Experiences of community-dwelling frail older adults with diabetes: Using phenomenological methods
Article information
Abstract
Purpose
This study explored the meaning and essence of life experiences among community-dwelling frail older adults with diabetes.
Methods
This study used Giorgi’s phenomenological methods to analyze in-depth interviews with 16 people who were diagnosed with diabetes and scored 3~5 on the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight (FRAIL) Scale. Participants were recruited from a public health and a senior welfare center in Jeollabuk-do province of South Korea.
Results
The data analysis revealed four essential themes and 12 subthemes derived from the interview data. These themes provided valuable insights into the experiences of frail older people with diabetes and shed light on their perspectives and challenges. The four essential themes were as follows: A feeble body falling into a bottomless pit, a narrowed range of activity, enduring heavy emotional burden, and the prospect of being supported for life.
Conclusion
This study revealed that community-dwelling frail older individuals with diabetes experience physical, psychological, and social frailty, exacerbating the need for aggressive diabetes management. These findings underscore the importance of providing holistic care to support this population in managing both diabetes and frailty.
INTRODUCTION
The global increase in older adult populations has led to an increase in the incidence of chronic diseases. The number of people over the age of 65 years with diabetes worldwide is predicted to increase from 110 million in 2019 to 195 million by 2030; this number is expected to reach 276 million by 2045 [1]. Older adults with diabetes often experience severe symptoms such as malnutrition, muscle loss, falls, cognitive decline, depression, and frailty caused by reliance on multiple drugs [2].
Frailty is a geriatric syndrome characterized by weight loss, decreased grip and walking speed, severe fatigue, and difficulty in performing activities of daily living due to age-related physiological weakness [3]. Frail older adults are distinguished from their healthy counterparts, who do not have diseases or difficulties associated with age-related physiological vulnerabilities [3]. Frailty often results in adverse outcomes such as falls, hospitalizations, functional dependence, disability, and death [3-5]. However, frailty is sometimes a reversible condition that can be managed through effective interventions and active efforts. This study addressed the critical issue that older individuals with diabetes are at a higher risk of developing frailty, emphasizing the need for aggressive diabetes management.
Diabetes-induced frailty leads to various physical and psychological consequences. Older adults with diabetes are more prone to a decrease in skeletal muscle mass due to hypoglycemia and dietary disorders compared to those without diabetes, which contributes to reduced physical activity [2]. Additionally, insulin resistance and the use of multiple medications [4] can lead to irregular blood glucose levels and inflammation, and malnutrition [6] combined with decreased muscle mass increases the risk of falls [7], making them more vulnerable to physical frailty. It is also observed that older adults with diabetes experience depression at a rate three times higher than their non-diabetic counterparts [8], and mental health conditions such as depression, schizophrenia, substance abuse disorders, and anxiety are associated with an increase in frailty [9]. Older adults with diabetes are more likely to experience depression due to factors such as loss of family or friends, financial issues due to retirement, loneliness, isolation, as well as concerns about diabetes complications, psychological distress related to blood sugar management, and biochemical changes caused by hyperglycemia [8,10]. These characteristics of diabetes make it more prone to psychological frailty than other chronic diseases. In other words, frail seniors with diabetes face a greater risk of sarcopenia, higher complications, increased hospitalization and mortality rates, and distinct patterns of comorbidity and functional decline compared to seniors with other chronic conditions. As such, older adults with diabetes are at greater risk for physical, cognitive, and psychological frailty than those without diabetes [6,9]. Compared to other chronic diseases, diabetes is more prone to complications and frailty if not managed throughout life.
Although some qualitative studies have examined the experiences of older adults with diabetes [11-15] or investigated frail older individuals [16-22], there is still a significant gap in qualitative research on frail older adults with diabetes. To our knowledge, no extant qualitative study has aimed to comprehensively understand the lives of community-dwelling older adults with both frailty and diabetes. There is a dearth of literature reflecting on the psychological aspects of their conditions and exploring their experiences with frailty and diabetes management. The purpose of this study is to understand what frail older adults with diabetes living in the community experience in their physical, cognitive, and psychological lives as a result of diabetes management and aging.
This study applied phenomenological qualitative method as it is particularly suited to understanding the personal experiences and meanings attached to those daily living experiences among community-dwelling frail older adults with diabetes.
