Can J Diabetes 40 (2016) 43–49

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Original Research

Classification of Support Needs for Elderly Outpatients with Diabetes

Who Live Alone
Yoshiko Miyawaki RN, MSN *, Yasuko Shimizu PhD, Natsuko Seto PhD
Department of Evidence-Based Clinical Nursing, Division of Health Science, Graduate School of Medicine, Osaka University, Osaka, Japan

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To investigate the support needs of elderly patients with diabetes and to classify elderly patients
Received 5 August 2015
with diabetes living alone on the basis of support needs.
Received in revised form
Methods: Support needs were derived from a literature review of relevant journals and interviews of out-
10 September 2015
Accepted 10 September 2015 patients as well as expert nurses in the field of diabetes to prepare a 45-item questionnaire. Each item
was analyzed on a 4-point Likert scale. The study included 634 elderly patients with diabetes who were
recruited from 3 hospitals in Japan. Exploratory factor analysis was performed to determine the under-
Keywords:
Comprehensive needs lying structure of support needs, followed by hierarchical cluster analysis to clarify the characteristics of
Elderly patients patients living alone (n=104) who had common support needs.
Living alone Results: Exploratory factor analysis suggested a 5-factor solution with 23 items: (1) hope for class and
Support needs gatherings, (2) hope for personal advice including emergency response, (3) supportlessness and hope-
lessness, (4) barriers to food preparation, (5) hope of safe medical therapy. The hierarchical cluster analy-
sis of subjects yielded 7 clusters, including a no special-support needs group, a collective support group,
a self-care support group, a personal-support focus group, a life-support group, a food-preparation support
group and a healthcare-environment support group.
Conclusions: The support needs of elderly patients with diabetes who live alone can be divided into
2 categories: life and self-care support. Implementation of these categories in outpatient-management
programs in which contact time with patients is limited is important in the overall management of elderly
patients with diabetes who are living alone.
© 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.

r é s u m é
Mots clés :
Objectifs : Examiner les besoins de soutien des patients âgés diabétiques et classifier les patients âgés
Besoins globaux
Patients âgés vivant seuls
diabétiques vivant seuls selon les besoins de soutien.
Besoins de soutien Méthodes : Les besoins de soutien ont été tirés d’une revue de la littérature de journaux et d’entretiens
pertinents de patients en consultation externe aussi bien que du personnel infirmier spécialisé dans le
domaine du diabète pour préparer un questionnaire comportant 45 questions. Chaque question a été
analysée sur une échelle à 4 points selon la méthode de Likert. L’étude a inclus 634 patients âgés diabétiques
qui ont été recrutés dans 3 hôpitaux du Japon. L’étude exploratoire des facteurs a été réalisée pour déterminer
la structure sous-jacente des besoins de soutien, puis a été suivie de la classification hiérarchique pour
clarifier les caractéristiques des patients vivant seuls (n = 104) qui ont eu des besoins de soutien courants.
Résultats : L’étude exploratoire des facteurs a suggéré une solution à 5 facteurs comportant 23 questions
: l’espoir de cours et de réunions, l’espoir de conseils individuels, dont les interventions d’urgence, l’absence
de soutien et le désespoir, les obstacles à la préparation des aliments, l’espoir d’un traitement médical
sûr. La classification hiérarchique des sujets a généré 7 groupes, dont un groupe de besoins de soutien
non particulier, un groupe de soutien collectif, un groupe de soutien aux autosoins, un groupe de dis-
cussion sur le soutien individuel, un groupe de soutien à la vie, un groupe de soutien à la préparation
des aliments et un groupe de soutien en milieu de soins de santé.

