Health issues in Gerontology

This article discusses the growing incidence of diabetes among the elderly population, particularly among the Aboriginals and Torres Strait Islanders in Australia. It highlights the impact of diabetes on the individual's physical and mental health, and the economic burden on the healthcare system of Australia. The article also emphasizes the role of nurses in assessing and preventing diabetes among the elderly population.

Health issues in Gerontology
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Introduction
The number of elderly or geriatric patients of diabetes in Australia and the world are
growing due to higher life expectancy, increase in population of the aged and lifestyles that
are sedentary and diets that are nutrition dense. Of particular concern is the high prevalence
of diabetes among the Aboriginals and Torres Strait Islanders in Australia. Their socio-
economic status and lower levels of awareness about lifestyle choices could have put them at
a greater risk. The risk of complications associated with diabetes and the presence of co-
morbidities in the geriatric population makes it important for high quality of care delivery.
The diagnosis of diabetes and related complications among the elderly impacts their well
being and if associated with cognitive decline their ability to self-manage medication, diet
and exercise regimen is affected. The delivery of care through government programs in
Australia is available but the growing numbers of patients poses a challenge. Nursing staff is
trained in dealing with in-patients at hospitals and many of them are trained as diabetes
educators. The role played by the educators can help patients and their families to cope with
the stress of dealing with diabetes. Nurses also help in the transition of patients from the
hospital and ensure that after the discharge the patient is able to receive medication.
Incidence of Diabetes mellitus in older adults
The incidence of Diabetes Mellitus among those aged 65 and above has seen an
increase all over the world and in Australia more than half a million people in this age group
suffer from diabetes (AIHW, 2017). 10.8 million people among the aged in the US suffer
from diabetes as detected by the fasting blood levels and the HbA1c (Caspersen, Thomas,
Boseman, Beckles, & Albright, 2012). In most of the cases patients are type 2 diabetics.
Diabetes is a group of diseases that results due to high blood glucose levels that could be n
outcome of reduced insulin production by the pancreas or defects in insulin action, at times

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both the reasons are attributed to the condition (CDC, 2011). The prevalence of diabetes
among the Aboriginal and Torres Strait Islanders is 38% as compared to the 12% rate of
prevalence among the non-indigenous Australian elderly population (AIHW, diabetes, 2017).
The risk of complications due to diabetes, such as, foot complications is more common
among the Aboriginals and Torres Strait Islander people (West, Chuter, Munteanu, & Hawke,
2017). Aboriginals are 4.3 times more likely to be hospitalised due to diabetes related
complications than the general population (Gibson, 2017). Several complications are
associated with diabetes when blood sugar levels are uncontrolled. Cardiovascular disease,
kidney disease, retinopathy, peripheral neuropathy, depression, anxiety and distress are major
risks. However, well managed blood glucose levels can help patients stay safe from
complications.
Impacts on the individual
The impact of a diabetes diagnosis on the patient can be enormous. The patient may
feel overwhelmed with the possibility of complications, frustrated with having to make
lifestyle changes and may feel lonely. Some patients may be able to cope better than others,
but those with weaker coping mechanisms may feel a greater impact. A newly diagnosed
patient may suffer from mental health issues, such as, depression and anxiety. There may be
distress due to the need to constantly watch one's diet, remember to take medication and
include some form of physical exercise. Periodic checks for glycosylated hemoglobin,
systolic blood pressure and blood lipids require the patient to be engaged in self-care all the
time. The economic burden of the medicines and tests also impact the patient. Health related
quality of life does not remain as it was before the diagnosis of diabetes (Leach, et al., 2013).
The annual direct costs of people who have complications are more than double the cost of
those living without complications and can surge to $9600 from $3500 (Health.gov.au, 2015).
The challenge of living with diabetes is significant for the elderly because of episodes of

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hypoglycemia, co-morbidities, poor food intake, recent hospitalisation may cause reduced
independence (Jafari & Britton, 2016). There are a large number of elderly diabetics who face
disability due to loss of vision or due to amputation caused by prolonged hyperglycemia.
These are complications that are preventable through proper management of blood sugar
levels (Wong, et al., 2016). Of particular concern is the impact of diabetes on the cognitive
function of the brain. Self care and management of the disease requires that even in old age
the patient should be able to make informed choices and remember to take medication as per
schedule. The decline in cognitive function can increase the dependence of the elderly on the
carers. Mild cognitive decline may advance to dementia with advancing age. Issues with
maintaining glycemia, inflammation, vascular and metabolic impacts of diabetes can affect
the brain in those with long-standing diabetes and the newly diagnosed patients. A 2.0 to 3.4
fold increase in the risk of vascular dementia has been reported by studies carried out on
elderly diabetes patients (Samaras & Sachdev, 2012). Ongoing treatment of chronic
conditions due to diabetes can incur out of pocket expenditure for the elderly and impact their
household budgets negatively, leaving less availability of money for other expenses (Islam,
Yen, Valderas, & McRae, 2014).
Impacts on the health system of Australia
The impact of diabetes among the elderly and the costs incurred in treatment of the
mostly preventable complications are enormous even for a high income country like
Australia. The economic burden not only impacts the households of diabetic patients but the
healthcare system of Australia is also affected. With passing time the cost of illness has
increased. In situations where the elderly are not able self care, an at home carer, residential
aged care or institutionalised care may be required. There are times when the elderly need
help to check for the accuracy of blood glucose tests or whether their instruments are
functioning optimally, whether the meaning they decipher from food labels is correct, for