METHODS
Ethic statement: All research methods were approved and conducted in accordance with the ethical requirements of the Jeonbuk National University Institutional Human Subjects Review Committee (approval No.: 2018-09-013-001).
1. Design
This study used a qualitative research design that applied Giorgi’s phenomenological method to uncover the meaning and nature of frailty as experienced by older adults with diabetes in their lives. Giorgi’s phenomenological research method utilized in-depth interviews to elaborate on the unique experiences of each participant in a contextualized structured statement [23].
This study was described in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines (https://www.strobe-statement.org).
2. Study Participants and Recruitment
Study participants were recruited through convenience sampling from a public health and a senior welfare center in Jeollabuk-do Province, South Korea. Frailty instruments and the Mini-Mental State Examination-Dementia Screening (MMSE-DS) were measured in older adults with diabetes who agreed to participate in the study, and those who met the inclusion criteria were selected.
Eligible participants were community-dwelling individuals aged 65 and older, diagnosed with diabetes and insulin treatment for at least 5 years. Frailty was measured using the Korean version of the fatigue, resistance, ambulation, illnesses, and loss of weight scale (K-FRAIL). These five items are categorized into healthy (0), pre-frail (1~2), and frail (3~5) with a total score of 5 points with higher scores indicating frailty. The K-FRAIL scale is a validated tool used to assess frailty in older adults, specifically adapted for the Korean population. It has been commonly used in geriatric healthcare to help quantitatively assess and manage frailty in older adults [24].
As an instrument to evaluate participants’ cognitive function, the Korean version of the MMSE-DS [25]. The MMSE has been used globally to assess the level of cognitive function disorder quantitatively and monitor changes in cognitive function based on iterative measurements. The tool consists of 19 questions and is scored 0 to 30: 10 points for orientation, 6 points for memory, 5 points for attention, 3 points for language, 3 points for registration, 1 point for copying figures, and 2 points for judgment and common sense. The total score is calculated according to sex, level of education, and age in accordance with the guideline for the use of the measure.
Inclusion criteria include being classified as ‘frail’ on a scale of 3~5, scoring 24 or higher on the MMSE-DS, no history of mental illness or communication disorders, and willingness to participate in the study. The first author introduced the study to the facility directors, and permission was granted to carry out the study. The staff and visiting nurses informed eligible patients of the study, and potential participants were evaluated to ensure they met all inclusion criteria.
3. Data Collection
In-depth interviews were conducted comfortably in the participants’ homes or at the welfare center office, with guaranteed confidentiality. The interviews began with basic conversations and were followed by open-ended, semi-structured questions about the participants’ life experiences related to living with frailty and diabetes. Introductory questions include “How has your health changed compared to before?” and ”Do you consider yourself to be frail?” These are followed by more exploratory questions, such as, “What specific event or factor led to a sudden change in your health?”, “In what ways has your condition of frailty altered your daily life compared to before?”, “Who assists you in managing your health?”, “What emotional changes have you experienced as a result of the changes in your health?”, “What strategies have you implemented to address or manage your frailty?” During the interview, if a participant mentions something that is unclear or requires further explanation, the question “Could you please clarify what you mean by that?” was posed.
The interviews were designed to elicit anecdotes and stories that provided insight into participants’ experiences. Observations of non-verbal cues, such as emotions, actions, facial expressions, and tone of voice, were recorded in field notes, along with thoughts and questions raised during the interviews. Each participant sat for one or two interviews, an average of 80 minutes (40 minutes to 2 hours). A small incentive of 30,000 won (approximately 25 USD) was paid to each participant after the interviews. Data were collected between December 2018 and March 2019.
4. Data Analysis
The interview recordings were transcribed verbatim and compared to the transcripts and field notes. The accuracy of the interview data was enhanced by confirming any unclear or ambiguous sections with a phone call or during subsequent interviews. In order to grasp the essential meaning of the phenomenon under study, the collected in-depth data was analyzed by applying the four steps of Giorgi’s analysis method of phenomenological research.
First, we read the interview data repeatedly and examined the statements on participants’ life experiences. All data were reviewed and analyzed carefully to accurately describe the participants’ unique perspectives and experiences. Second, meaning units were identified and delineated; third, the meaning units were transformed into psychologically sensitive statements of their lived meanings; and forth, a general psychological structure of the experience was synthesized. Focusing on the participants’ reactions or feelings, thematic statements were drawn and replaced with terms implied in the meaning of the experience. The derived concepts were classified as essential subjects, with more abstraction added through additional discussion.
