Older people with diabetes are not a heterogeneous group. Some are healthy and active; others are frail and have multiple health problems. Managing diabetes in older people is complex and is an increasingly important aspect of nursing care as the population ages and the incidence and prevalence of diabetes increases with increasing age. Diabetes manifests differently in older people and their healthcare needs are different. Likewise, diabetes is likely to adversely affect many activities of daily living including, socialising and driving as well as physical and mental functioning all of which affect self-care ability.

Older people in hospital and care facilities are a vulnerable group and the latter often receive suboptimal care (Kirkland 2000). Sinclair et al. (1997) found 40% of residents in elderly care facilities were on long-acting sulphonylureas, fewer than 1 in 10 had any regular diabetes follow-up, they had more hospital admissions than people without diabetes, stayed in hospital longer and had more complications. In addition, staff and resident knowledge about diabetes was deficient. Likewise, functional decline occurs in 30–50% of older people during hospitalisation and ∼30% >70 years return home with ADL deficits (Royal Melbourne Hospital 2002). Functional decline is associated with long duration of hospitalisation and manifests gradually as malnutrition, reduced mobility, compromised skin integrity, incontinence, falls, delirium, depression, and inadequate self-care.

Cognitive decline in older people with diabetes is multifactorial due to advancing age and vascular dementia but not other forms of dementia (Allen et al. 2004), hyperglycaemia (Morley & Flood 1990), and hypoglycaemia, and increasing duration of diabetes. Large community studies suggest older people with diabetes have worse cognitive functioning than non-diabetics (Croxon et al. 1995; Gregg et al. 2000; Logroscino et al. 2004), and the decline is more rapid in those with diabetes (Biessels et al. 2002). The Framingham Study suggests hypertension and diabetes are independent risk factors for poor performance on memory and visual organisation tests (Elias et al. 1997). In contrast, Asiakopoulou et al. (2002) demonstrated minimal effects on verbal and logical memory when blood glucose control is optimal.

In acute illness it is important to differentiate cognitive decline from hypoglycaemia, hyperglycaemia, and hyperosmolar states, delirium, MI, and other causes. Delirium is associated with:

• Prolonged hospitalisation, poor outcomes and admission to aged care facilities.
  
• Functional decline.
  
• Increased use of chemical and other restraints that increase the falls risk.
  
• Presence of infection, which can precipitate hyperosmolar states.
  
• Multiple comorbidities.
  
• Severe illness.
  
• Dehydration, which can precipitate hyperosmolar states and may lead to a diagnosis of diabetes in undiagnosed at risk individuals, see chapter 7.
  
• Alcohol abuse.
  
• Falls and fractures.
  
• Psychotropic medications.

Delirium, but not the severity, can be distinguished from non-reversible cognitive impairment using the Confusion Assessment Method (CAM) (Waszynski 2004). The CAM has concurrent validity with the MMSE but has not been tested in clinical settings and is associated with a 10% false-positive rate. The key aspects of the CAM are shown in the following list. A diagnosis of delirium is made if 1 and 2 and either 3 or 4 are present:

Fluid balance disturbances are common in older people largely as a result of changes in body water composition, declining renal function, and reduced thirst perception (Davies et al. 1995). Dehydration is common in community dwelling older people (Warren et al. 1996) occurring in ∼6.7% of those >65 years in hospital and is the principal diagnosis in 1.4% (Warren et al. 1994). Dehydration is present in 50% of residents in aged care facilities with a febrile illness who are often referred to hospital due to dehydration (Bourdel-Marchasson et al. 2004). Dehydration should be preventable in hospital and aged care facilities. Management guidelines should encompass strategies to do so considering the following information.

Dehydration is associated with hyperglycaemia and DKA and HONK (see Chapter 7), thromboembolism, infections, renal calculi, falls and constipation, and causes up to 50% mortality if it is not adequately managed (Wilson et al. 2003), and poor mental functioning (Wilson et al. 2003; Faes et al. 2007). Early diagnosis is difficult because of the atypical presentation in older people and because there is no absolute definition of dehydration (Weinberg et al. 1995). A commonly used definition is:

‘… a clinically relevant decrease of an individual’s optimal Total Body water (TBW) amount and may occur with or without loss of electrolytes’.