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example, should they drink fruit juice that has no added sugar. The Department of Health of
the Australian government has the National diabetes Service Scheme through which
registered patients can receive subsidies on medicines, insulin, blood glucose strips and other
requirements for keeping the hyperglycemia and hypoglycemia under check. Government
spending on the treatment of diabetes monitoring and treatment is therefore substantial.
Role of nurse in assessment and prevention strategies
The causes for diabetes among the elderly could be several. Some may have suffered
from the condition since a younger age while most could have become resistant to insulin or
have low insulin secretion from the pancreas post the age of 65 years. In both cases the
sedentary life styles and nutrient dense western food consumption could be the cause. Among
the Aboriginals and Torres Strait Islanders, the elderly are particularly prone to diabetes. Poor
diet that is devoid of the recommended servings of fresh fruit and vegetables is an important
reason. For members of the community who live in remote locations and do not have access
to fresh produce. Even those who live in non-remote areas and have access to fresh produce
may make unhealthy choices and consume high amounts of sugar in the form of sweetened
beverages and cakes, pastries. Only 15% of the population consumes the recommended five
serves a day. Obesity and high body mass index among the indigenous people make them
more likely to suffer from diabetes (Healthinfonet, 2013). They are four times more likely
than non-indigenous Australians to suffer from diabetes (Diabetesaustralia). Consumption of
food rich in fats, sugar and salt is often considered to increase the risk of getting diabetes.
The diabetesaustralia.com.au website has several resources on educating the indigenous
people about the awareness to detect and diagnose diabetes at an early stage, before
complications can set in. Differences in body mass index and the level of awareness and
education have made the Aboriginals and Torres Strait Islanders more prone to diabetes.
Their low socio-economic status makes it more likely that they suffer from diabetes due to

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maintenance of a poor lifestyle. Removal from families has caused stress that could be a
contributing factor (Reeve, Church, Haas, Bradford, & Viney, 2014).
Nursing practitioners can play an important role in the assessment and prevention
strategies. A diabetes nursing practitioner can order blood tests, help the patients and their
families to understand self-management, adjust insulin doses, and even prescribe medication
for managing the blood sugar levels in a better manner. Nurses can help in making the patient
aware about the complications associated with poorly controlled diabetes. They can also raise
awareness among people who are pre-diabetic and have higher values of fasting blood
glucose, so that they can make lifestyle modifications and postpone the onset age of diabetes
as far as possible. Since they are in constant contact with patients they can help in
communicating case specific information to the physician. Specific recommendations and
reminders about diet, exercise can be given to the patient. The need to check blood sugar
levels at different times of the day, and tests for HBA1c, lipids and renal function are
important considerations when caring for an elderly diabetes patient. Elderly patients living
in the community or residential aged care can receive help from a diabetes nurse who can
assess their level of confidence in managing diabetes and reducing the chances of
complications (Murfet, 2014). The set of problems faced by elderly patients include fraility,
propensity to fall and cognitive impairment. An assessment of the patient with regard to
whether they can return to the pre-hospitalisation levels of self-care is an important step to be
carried out by the nurse at the time of discharge. The patient's hydration status and episodes
of hypoglycemia during the stay at the hospital are important and patient's home care-giver or
the patient should be instructed about how to deal with similar situations upon discharge. The
nurse needs to ensure that transition from the hospital to home environment occurs smoothly
and the patient's co-morbidities are taken care of. Many elderly patients have multiple
medications and polypharmacy (the use of 5-9 drugs) is more likely. It is important to check

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whether an antibiotic leads to hypoglycemia in the patients or if there is the risk of other drug
interactions (Runganga, Peel, & Hubbard, 2014). Direct communication with family
members about the plan of the treatment and the importance of maintaining blood sugar
levels within the normal range are important aspects of transition from in-patient to home
setting. Several challenges are presented by elderly diabetes patients. The presence of co-
morbidities makes the task of the nurse more complicated. Communication of the nurse with
the patient and the family is important in trying to ensure a safe transition from an inpatient to
home or residential care. A good reference for nurses is the Diabetes Management Journal
that is published by Diabetes Australia. It provides evidence based information and the latest
guidelines released by the National Health and Medical Research Program (NHMRC). It is a
good source to learn about the newly developed products that help in management of
diabetes. The best practices in the management of diabetes are also published in the journal
regularly (Diabetesaustralia.com.au).
Conclusion
The care of elderly patients with diabetes is an important public health concern
because of the growing number of patients, some who have been newly diagnosed and some
have longstanding disease. With increasing age the risk of complications increases
substantially and good glycemic control through medication and follow up with blood
glucose testing, testing for blood pressure, lipids and renal testing assume importance. The
high occurrence of diabetes mellitus among the Aboriginals and Torres Strait Islanders has
been understood to result from their low socio-economic status and low education levels. The
stress of broken families has taken its toll on them and they are unable to make healthy life
style choices. The impact of diabetes and the resulting complications on the elderly takes a
toll on their overall well being. They may suffer from cardiovascular disease, chronic kidney
disease, retinopathy, microvascular and macrovascular problems. The economic impact on

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the family is an added stressor because even if the government provides subsidies on glucose
monitors, glucose strips and medication, out of the pocket expenditure on the treatment
strains the family's financial resources. The high cost of treatment is a burden on the national
exchequer. Nurse educators trained in helping patients to self manage the disease and to
provide smooth transitions to hospitalised patients have a major role to play in assessing the
ability of the elderly patients to self manage their medication, diet requirements depending on
their levels of cognition.

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