabetescare.nshealth.ca/sites/default/files/files/LTCBackground2010.pdf.