Quality Standards for Diabetes Care Toolkit

Older adults and residential care

Vision and eight objectives taken from the Ministry of Health (2002) Health of Older People strategy:

Older people participate to their fullest ability in decisions about their health and wellbeing and in family, whānau and community life. They are supported in this by coordinated and responsive health and disability support programmes.

Older people, their families and whānau are able to make well-informed choices about options for healthy living, health care and/or disability support needs.

Policy and service planning will support quality health and disability support programmes integrated around the needs of older people.

Funding and service delivery will promote timely access to quality integrated health and disability support services for older people, family, whānau and carers.

The health and disability support needs of older Māori and their whānau will be met by appropriate, integrated health care and disability support services.

Population-based health initiatives and programmes will promote health and wellbeing in older age.

Older people will have timely access to primary and community health services that proactively improve and maintain their health and functioning.

Admission to general hospital services will be integrated with any community-based care and support that an older person requires.

Older people with high and complex health and disability support needs will have access to flexible, timely and coordinated services and living options that take account of family and whānau carer needs.

Specific to diabetes care, treat the individual not the HbA1c. Guidelines and commentary around the care of the elderly or frail living with diabetes at home or in residential care suggest individualised care plans are imperative when treating diabetes (Diabetes UK 2010). Essential components of the individualised plan are that it maximises quality of life, avoids unnecessary medical and therapeutic interventions and provides support and opportunity for self-management where feasible (Diabetes Clinical Advisory Group 2012; Diabetes UK 2010). Additionally, the individualised care plan should consider the individual’s ability to self-manage, their cognitive status, comorbidities, risk of hyper/hypoglycaemia and life expectancy (Diabetes UK 2010; Mallery 2009; McLaren et al 2013).
Key messages contained in the International Diabetes Federation (IDF) guidelines:

Prevention through proactive risk assessment, screening and ongoing assessment.

Planned individualised care based on an individual’s functional status (mental and physical competence).

The need for more frequent assessment – ‘Older people do very well until something goes wrong, and then they often deteriorate suddenly, so those assessments might need to be more frequent than the annual ones we normally do’(Dunning, accessed at www.medscape.com/viewarticle/817705).

Medication management – reducing unnecessary poly-pharmacy and hyper/hypoglycaemia and prevention of other adverse events (such as falls).

Referral to geriatricians or doctors/nurses skilled in the care of the elderly with diabetes.

Involvement of a multidisciplinary team.
These guidelines also include decisions such as when to stop driving and end-of-life care planning.
The following framework for considering treatment goals for glycaemia, blood pressure and dyslipidaemia in older adults with diabetes is taken from the American Diabetes Association position statement (ADA 2014b). Note that this represents a consensus framework for considering treatment goals for glycaemia, blood pressure, and dyslipidaemia in older adults with diabetes. The patient characteristic categories are general concepts. Not every patient will clearly fall into a particular category. Consideration of patient/caregiver preferences is an important aspect of treatment individualisation. Additionally, a patient’s health status and preferences may change over time. A lower HbA1c goal may be set for an individual if achievable without recurrent or severe hypoglycaemia or undue treatment burden. Coexisting chronic illnesses are conditions serious enough to require medications or lifestyle management and may include arthritis, cancer, CHF, depression, emphysema, falls, hypertension, incontinence, stage 3 or worse CKD, MI, and stroke. By multiple, we mean at least three, but many patients may have five or more.