* Address for correspondence: Yoshiko Miyawaki, Department of Evidence-Based Clinical Nursing, Division of Health Science, Graduate School of Medicine, Osaka Uni-
versity, 1-7 Yamadaoka, Suita, Osaka 565-0871, Japan.
E-mail address: yopiko@sahs.med.osaka-u.ac.jp

1499-2671 © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jcjd.2015.09.005
44 Y. Miyawaki et al. / Can J Diabetes 40 (2016) 43–49
Conclusions : Les besoins de soutien des patients âgés diabétiques qui vivent seuls peuvent être divisés
en 2 catégories : soutien à la vie et aux autosoins. La mise en place de ces catégories dans les pro-
grammes de prise en charge des patients en consultation externe au cours desquels la durée de rencontre
avec les patients est limitée joue un rôle important dans la prise en charge globale des patients âgés
diabétiques qui vivent seuls.
© 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.
Introduction
In 1984, The World Health Organization proposed that the health
status of elderly patients should be judged by functional capacity
and extent of functional dependency rather than by the presence
or absence of disease (1). Extension of lifespan is no longer the goal
of management; rather, improvement in functional independence
and the achievement of better qualities of life are becoming more
important. On the other hand, self-care is a key element of a chronic
illness such as diabetes mellitus, and that requires maintenance
of functional independence and prevention of any decline in
functional status. It is a great burden for elderly patients with dia-
betes, especially those with functional impairment, to provide self-
care and maintain functional independence (2–5). These people need
support from children, friends and volunteers (6,7). However, some
elderly patients with diabetes who live alone cannot obtain the nec-
essary support and, thus, find it difficult to maintain functional inde-
pendence and continue self-care.
Elderly patients with diabetes who live alone have various prob-
lems related to self-care, such as barriers to preparing meals (3,8),
forgetting to take medicines (4), depression (9–11) and isolation.
Isolation, especially, is a serious issue. Support by children as well
as friends and neighbors is important for elderly patients living alone
with chronic illness including diabetes (12,13). Although elderly
patients living alone can sometimes receive assistance with medi-
cation management, transportation, advocacy and representation,
emergency help and security (14,15), such networks are liable to
diminish, which could increase their sense of isolation because of
worrying about being a burden on the family (16,17), reduced com-
panionship caused by illness and ageing (18,19) and lengthened geo-
graphic distance from others (15,20). In particular, elderly patients
with diabetes are considered to need comprehensive support for
self-care as well as for maintaining functional independence because
functional decline directly influences self-care (21). Is it possible
to provide support for elderly patients with diabetes living alone
during their monthly hospital appointments? The purpose of the
present study was to examine the support needs of elderly patients
with diabetes and to classify those patients living alone based on
such support needs.
Methods
Participants
Patients with diabetes (n=634) were recruited from 3 different
types of hospitals in Japan, including a university hospital, a city
hospital and a clinic. Patients eligible for inclusion in this study were
≥65 years of age, were patients at one of the facilities, had been diag-
nosed with diabetes mellitus and were able to communicate in Japa-
nese. Subjects with mental confusion or physical pain were excluded
from the study.
Data collection
The study protocol was approved by the human ethics commit-
tees of the university and participating hospital. The study was con-
ducted between September 2014 and April 2015. Potential subjects
were informed of this study by their physicians or nurses before
or after their scheduled appointments. Upon agreement, they were
introduced to a representative member of the research team who
explained the purpose of the study and the nature of participa-
tion. After agreement to participate, each subject received a ques-
tionnaire to self-complete at home or at the facility. In principle,
participants were asked to fill out the questionnaires by them-
selves; however, for some patients and in consideration of their ages,
the questions were read aloud by the researcher in a private inter-
view room, and the answers were recorded by the subject. Partici-
pants provided consent by completing and submitting the
questionnaires.
Measures
The questionnaires consisted of the Support Needs Survey Form
(SNSF) and the Instrument of Diabetes Self-Care Agency (IDSCA).
The SNSF was designed to identify the barriers to and relation-
ships between functional decline and self-care. It was a self-
reported questionnaire comprising questions about socioeconomic
status, state of diabetes and support needs. Support needs were
extracted from literature reviews of relevant journals and inter-
views with 6 diabetes outpatients as well as 3 certified diabetes
nurses; they were converted into the contents of questions. Ques-
tions about support needs consisted of 45 items, and the response
to each item was rated on a 4-point Likert scale: 1 (agree) to 4 (dis-
agree) or 1 (never) to 4 (frequent). Support needs included the fol-
lowing indices: barrier to cooking, hope for diabetes class, and advice
on anxiety and trouble. Questions concerning socioeconomic status
covered the following indices: age, sex, facilities within 10 minutes’
walking distance, activities of daily living (ADLs), levels of care
needed, frequency of going out (days/week), meal times (times/
day), and presence of a reliable person during illness. ADLs were
estimated by using a Roken score with 13 items. The Roken score
was developed to assess the ADLs of the elderly and has sufficient
reliability and validity (22). The level of care needed refers to a class
of the long-term care insurance system. The long-term care insur-
ance system is a social security system provided to applicants (mainly
those ≥65 years of age) by the insurer and is designed to provide
care according to the physical and mental status of the applicants.
The care needed is classified into 3 major levels: independence, assis-
tance required and care required. The care-required category rep-
resents the highest care level (23). The state of diabetes was assessed
using the following indices: glycated hemoglobin (A1C) levels, body
mass indices (BMIs), duration of diabetes and treatment regimes
used for diabetes.
A pilot test was conducted with 10 elderly outpatients with dia-
betes to assess the time required to complete the questionnaire and
to determine any difficulties experienced in comprehending any of
the questionnaire items.
The IDSCA is a comprehensive measurement of the self-care abili-
ties of patients with diabetes. It consists of 35 items and 7 domain
scales (ability to make the most of the support available; monitor-
ing ability; motivation to self-management; ability of one’s own self-
management; stress-coping ability; application or adjustment ability;
and ability to acquire knowledge); higher scores indicate a higher
self-care ability. IDSCA has sufficient reliability and validity (24).
 Y. Miyawaki et al. / Can J Diabetes 40 (2016) 43–49 45