5. Ethical Considerations
This study was approved by the Research Institutional Review Board (IRB) of Jeonbuk National University (IRB No.: 2018-09-013-001). All transcripts, written consent forms, and field notes were kept in a locked cabinet to ensure participants’ confidentiality.
6. Enhancing Validity and Rigor
The study’s rigor adhered to Lincoln and Guba’s criteria of truth value, applicability, consistency, and neutrality [26]. Truth value was ensured by cross-checking interview recordings with transcripts for accuracy and participant validation of their experiences. Applicability was assessed through the relevance of findings to community-dwelling frail older adults with diabetes, not involved in the study. In-depth interviews were conducted with participants once or twice, lasting 40 minutes to 2 hours, and participants were encouraged to fully express their experiences through rapport building with the researcher. The data and interpretations were meticulously reviewed and corroborated by three seasoned experts specializing in qualitative research. Their extensive experience in this field was instrumental in validating the accuracy and reliability of our findings, thereby strengthening the credibility of our study. To maintain neutrality, semi-structured interview questions with minimal researcher bias were used.
RESULTS
1. Characteristics of the Participants
The study involved 16 older adults, primarily female (12 female, 4 male), with an average age of around 79.13 years. The majority of the participants had an elementary education level, and 11 were religious. Their living arrangements varied, with most living with spouses while others lived alone or with family. The average duration of diabetes in the group was about 19.38 years, with a range from 5 to 50 years, highlighting varied experiences with the condition.
2. Situational Structural Description
The data analysis revealed four essential themes and 12 subthemes derived from the interview data. The four essential themes were as follows: 1) A feeble body falling into a bottomless pit, 2) a narrowed range of activity, 3) enduring heavy emotional burden, and 4) being supported for life (Table 1).
Essential Themes for the Experiences of Frail Older Adults With Diabetes
1) A Feeble Body Falling Into a Bottomless Pit
The first theme, “A feeble body falling into a bottomless pit,” captures the experiences of frail older people with diabetes as they struggle with their condition’s physical and emotional challenges.
(1) Differences between inward and outward appearances
Study participants noted that while they may not appear sick on the outside, they often feel sick on the inside. They experience a tingling sensation in their legs and a lack of energy due to diabetes complications. However, they felt that others could not understand their situation.
It’s diabetes, and it’s all about it. I don’t look, but I can’t help it. It’s powerless and invigorating, and sometimes when I do it, it’s okay. [...] Nobody knows. I have nothing to say about my situation. [...] (Female, age 78, diagnosed with diabetes 15 years ago)
(2) A body rusting over the years
The participants in this study dealt with the effects of aging, with their bodies slowly deteriorating over time. Many of them struggle with conditions such as stenosis and arthritis, making it difficult to move comfortably. In addition, their blood sugar levels are not under control, which creates further difficulties when they require surgery. As a result, they often receive treatment only for their pain rather than being able to address the underlying issues.
My eyes aren’t good and be the same as before. If I go out now, I have to go to OOO hospital for cataract surgery. I was told I had to operate from the summer, but I couldn’t because the blood sugar was high. Going to the hospital is a job. There was something? Life is just like that. [...] I’m dying because of bad eyes. (Female, age 72, diagnosed with diabetes 8 years ago)
Participants frequently struggled to maintain their appetite, and consuming the hard grains recommended for their diabetic diet was uncomfortable. When they could not eat, they reported feeling weak and lacking energy. Family members would often recommend that they go to the hospital to investigate their weight loss, as they may not have been aware of it themselves.
I have lost weight since last year. The kids say, “Mom, go to the hospital, go.” I didn’t know much [about my weight loss]. [...] My hands and things go inside. When I sit, my butt and tail hurt so much so I can’t sit. (Female, age 76, diagnosed with diabetes 23 years ago)
(3) Troubling blood sugar levels
The participants in this study were dealing with troubling blood sugar levels as their diabetes progressed, with many of them reporting receiving insulin injections to control their blood sugar levels. They carry candy in their pockets as a ready source of glucose and have a travel bag prepared in anticipation of needing to go to the emergency room for low blood sugar during the night.