(Faes et al. 2007)

Thus, the degree of dehydration depends on the relative rather than the actual total intracellular and extracellular water loss. People with low body weight show signs of dehydration after losing small amounts of water. Significantly, ∼25% of older people drink < 1 litre of fluid per day, especially those over 85 (Volkert et al. 2004). Risk factors for dehydration include:

• age over 85 years
  
• female
  
• having ≥chronic diseases
  
• using ≥5 medicines
  
• medicine-related factors such as high protein oral or enteral feeds, laxatives, antidepressants, and diuretics
  
• fasting for surgery or investigative procedures
  
• fluid loss such as diarrhoea, vomiting, hyperglycaemia
  
• being confined to bed/chair
  
• poor mobility including manual dexterity
  
• poor eye-hand coordiantion
  
• communication difficulties
  
• inability to feed themselves
  
• social isolation
  
• hot weather
  
• having Alzheimer’s disease and other cognitive disturbances (Lavizzo-Mourey et al.1988).

The diagnosis is made on clinical signs such as recent weight loss >3% body weight, presence of an intercurrent illness, dry mucous membranes, coated tongue, sunken eyes, confusion, hypotension, muscle weakness in the upper body, and falls. Laboratory investigations such as serum osmolality, creatinine, blood urea nitrogen (BUN), BUN/ creatinine ratio, and electrolytes as well as urine pH and output are useful. Three forms of dehydration occur:

• Hypertonic: sodium >150mmol/L or serum osmolality >300 mosmol/L.

• Isotonic dehydration occurs when water and electrolyte loss are balanced, for example, diarrhoea and vomiting.

• Hypotonic dehydration results when electrolyte loss is greater than water loss, for example, overuse of diuretics.

The prevalence of the isotonic and hypotonic dehydration has not been studied systematically and may be under-recognised. Having a high level of suspicion and care strategies to ensure optimal fluid intake such as prompting older people to drink are important preventative measure. Specific treatment depends on the clinical assessment and may include IV fluid replacement, preventing venous stasis, pressure ulcers and falls, as well as managing the underlying cause, and uncontrolled hyperglycaemia. Care must be taken not to over hydrate the individual and cause cerebral oedema or water intoxication.

Given the increasing prevalence of diabetes in older people, the fact that depression is a risk factor for diabetes, the 2-fold increased risk of depression in people with diabetes (Bogner 2007), it is likely that many older people have undetected diabetes as well as undetected depression. Undiagnosed depression contributes to physical and mental functional impairment.

Depression frequently precedes and may be the cause of placement in an aged care facility. Depression may be due to grief over loss of functional and self-care ability and independence (Fleming 2002) and is significantly correlated with quality of life (Goldney et al. 2004). Depression is often associated with diabetes-related complications such as cardiovascular disease (Fenton 2006) and is more likely to be recurrent in older people (Cluning 2001), and leads to inadequate self-care, unstable blood glucose patterns, and affects cognitive functioning. Treating depression in older people reduces mortality by 50% (Bogner et al. 2007).

Some clues to the presence of depression in older people are:

• Talking about physical symptoms and believing they have a serious illness (Cluning, 2001).
  
• Grief over lost opportunities, abilities, and self-determination.
  
• Withdrawing from communal activities.
  
• Experiencing chronic pain.
  
• Having had a stroke or MI.
  
• Not receiving any visitors at least once a week in hospital and aged care facilities.
  
• Difficulty establishing relationships with staff and other aged care residents in the first four weeks after admission.

Depression management is discussed in Chapter 15. When possible, non-pharmacological options should be used first.

The prevalence of dementia increases with age and ranges from 63% to 81% (Zimmerman 2007). Approximately one-in-4 Australians over age 85 have dementia (Gray et al. 2002). There are two main forms of dementia: Alzheimer’s disease (AD) accounting for 70% of known dementias and Vascular Dementia (VD) accounting for the remaining 20%. Both AD and VD are present in ∼20% of people especially those with diabetes (Stewart & Liolitsa, 1999).