Statistical analysis Table 1

General characteristics

Data were analyzed by using the Statistical Package for Social Variable Total sample Living alone
Sciences software (SPSS, Chicago, Illinois, United States). First, the (n=632) (n=104)
exploratory factor analysis (EFA) with the principal factor method Sex
was conducted to identify the underlying structure of support needs Male 362 (57.3) 44 (42.3)
for elderly patients with diabetes (25). The Bartlett’s test of sphe- Female 270 (42.8) 60 (57.7)
Age (years) 73.5±5.8 74.3±6.2
ricity and the Kaiser-Mayer-Olkin (KMO) test were used to justify Level of care needed
undertaking EFA (26,27). KMO values between 0.7 and 0.8 were con- Independence 545 (86.2) 75 (72.1)
sidered good, values between 0.8 and 0.9 were considered very good Assistance required 47 (7.4) 18 (17.3)
and values above 0.9 were considered excellent. We conducted the Care required 37(5.9) 10 (9.6)
Frequency of going out (days/week) 5.6±2.1 5.5±2.1
EFA using the following steps. Step 1 identified the number of mean- Facilities walking 10 minutes distance
ingful factors to retain based on the scree test (28). Step 2 adopted Grocery store 493 (78.0) 75 (72.1)
the promax (oblique) rotation in the rotational factors to help with Hospital 388 (61.4) 56 (53.8)
interpretations. Step 3 analyzed the rotated solution. This step iden- Reliable person for sickness
Have 588 (93.0) 71 (68.3)
tified the items that load on each retained factor and examined the None 44 (7.0) 33 (31.7)
conceptual meanings of items that load on the same factor and the Meal times (times/day)
conceptual differences of items that load on different factors. Factor 2 times 37 (5.9) 15 (14.4)
loading greater than or equal to 0.3 in its absolute value was used 3 times 591 (93.5) 89 (86)
4 or more times 4 (0.6) 0
to interpret the results (29). The Cronbach’s alpha was computed Body mass index (kg/m2) 23.6±3.7 23.5±3.6
to measure internal consistency. The typically used criterion for Activities of daily living (/13) 11.8±2.1 11.7±2.1
acceptable Cronbach’s alpha is >0.7 (30). A1C (%) 7.2±1.0 7.3±1.0
Second, the hierarchical cluster analysis (HCA) using the Ward Duration of diabetes (years) 16.5±10.7 16.3±11.0
Treatment regime
method was conducted to clarify similarities in elderly patients with Diet/exercise 30 (4.7) 3 (2.9)
diabetes living alone based on support-need factors (31,32). Oral hypoglycemic agent 342 (54.1) 57 (54.8)
Hierarchical clusters are summarized as a dendrogram with dis- Insulin 260 (41.1) 44 (42.3)
tances or dissimilarities between clusters. We started to explore Data are mean ± SD or n (percentage).
the number of clusters by picking up a few more clusters than the
optimal number of clusters and merging close clusters together. The
final number of clusters was determined by evaluating the char- Factor 1, consisting of 4 items, was named Hope for Class and
acteristics of support needs within the practical number of clus- gathering. Factor 2, consisting of 7 items, was named Hope for Per-
ters. The deviation value (DEV) is the linear transformation of the sonal Advice Including Emergency Response. Factor 3, consisting
standardized score, which is obtained by subtracting the mean and of 7 items, was named Supportlessness and Hopelessness. Factor
dividing it by the standard deviation; thus, its value ranges from 0 4, consisting of 2 items, was named Barrier to Food Preparation.