It is (low blood sugar) that sleeps at night in the evening, and when the blood sugar falls when it is around dawn, there is no energy, and it seems to be dying and sweating. Then my husband wakes up in surprise, gives me a drink from the refrigerator; I eat it, close my eyes, and wake up. Then it’s better. I don’t sweat, and it’s nothing. During the day, it doesn’t do much. I don’t want the sugar to fall out while sleeping. [...] What should I do? Blood sugar is high during the day but falls only at night. [...] I am afraid of falling into low blood sugar at dawn. (Female, age 82, diagnosed with diabetes 30 years ago)
2) A Narrowed Range of Activity
This theme highlights the difficulties older adults face as they experience a limited range of activity due to physical limitations and poor health conditions. Participants expressed a sense of loss as they missed their active, younger days and struggled to engage in activities they once enjoyed. Furthermore, the impact of reduced immunity and barriers to accessing healthcare can compound the narrowing of activities.
(1) Missing active, younger days
As the participants’ time spent at home increased, they reported missing their more active and energetic younger selves. The lack of mobility and independence is in stark contrast to their previous lives, leaving some feeling that everything in the present is futile.
I haven’t learned much, but I did all the school work, and I did the president and vice president of the parents’ association. I have done everything. Now I put it all down, resigned it, and do nothing. It came out in 2013. I’m only at home now. (Male, age 81, diagnosed with diabetes 30 years ago)
(2) A shrinking world due to reduced immunity
Participants noted that they were spending more time at home due to their fear of catching a cold, as their reduced immunity levels make them more susceptible to illness. While they recognize the importance of exercise for their health, they also know they could suffer from cold or pneumonia during rainy, cold, and windy conditions.
I am just cautious about taking medicine and going around the park as I would in the hospital. I can’t go out because it’s cold now. I can’t exercise because it’s cold. I think I’ll go out when the day gets warmer. It’s blowing a lot. I have a big deal if I catch a cold because I have no immunity. (Female, age 77, diagnosed with diabetes 22 years ago)
(3) Barriers to accessing healthcare
Participants found carrying out their insulin self-injection routines challenging based on a single education session. While they recognize the importance of returning to the hospital for additional diabetes education and management support. They recognized the importance of visiting the doctor for additional diabetes education and management support. However, because they have peripheral vascular disease due to their diabetes, poor vision, and limited mobility, the clinic seems far away.
I don’t know how to inject (insulin), and I learned it in the hospital before; my eyes are getting worse so now I can’t. I was told to come from the hospital. It’s far, so I didn’t go. (Female, age 72, diagnosed with diabetes 8 years ago)
3) Enduring Heavy Emotional Burden
This theme highlights the various difficulties older adults face, including limitations to self-care, feelings of inadequacy compared to peers, and struggles with depression and loss of control. It recognizes the importance of maintaining dignity and grace in the face of these challenges and the need for greater support and resources to help older adults maintain their quality of life and well-being.
(1) Self-care is not entirely in one’s control
Participants wanted to maintain a healthy lifestyle and avoid being a burden on their children due to their weakened state. However, they also acknowledged that it could be challenging to adhere to healthy practices, and things do not always go as intended. For example, participants may decide to quit smoking and stop drinking but often struggle to stay committed to this goal. The awareness of limited time before death can create difficulties in resisting the urge to smoke, particularly since smoking is often an enjoyable habit that is hard to quit.
I was dizzy and sick, so I didn’t take the medicine for quitting smoking. It is very difficult to quit smoking. Doctors say quit smoking, but it’s not easy. My age is 80. How long will I live if I live? This will make the cigarette less, but I can’t quit. I have to do what I like. (Male, age 81, diagnosed with diabetes 30 years ago)
(2) Feelings of inadequacy compared to peers
Participants expressed a desire to remain active and engaged in life, but many felt upset with their physical limitations and health conditions. Some participants compared themselves to peers of the same age who remained active, exercised, and traveled, leading to frustration and sadness. Furthermore, participants noted that their children might compare their health to that of their friend’s parents, which can lead to feelings of inadequacy and regret for being unable to live a more active life.