The association between diabetes and dementia may be due to:

• Cardiovascular disease: TIAs and stroke that can cause multifocal brain damage.
  
• Hypoglycaemia, especially if it is frequent and recurrent, which may cause permanent neuronal destruction.
  
• Persistent hyperglycaemia increases protein glycosylation and contributes to the development of advanced contributes to AGE (see Chapter 8) found in AD plaques (Phillips & Popplewell, 2002).

Nay and Garratt (1999) outlined three main stages of AD. The first is characterised by absent-mindedness, emotional instability and poor concentration. These symptoms can include spatial disorientation, disturbed perception, changes in personal appearance and hygiene, a tendency to blame others for a range of occurrences, and an inability to successfully perform ADLs. Depression is often present in the early stages because the person is aware that something is ‘not quite right’ and they realise ‘things are slipping away’ from them (Katona, 1994).

Stage two can last up to 12 years. The person may withdraw and behaviour is often variable including anger, transient crying, poor sleep patterns, disorientation, and profound short-term memory loss. Gait often changes, people have difficulty recognising their own face in a mirror, and continence issues emerge as well as other behaviours such as exhibitionism. The person cannot live safely by themselves in the community.

Stage three is often the shortest, lasting up to 2 years. Profound physical and cognitive decline occurs, finally resulting in stupor and coma. Miller (1999) developed a useful process for distinguishing between depression and dementia.

Age, life expectancy, other health problems and the person’s social situation should be taken into account when planning care. Achieving near normal blood glucose levels and preventing long-term complications may not be priority management aims. It is important to control uncomfortable symptoms (polyuria, polydipsia, lethargy), maintain quality of life (QoL) and minimise the risk of hypoglycaemia and the attendant risk of falling.

Suboptimal metabolic control is associated with urinary incontinence, leg/foot ulcers, infections, nutritional deficiencies, exacerbation of neuropathic pain, affects the ability to communicate and cause confusion and aggression (Kirkland 2000). Strategies and priorities need to be implemented using a stepwise approach and non-pharmacological measures where possible.

The issues outlined in the DHS, UK, and other policies and guidelines provide a useful framework for planning care. The main aims of care are to:

• Improve nutrition.
  
• Prevent hypo-and hyperglycaemia.
  
• Undertake a structured medication management programme using a quality use of medicine framework.
  
• Proactively screen for and prevent and/or manage diabetic complications, comorbidities, depression, and maintain independent self-care as long as possible.
  
• Undertake general preventative health measure such as vaccinations and health checks, for example, mammograms, prostate checks. Flu vaccine prevents respiratory illnesses, pneumonia, hospital admissions and death in older people (Gross et al. 1995). However, in years without influenza, booster vaccinations may not confer added benefits if routing trivalent vaccination does not produce seroprotection (Gaughran et al. 2007). Research suggests people with chronic diseases are less likely to receive preventative care despite attending health professionals frequently (Beckman et al. 2001; Lipscombe et al. 2005).
  
• Manage coexisting illnesses to improve functional ability and improve quality of life.
  
• Maintain a positive attitude.
  
• Maintain a safe environment to limit adverse events such as falls.
  
• Have plan for regularly assessing driving safety and help the individual develop and maintain a transportation plan to make the transition to stop driving. Be aware that operating motorised wheelchairs, Go-Fors, and farm machinery may also constitute a driving risk.
  
• Ensure a comfortable and peaceful death at the end of life.

• Age, but age alone may not give an accurate picture of an individual’s ability to cope with self-care tasks and activities of daily living. Functional level should be assessed using appropriate tools in an appropriate familiar setting.
  
• Current diabetes control and complication status including the presence of liver and kidney disease.
  
• Presence and severity of comorbidities.
  
• Life expectancy.
  
• Mental and physical capacity to self-care.
  
• Nutritional status. Inadequate nutrition predisposes the person to hypoglycaemia, falls, decreased immunity, delayed wound healing and infections, and other diseases.
  
• Learning capacity, which is influenced by the individual’s learning style, sight, hearing and cognitive ability, interest in the topic, and the way the individual presents the information, see Chapter 16.
  
• Social support from family and the community.
  
• Financial status and access to services.

Nutritional management