to 100. To calculate the DEV, the standardized score is multiplied Factor 5, consisting of 3 items, was named Hope of Safe Medical
by 10 followed by the addition of 50 to the product. The higher the Therapy. The magnitude of correlations among the 5 factors was
DEV is, the higher the need for support or for the self-care agency moderate, ranging from 0.42 to 0.87, which implies the absence of
is, depending on SNSF or IDSCA. marked redundancy among the factors. The overall Cronbach’s alpha
for the 5 factors with 23 items was 0.74. The 5 factors explained
34.7% of the total amount of variance.
In this EFA, each of the 3 criteria for judging interpretability and
Results overall results was met. First, at least 3 items loaded on 4 factors.
Although a factor with more than 3 items is stable and desirable
Participants (34), Barrier to Food Preparation, consisting of 2 items, was con-
sidered to be important to explain the difficulty of diet therapy.
Table 1 shows the baseline characteristics of the 632 elderly Hence, it was decided to retain this factor. Second, the items that
patients with diabetes. Of the total, 104 (16%) lived alone. Because loaded on a given factor had high factor loadings (≥|0.3|) on 1 factor
the proportion of those living alone is similar to that reported pre- and low loadings on the other factors. Therefore, the items that
viously by other investigators (16%) (33), we believe a reasonable loaded on different factors explained differing underlying con-
sampling procedure was followed in our study. structs. Finally, Cronbach’s alpha, among the 5 factors, ranged from
0.42 to 0.87, and the items that loaded on a given factor shared some
The exploratory factor analysis of elderly patients with diabetes conceptual meanings (30). The Cronbach’s alpha of Hope of Safe
Medical Therapy was 0.48 and low, comparatively. This was con-
The EFA was conducted to explore the underlying structure of sidered to relate to that of Hope of Safe Medical Therapy, compris-
the support needs of elderly patients with diabetes (n=632). The ing a few items. However, the global factors were considered to have
sample was appropriate for the EFA, as indicated by both the high internal consistency because the Cronbach’s alpha for the
KMO measure sampling adequacy of 0.745 and the Bartlett’s test 5 factors was 0.74 (30).
of sphericity significance level (χ2=3374.2; p<0.001) (26,27). Ini- Support needs consisting of 5 factors explained the barrier and
tially, 4 or 5 meaningful factors were suggested by the scree plot. potential close relationship between functional decline and self-
EFAs were performed repeatedly after excluding items of factor care and included various items. As typified by the Comprehen-
loading ≤|0.3|. Finally, a 4-factor solution with 22 items and a sive Geriatric Assessment (CGA), the needs of elderly diabetes
5-factor solution with 23 items were extracted. The 5-factor solu- patients have so far been measured using various scales (35–37).
tion was considered to contain more comprehensive items compared This is the first study to examine the comprehensive needs of elderly
to the 4-factor solution. Therefore, the 5-factor solution with 23 patients with diabetes with 1 concept. This concept is brief and
items was chosen based on the scree test and our requirements summary and thus, potentially, applicable and useful in clinical
(Table 2). practice.
46 Y. Miyawaki et al. / Can J Diabetes 40 (2016) 43–49

Table 2
Exploratory factor analysis: factor loadings, communalities (n=632)