It was a week ago. My wrist is sore on my cold. [...] My second son is worried and said, “Why my mom is sick so often. My friends’ mothers are still active and well. Mom, go around and cheer up you too.” (Female, age 78, diagnosed with diabetes 15 years ago)
(3) Struggles with depression and loss of control
Participants felt depressed as a result of their physical pain and illness. They do not want to become sick and fear breaking a bone in a fall or being forced to live unfulfilling lives due to their pain levels. Some referred to their daily diabetes medicine as annoying and did not feel the need to manage their blood sugar. Depression adds to their feelings of having an uncontrollable body and mind and leaves them feeling helpless about everything.
Depressed. I don’t know what life is. I hope it doesn’t hurt. My back hurts so I can’t move. Everything in the world is annoying. (Female, age 77, diagnosed with diabetes 22 years ago)
(4) Wishing for death
This theme highlights the difficulties experienced by the participants as they contemplate the end of their lives. Participants expressed a desire to maintain control over their lives and to have a say in their end-of-life care, including a preference for dying in a familiar place, surrounded by loved ones, and free from burdensome health conditions.
I just want to die. I just thought, “I wish I could go this way.” If I am not ill, I won’t even think about death, but it hurts. So I just want to die. I hope it doesn’t hurt, but it hurts. (Female, age 76, diagnosed with diabetes 17 years ago)
4) Being Supported for Life
They would cherish the opportunity to reconnect with old friends in the neighborhood, resolve past conflicts, and find emotional support. Participants adapted to their physical limitations and health conditions by seeking help from various sources. This support has helped ease the financial healthcare burden and provided some measure of security and stability for older adults and their families.
(1) Coping through religion
The participants reported turning to religion and deepening their faith as a coping mechanism for the physical challenges of pain and aging. They were praying to the absolute or talking to pastors and family members.
Because I believe in God, even if I can’t go to church, I pray and pray when I eat. When I was lying down in the intensive care unit, the pastor and the evangelist came and prayed. I pray, and my husband prays. Even I am at home, I pray and believe in God. (Female, age 71, diagnosed with diabetes 8 years ago)
(2) Reliance on community and social support systems
Participants, hindered by physical limitations and health conditions, relied on a network of support for daily living. This included assistance with meals, insulin injections, exercise, hospital visits, and household chores. Care primarily came from family members like spouses and children. However, those without family support turned to neighbors for help.
My husband looks after house and cook. My daughter comes once. [...] I don’t eat much, but I eat three times a day. I don’t want to eat. No appetite. But, I still have to eat. I don’t want to eat anything, but I try to eat a little bit. My husband takes care of it, so I don’t eat it. [...] I got insulin education but I’m illiterate, so my husband takes care of it. (Female, age 82, diagnosed with diabetes 30 years ago)
Additionally, participants utilized social support systems, applying for long-term care and receiving aid from nursing caregivers for various daily tasks. Despite financial challenges, particularly with hospital costs, there was a sense of gratitude for governmental support through pensions and welfare benefits.
It’s hard (hospital costs). The kids have a life, so they can’t make it, and the old pension and our living are the only ones in this house. I live with some money from basic supply and demand and old age pension. (Female, age 76, diagnosed with diabetes 23 years ago)
3. General Structural Statements of Frail Older Adults With Diabetes
Frail older adults living with diabetes encounter a range of physical and emotional challenges. Their lives are marked by a continuous battle with despair, as complications from diabetes exacerbate the vulnerability of their aging bodies. Participants frequently faced unexpected physical declines and diabetes-related complications, often feeling isolated in their struggles, unknown and misunderstood by their families and others. Many had to adapt to insulin injections due to insulin resistance, facing the daily unpredictability of high blood sugar levels during the day and dangerously low levels at night. This erratic glycemic control often resulted in falls, hypoglycemic comas, and repeated emergency room visits, adding to their sense of embarrassment and desperation. Efforts to manage their blood sugar through lifestyle changes like walking were hindered by compromised immune systems, leading to respiratory issues such as colds and pneumonia, and exacerbated by existing conditions like degenerative osteoarthritis. Attempts to control blood sugar levels at home were further complicated by a dislike for dietary changes, such as the taste of multigrain rice, and reduced appetites. This often led to rapid weight loss, diminished muscle strength, increased lethargy, weakness, and feelings of confinement and depression. Once energetic and healthy, these individuals now grapple with loneliness and the fear of being a burden to their children due to their increasingly unmanageable health. Visits to the hospital for diabetes management education were hindered by poor eyesight and mobility challenges. Advice from healthcare professionals to cease long-enjoyed habits like drinking and smoking seemed insurmountable to follow. Their physical frailty not only barred them from engaging in activities they once enjoyed but also plunged them into deep depression. Despite their desire for a peaceful end at home, away from the burden they felt they imposed on their families, the support from family, neighbors, and the community, alongside government assistance like long-term care insurance and pensions, provided a lifeline. They continually reflected on their lives, drawing strength from their faith and the support around them to navigate the trials brought on by their diabetes and frailty.
DICUSSION
This study utilized Giorgi phenomenology to gain an in-depth understanding of the essential themes of the experiences of frail older adults with diabetes [23]. All participants had been diagnosed with diabetes and were considered frail due to the natural effects of aging on their bodies, which limited their range of activities. Many participants reported being depressed but could manage with the assistance of others, even though they often thought about death.
The first essential theme of these life experiences is falling into a bottomless pit. For older adults with diabetes, a frail life is one in which their internal experiences differ from the outside world’s views. Their bodies have become less healthy over the years, their blood sugar levels are concerning, and they have become thin, despite their efforts to stay at a healthy weight.
This is similar to the theme of a person’s life “… running out,” as noted by Park [17], and “being trapped in a frail and deteriorating body,” as noted in other studies of frail older adults with common chronic disease [22]. However, participants in this study noted that the co-occurrence of frailty and diabetes can exacerbate each other, and interventions such as dietary adjustments and increased physical activities to control blood sugar levels could trigger the emergence of frailty. Therefore, older adults with diabetes need more comprehensive and diabetes-specific education to manage blood glucose levels and prevent the development of frailty and related complications. Many participants in this study were obese before becoming frail but experienced weight loss over time. Obesity can lead to insulin resistance, causing diabetes and muscle loss. Similar to obesity, being underweight can also lead to frailty [27]. Furthermore, participants experienced decreased appetite. The theme of loss of self-control was derived from the self-care experience of older adults with diabetes who complained of stress related to an uncontrolled diet [14]. The findings of Park [17], who found that in chronically ill frail older adults, anorexia and dyspepsia were the causes of weight loss, differed from the causes of anorexia in the diabetic older adults in this study. Personalized management is needed to determine the individual causes of anorexia, manage medicinal side effects, and intervene in cases of anorexia in older adults with diabetes.
In the second theme, participants struggled with a narrower range of activities compared to their youth. Participants experience anxiety about falls due to impaired sensory function, muscle weakness, diabetic neuropathy, hypoglycemia, and cognitive impairment. This reduction in range of motion was both a cause and a consequence of participants’ functional decline and frailty. Participants in this study attempted to exercise to lower their blood sugar, but they also avoided exposure to cold environments because their weakened immune systems meant that even a mild cold could develop into pneumonia, which frequently resulted in hospitalization. This was similar to the negative experiences of frail older adults with diabetes managing their diabetes on their own [13]. Frail older adults with diabetes would benefit from supportive programs, such as indoor exercise programs that can be practiced at home, and diabetes management and education initiatives to lower blood sugar and increase muscle sarcopenia. Frail diabetic older adults may be unable to visit a hospital easily due to reduced eye sight and limited mobility. This may lead them to continue taking outdated medicines obtained by their families visiting a doctor on their behalf, which can cause uncontrolled blood sugar and risk other complications. The participants in the current study had difficulty accessing information and community programs. The challenges of diabetes management and access to health care highlight the need for improved support and resources for older adults.
The third theme, “Enduring heavy emotional burden,” shows the participants’ limited self-care (e.g., reducing drinking and smoking) and emotional states over time. In Korean culture, drinking with others is an important aspect of human relationships, so some participants have felt that they must continue drinking to maintain a social life. This is similar to the experience of drinking as a barrier to self-management identified in a qualitative study of older adults with diabetes [12]. It is well known that smoking and drinking are detrimental to health; however, the association between smoking [6], drinking [28], and frailty is often overlooked among older individuals. To promote greater control over frailty among older adults with diabetes, nurses should educate them on the relationship between smoking, drinking, and frailty, taking into account the social and cultural context of each country. Participants in the present study reported feeling weak and unhappy about their weaknesses compared to peers of the same age. Diabetes is a cause of accelerated frailty compared to other chronic diseases [4]. Older people perceive and internalize their own states by comparing themselves with others [16]. The frustration experienced by older adults with diabetes regarding healthcare, such as blood sugar control, leads to general feelings of helplessness and depression, which also affect their quality of life [29]. Their irregular blood sugar made them more dependent on others for insulin injections and hypoglycemic episodes. The participants in this study, who require more self-management than other chronic diseases with frailty older persons [17,21], are in a state of frailty and pre-depression, and require active therapeutic interventions [2,5]. They felt guilty about being a burden on their families and lost their reason to live. As a Korean proverb says, “There is no filial piety in keeping your parents sick for a long time.” Older adults fear dying in a care facility, traveling to and from their children’s homes or hospitals, and worry that the long-term care and financial burden will be a source of family discord for their adult children.