Item Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 h2

Hope for joining a peer support group 0.910 −0.115 0.037 −0.001 0.117 0.718
Hope for diabetes class 0.855 −0.033 0.032 −0.040 0.077 0.689
Hope for meal class 0.685 0.079 −0.059 0.024 −0.043 0.544
Hope for exercise class 0.528 0.133 −0.023 0.020 −0.001 0.372
Advice on suitable diet 0.132 0.563 −0.056 −0.037 −0.251 0.560
Talk about coping strategy of sickness 0.021 0.560 −0.048 −0.004 0.189 0.282
Want advice counter, usable anytime −0.076 0.544 −0.031 0.030 0.216 0.235
Advice on suitable exercise 0.090 0.539 −0.019 −0.017 −0.248 0.496
Anxiety about falling without attention −0.058 0.479 0.207 −0.028 0.180 0.275
Advice on anxiety and trouble 0.039 0.341 0.033 0.063 0.011 0.151
Available emergency button −0.043 0.339 0.179 0.040 0.072 0.169
Lack of vitality for life −0.011 0.009 0.557 0.045 0.064 0.341
Block to the hospital by pain 0.037 −0.012 0.484 −0.018 −0.096 0.235
Worse health status endured alone 0.107 −0.020 0.431 0.068 −0.079 0.230
Hesitate to medicine and service from economic concern −0.040 0.036 0.428 −0.167 0.033 0.165
Lack of food variety with same menu 0.015 0.052 0.398 0.050 −0.124 0.207
Worthwhile role and contributions in family and society 0.054 0.048 −0.391 0.012 0.025 0.142
Reluctant to engage in conversation −0.020 0.081 0.316 0.030 0.026 0.127
Barrier to cooking −0.034 0.088 −0.035 0.902 0.013 0.732
Barrier to shopping foods 0.028 −0.048 0.020 0.854 0.000 0.820
Medication adherence 0.038 0.078 −0.067 0.002 0.459 0.191
Afraid of hypoglycemia 0.051 0.252 −0.061 −0.052 0.429 0.180
Carry own prescription record 0.102 0.025 0.018 0.058 0.328 0.113
Eigenvalue 4.04 2.47 1.54 1.42 1.36
Variance 3.51 1.99 1.01 0.80 0.65
Percentage of variance 15.28 8.67 4.40 3.49 2.83
Cronbach’s alpha 0.83 0.68 0.62 0.87 0.42
h2, communality of the measured variables.
Notes: KMO measure=0.745; Bartlett’s test of sphericity=3374.2; p<0.001.
Values in boldface are coefficients of factors with loading values of ≥|0.3|.

Table 3
Hierarchical cluster analysis based on 5 support need factors (n=104)

Cluster 1 Cluster 2 Cluster 3 Cluster 4 Cluster 5 Cluster 6 Cluster 7

No special Collective Self-care Personal Life Food Healthcare

support support support support support preparation environment
needs group group group focus group group support support
(n=35) (n=10) (n=10) (n=14) (n=17) group (n=10) group (n=8)

Factor 1: Hope for Class and Gathering 44.1±4.2 67.4±4.8a 65.7±6.9c 62.7±8.2 47.4±7.1 51.1±9.0 45.6±3.6
Factor 2: Hope for Personal Advice Including 48.5±8.1 50.4±6.6 66.7±7.4b 67.2±6.0a 49.8±11.3 54.8±10.6 55.5±11.6
Emergency Response
Factor 3: Supportlessness and Hopelessness 49.7±7.8 46.9±4.6 55.0±7.0 61.0±9.3 67.0±5.6b 59.6±12.3 73.1±6.9a
Factor 4: Barrier to Food Preparation 47.7±0.0 47.7±0.0 50.6±4.7 48.4±2.6 47.7±0.0 101.4±10.5a 78.2±8.1b
Factor: Hope of Safe Medical Therapy 48.4±9.8 46.4±6.3 61.9±0.0a 42.7±8.9 54.9±5.7 54.9±8.1 47.6±9.7
Deviation value ± SD.
a
Highest deviation value in 1 factor.
b Highest deviation value in 1 cluster.
c Deviation value≥65, but it is not the highest deviation value in factors or clusters.