The fourth theme has shown that various supporting resources, such as family members, neighbors, visiting nurses, caregivers, government pensions, and religious faith, can help frail older adults with diabetes overcome some difficulties. The study participants found solace in their faith, which was a source of relief from loneliness at home. This mirrors other findings of Li et al. [15] on the coping experiences of female living alone with diabetes; they found that depending on the absolute is a stress-coping strategy. In older adults with chronic conditions, support systems such as family, social networks, healthcare professionals, and religious beliefs are crucial in aiding disease self-management. These support systems play a significant role in providing emotional, social, and medical assistance, helping these individuals cope with the daily challenges of their conditions [30]. Therefore, nurses could potentially help older adults with religious activities such as prayer and spiritual counseling.
Our participants were financially burdened by medication costs, blood sugar testing, special diets, and transportation costs to visit the hospital. However, they were grateful for their national pensions, the hospitalization fee schedule for the vulnerable, and other government benefits. A study on older adults’ experiences with diabetes [13] revealed the issue of “insufficient financial support for disease treatment.” [13]. Fortunately, all participants in our study received a minimum payment from the government to cover their living expenses. This study found that older adults with both frailty and diabetes want both in-home care from skilled providers and financial services to support their health care and living arrangements. They also reported that the place they choose to live or need to live in the final stages of their lives is a familiar environment, which is an important factor that can help this population live more autonomously. Therefore, it is important that diabetes complications and healthcare providers, especially home visiting nurses, provide continuity of diabetes care and education across healthcare settings for frail older adults with diabetes who have difficulty getting to the hospital, and that multidisciplinary collaboration is needed to recognize the physical, psychological, and environmental conditions of frail older adults with diabetes as they remain at home. Health policies should play a pivotal role in promoting regular social interaction between patients and healthcare providers and increasing social inclusion in the community by providing medical and living support for frail older adults with diabetes.
This study has some limitations that should be considered when interpreting the findings. The abstract nature of some topics and some participants’ difficulties in expressing their experiences limited the depth of some interviews. More direct and closed-ended questions were used in these cases to obtain useful responses.
CONCLUSION
This study was conducted to understand the phenomena associated with the life experiences of diabetic fragile older adults. Sixteen older adults’ experiences were examined and analyzed using a phenomenological approach. Themes such as falling into a bottomless pit, a narrower range of activity, enduring heavy emotional burden, and being supported in life emerged. This study provides suggestions for helping to reduce physical frailty among older adults; psychological and social frailty are also addressed. As individuals strive to improve their health even in the face of impending mortality, they may discover opportunities that reignite hope and enthusiasm for life, with the aid of the social support and assistance offered by their loved ones. The results of this study could be an important starting point for suggesting nursing interventions for older adults with diabetes and for shaping the creation and focus of integrated community care services for this at-risk community. Further research could be conducted among fragile older adults with diabetes with diverse socioeconomic backgrounds, different perspectives on health management efforts, and varying levels of quality of life. Finally, there is a need for a study on the development and evaluation of a tailored nursing interventions for frail older adults with diabetes.
Notes
Authors' contribution
Conceptualization - JA and YY; Data analysis - JA; Investigation - JA; Methodology - JA; Supervision - YY; Writing–original draft & editing - JA and YY
Conflict of interest
None.
Funding
This work was supported by the 2023 Graduate Student Research Grant from the Research Institute of Nursing Science, Seoul National University.
Data availability
Raw data (qualitative interview data) are available from the corresponding author upon reasonable request.
Acknowledgements
This manuscript is a revision of the first author’s doctoral dissertation at the Jeonbuk National University.