Hierarchical cluster analysis of elderly patients with diabetes who
live alone
The HCA was conducted to classify the elderly patients with dia-
betes living alone (n=104) based on 5 support-need factors. The HCA
yielded 7 clusters (Table 3). Cluster 1 consisted of 35 persons who
did not have high support needs (DEVs≤50) and was named the No
Special-Support Needs Group; it included 31 persons (89%) who were
independent in terms of their care-need levels and had ADL scores
of 12.3, and their frequency of going out was 6.5 days. Of the group,
21 individuals (60%) were being treated with oral medications. The
total of IDSCA was 47.1, and the DEVs of 5 of the 7 factors were ≤50
(48.1 for Ability to Acquire Knowledge, 45.7 for Ability to Make the
Most of the Support Available; 46.8 for Monitoring Ability, 49.9 for
Application or Adjustment Ability and 46.3 for Motivation to Self-
Management.
Cluster 2, consisting of 10 individuals, had a high support need
on Hope for Class and Gathering (DEV: 67.4) and was named the
Collective Support Group by the Class and Gathering; 8 of the indi-
viduals (80%) were independent in terms of the care-need level and
had ADL scores of 12.3. The frequency of going out was 6.0 days.
There were 6 individuals (60%) who were being treated with oral
medications. The DEVs of 2 factors of IDSCA were ≥50 (51.3 for Ability
to Acquire Knowledge and 52.8 for Motivation to Self-Management.
Cluster 3, consisting of 10 individuals, had 3 high-support needs
(DEV: 65.7 for Hope for Class and Gathering, 66.7 for Hope for Per-
sonal Advice Including Emergency Response, and 61.9 for Hope of
Safe Medical Therapy). For this reason, Cluster 3 was named the Self-
Care Support Group Including Collective and Personal Support. There
were 7 individuals (70%) who were independent in terms of the care-
need level and had ADL scores of 12.4; the frequency of going out
was 6.1 days. There were 6 individuals (60%) who were being treated
with insulin, and the DEVs of 2 factors of IDSCA were ≥50 (55.2 for
Ability to Acquire Knowledge, and 54.9 for Motivation to Self-
Management).
Cluster 4 consisted of 14 individuals with high support needs
in Hope for Personal Advice Including Emergency Response, (DEV:
 Y. Miyawaki et al. / Can J Diabetes 40 (2016) 43–49
67.2), and it was named the Personal Support Focus Group
Including Emergency Response. Six individuals (43%) required assis-
tance in terms of the care-need level; they had ADL scores of 11.9.
The frequency of going out was 4.6 days. Eight individuals (57%)
lacked a reliable person. The DEVs of 2 factors of IDSCA were 46.8
for Ability to Acquire Knowledge and 37.8 for Ability to Make the
Most of the Support Available.
Cluster 5 consisted of 17 individuals with a high support need
for Supportlessness and Hopelessness (DEV: 67.0) and were named
the Life Support Group in Terms of Support and Hope. Ten indi-
viduals (59%) were independent in terms of the care-need level and
had ADL scores of 10.8. The frequency of going out was 4.5 days.
Seven persons (41%) were without reliable persons. The DEV of
Ability to Make the Most of the Support Available of IDSCA was 37.8.
Cluster 6 consisted of 10 individuals with high support need for
Barrier to Food Preparation (DEV: 101.4) and was named the Food
Preparation Support Group. Three individuals (30%) required assis-
tance, and 1 (10%) required care in terms of the care-need level. Five
individuals (50%) did not have nearby grocery stores. The DEV of
Ability to Make the Most of the Support Available of IDSCA was
43.2. Two individuals (20%) ate twice a day only, and their BMIs
(21.1 kg/m2) were lower than the standard value for elderly persons
(≥21.5 kg/m2) (38).
Cluster 7 consisted of 8 individuals with 2 high support needs
(DEV: 73.1 for Supportlessness and Hopelessness and 78.2 for Barrier
to Food Preparation). For this reason, Cluster 7 was named the
Healthcare Environment Support Group. The frequency of going out
was 4.0 days. Four individuals (50%) did not have a reliable person,
and the DEV of Ability to Make the Most of the Support Available
of IDSCA was 36.9. Three individuals (38%) did not have nearby
grocery stores, and 2 (25%) had 2 meals a day only, and their BMIs
(20.8 kg/m2) were lower than the above-quoted standard value for
elderly people (38).
Discussion
Our study highlights the need for the provision of effective
support for elderly patients with diabetes who are living alone, espe-
cially at outpatient services where the contact time with patients
is limited.
First, 2 support-need factors (Hope for Personal Advice Includ-
ing Emergency Response, Supportlessness and Hopelessness) had
DEVs≥50 on 5 of the 7 clusters, and all clusters tended to have high
DEVs. Therefore, elderly diabetes patients living alone Hope for Per-
sonal Advice Including Emergency Response and support concern-
ing Supportlessness and Hopelessness. The World Health
Organization has indicated that elderly individuals suffer from an
average of 4 to 6 chronic illnesses, in addition to disability and age-
related dysfunction (1). In addition, elderly patients with diabetes
of long duration were reported to be at higher risk for hypoglyce-
mic coma compared to younger patients, due mainly to lack of edu-
cation about hypoglycemia and delay in treatment of hypoglycemia
(39). Elderly patients with diabetes also have anxieties in daily life
and need support from relatives and friends for security and safety
(12–16). Our study showed that some elderly patients who live alone
get support only from outpatient clinics. Accordingly, outpatient
clinics must provide not only traditional medical treatment but also
support the foundation of lives of the elderly while preventing the
aggravation of care-need levels. The outpatient clinic must explore
the role of the hospital as well as the methods of support and take
the initiative in supporting elderly patients with diabetes living alone.
Recognition of this role by the hospital is important in the overall
management of elderly patients with diabetes who live alone.
The support needs were roughly divided into 2 broad categories.
One category is the support related to life, such as Supportlessness and
47
Hopelessness and Barrier to Food Preparation; the other category is
support related to self-care, such as Hope for Class and Gathering, Hope
for Personal Advice Including Emergency Response and Hope of Safe
Medical Therapy. Of the 2 categories of support needs, the self-care
support is mainly for Clusters 2, 3 and 4, whereas life support is mainly
for Clusters 5, 6 and 7. Strauss (40) pointed out that “Chronic illness
brings a variety of problems (e.g. disease management, time manage-
ment, isolation) to everyday life and they must be adjusted and managed
in order to maintain the health-related quality of life.” Thus, the medical
staff should provide support to patients not only by managing the disease
but also by helping them to live with the disease. In this way, the medical
staff can help the patients to continue their own ways of life to main-
tain health-related quality of life. These 2 supports (life support and
self-care support) are both important for elderly patients with diabe-
tes who live alone, and division of such help into 2 broad categories
should be considered in any support program.
Our results showed that the most characteristic cluster is
Cluster 1, the No-Special Support Needs Group. Most patients in this
cluster were independent in terms of the care-need level and were
treated with oral medications. Their ADL scores were relatively high,
and the DEVs of all support needs were relatively low. However, the
total of IDSCA and 5 of the 7 factors had relatively low DEVs. Accord-
ingly, Cluster 1 is considered to provide potential support needs that
take into consideration the characteristics of elderly individuals living
alone, and it is necessary to identify the needs and timing for support
while assessing self-care and daily living.
Although Clusters 2, 3 and 4 mainly seek self-care support,
Cluster 2 seeks collective support, and Clusters 3 and 4 seek both
collective and personal support. Two features characterize the back-
ground of seeking collective support. First, patients in Clusters 2 and
3 were likely to be independent in terms of the care-need level, their
ADL scores were relatively high and they tended to go out fre-
quently. The DEVs of these 2 clusters were ≥50 on Ability to Acquire
Knowledge of the IDSCA and were relatively high on the Motiva-
tion to Self-Management of IDSCA. Thus, the first feature of seeking
collective support is that individuals with high ADL scores who go
out frequently hope to participate actively in diabetes classes and
to acquire knowledge about self-care. In contrast, patients in
Cluster 4 tended to require assistance and go out infrequently. The
DEV of Ability to Acquire Knowledge of the IDSCA was not high, and
the DEV of Ability to Make the Most of the Support Available of the
IDSCA was relatively low. Accordingly, the second feature of seeking
collective support is that individuals with low ADL scores who com-
municate with others infrequently hope to communicate and link
with others through classes and gatherings. Accordingly, we con-
sider it important for any collective support program to provide
classes as well as peer-support programs. Two features character-
ize seeking personal support. Patients in Cluster 3 tended to be
treated with insulin, and the DEV of Hope of Safe Medical Therapy
was relatively high. Thus, the first feature of seeking personal support
is that persons who are treated with insulin and are worried about
hypoglycemia strongly hope to get personal advice concerning dif-
ficulties with self-care, including emergency responses such as treat-
ment of hypoglycemia. In addition, patients in Cluster 4 were unlikely
to have reliable persons, and the DEV of Ability to Make the Most
of the Support Available of the IDSCA and the ADL score were rela-
tively low. Thus, the second feature of seeking personal support is
that persons who suffer anxiety associated with low ADL and lack
the support of reliable persons hope to get personal advice on self-
care and life, including emergency response. Whether such patients
seek each support or both, the collective and personal support should
be considered in any management program.
Although Clusters 5, 6 and 7 seek mainly life support,
Clusters 5 and 7 seek support for Supportlessness and Hopeless-
ness, and Clusters 6 and 7 seek support for Barrier to Food Prepa-
ration. Clusters 5 and 7, seeking support for Supportlessness and
48 Y. Miyawaki et al. / Can J Diabetes 40 (2016) 43–49
Hopelessness, share some commonalities. Patients in Clusters 5 and
7 were not likely to go out or have reliable companions. The DEV
of Ability to Make the Most of the Support Available of the IDSCA
was relatively low. Thus, elderly individuals who seek support for
Supportlessness and Hopelessness are considered those who do not
have reliable persons, cannot communicate with others in asso-
ciation and have infrequent socialization. In addition, the cat-
egory of Supportlessness and Hopelessness includes items about
economic concern. Economic concern is one of the top points in the
consideration list, especially considering the high poverty rate among
older women living alone (41). The costs of medical expenses and
food expenses are high, in addition to other costs, such as trans-
portation expenses and home-maintenance costs. Such expenses
must be paid by their own savings, pensions, medical insurance and
long-term care insurance (41). Such patients are considered to have
difficulty in hoping for better futures because they cannot share their
problems and concerns with anyone and cannot secure economic
support. Then, it is important to reduce the anxieties and solve the
problems of the elderly living alone by providing support and oppor-
tunities to identify, expose and share their concerns about finances,
to review their treatment regimes and to explore with them the
available benefits of the social security system while involving pro-
fessionals such as government staff and case managers.
Clusters 6 and 7, seeking support for Barrier to Food
Preparation, share commonalities. Patients in Clusters 6 and 7 tended
to have 2 meals a day, and their BMIs were lower than the stan-
dard value for the elderly (38). They tended to live in areas without
close grocery stores, and the DEV of Ability to Make the Most of
the Support Available of the IDSCA was relatively low. Thus, indi-
viduals who seek support for Barrier to Food Preparation tended
to have various barriers to meal preparation, such as lack of nearby
grocery stores and support persons and poor nutrition because of
the few meals. Such persons are considered to need the following
support: information about available food-delivery services, food
storage and cooking devices, as well as building a support system
that includes family members or government staff. Cluster 6 also
has a relatively high DEV of Supportlessness and Hopelessness, so
support for Barrier to Food Preparation is considered to contrib-
ute to meeting the need of Supportlessness and Hopelessness.
The Outpatient Department is required to serve a new func-
tion based on the isolation of the elderly living alone and the asso-
ciated changes in socioeconomic conditions, such as the rapid
decrease in birthrate and the ageing population. The Outpatient
Department needs to provide not only disease management but also
support for daily living. The outpatient service has a great role and
potentiality for supporting elderly patients with diabetes who live
alone.
To our knowledge, this is the first study that has identified com-
prehensively the significant support needs of elderly patients with
diabetes who live alone. Further clinical studies are needed to
confirm the usefulness of needs classification in clinical practice.
Acknowledgements
The authors are grateful to Ishii Hidetoki and Shintani Ayumi for
advice on statistical analysis. They also thank doctors Shimomura,
Iwahashi, Mineo, Okauchi and Shiraiwa and nurses Koshimura,
Kashima, Fujiwara, Osada, Kodama and Mima for help in collect-
ing the study data.
Author contributions
YM completed the data, analyzed the data and wrote the
manuscript; YS planned the study and reviewed and edited
manuscript; NS contributed to discussion and reviewed and edited
the manuscript.
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