Frailty and Diabetes in Older Hospitalized Adults: The Case for Routine Frailty Assessment

Prevalence and risk factors of frailty in older adults with diabetes: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the prevalence of frailty and pre-frailty in older adults with diabetes; and to identify the risk factors associated with frailty in this population.

DESIGN

Systematic review and meta-analysis.

PARTICIPANTS

24,332 people aged 60 years and older with diabetes.

METHODS

Six databases were searched (PubMed, Embase, the Cochrane Library, Web of Science, China Knowledge Resource Integrated Database, and Chinese Biomedical Database) up to 15 January 2024. Random effects models were used in instances of significant heterogeneity. Subgroup analysis and meta-regression were conducted to identify the potential source of heterogeneity. The Agency for Healthcare Research and Quality (AHRQ) and the Newcastle-Ottawa Scale (NOS) were applied to assess the quality of included studies.

RESULTS

3,195 abstracts were screened, and 39 full-text studies were included. In 39 studies with 24,332 older people with diabetes, the pooled prevalence of frailty among older adults with diabetes was 30.0% (95% CI: 23.6%-36.7%). Among the twenty-one studies involving 7,922 older people with diabetes, the pooled prevalence of pre-frailty was 45.1% (95% CI: 38.5%-51.8%). The following risk factors were associated with frailty among older adults with diabetes: older age (OR = 1.08, 95% CI: 1.04-1.13, p<0.05), high HbA1c (OR = 2.14, 95% CI: 1.30-3.50, p<0.001), and less exercise (OR = 3.11, 95% CI: 1.36-7.12, p<0.001).

CONCLUSIONS

This suggests that clinical care providers should be vigilant in identifying frailty and risk factors of frailty while screening for and intervening in older adults with diabetes. However, there are not enough studies to identify comprehensive risk factors of frailty in older adults with diabetes.

TRIAL REGISTRATION

PROSPERO registration number: CRD42023470933.

Frailty, Body Composition, and Glycemic Control in Older Adults with Type 2 Diabetes

The relationship between frailty and glycemic control in older adults with diabetes remains uncertain, mainly due to the fact that previous studies have not accounted for measures of body composition. In older adults with diabetes, we examined the association between three types of frailty measures and glycemic control, while accounting for fat-free mass (FFM) and waist circumference (WC). Eighty older adults (age ≥65, 27 women and 53 men, mean age 80.5 ± 0.6 years) had gait speed, Cardiovascular Health Study Index (CHSI), Rockwood Clinical Frailty Scale (RCFS), and glycosylated hemoglobin (HgA1C) measured. HgA1C showed a negative association only with CHSI (standardized β = -0.255 ± 0.120, p = 0.038), but no association with gait speed or the RCFS. Even after accounting for FFM and WC, we demonstrated a negative association between glycated hemoglobin and increasing frailty in older adults with diabetes.

Frailty Detection in Older Adults with Diabetes: A Scoping Review of Assessment Tools and Their Link to Key Clinical Outcomes

Objectives: With the increasing prevalence of diabetes and frailty among older adults, there is an urgent need for precision medicine that incorporates comprehensive geriatric assessments, including frailty detection. This scoping review aims to map and synthesize the available evidence on validated tools for detecting pre-frailty and frailty in community-dwelling elderly individuals with diabetes and outpatient diabetes patients. Specifically, it addresses: (1) What validated tools are available for detecting pre-frailty and frailty in this population? (2) How are these tools associated with outcomes such as glycemic control, hypoglycemia, and metabolic phenotypes? (3) What gaps exist in the literature regarding these tools? Methods: The review followed PRISMA-ScR guidelines, conducting a systematic search across PubMed, Cochrane Library, and Web of Science. The inclusion criteria focused on studies involving individuals aged 70 years and older with diabetes, emphasizing tools with predictive capacity for disability and mortality. Results: Eight instruments met the inclusion criteria, including the Frailty Index, Physical Frailty Phenotype, and Clinical Frailty Scale. These tools varied in domains such as physical, psychological, and social aspects of frailty and their association with glycemic control, hypoglycemia, and metabolic phenotypes. The review identified significant gaps in predicting diabetes-related complications and their clinical application. Conclusions: Routine management of older adults with diabetes should incorporate frailty detection, as it is crucial for their overall health. Although widely used, the reviewed tools require refinement to address the unique characteristics of this population. Developing tailored instruments will enhance precision medicine, leading to more effective, individualized interventions for elderly individuals with diabetes.

The impact of frailty on clinical outcomes among older adults with diabetes: A systematic review and meta-analysis

BACKGROUND

Frailty has been identified as a risk factor for adverse outcomes in older adults with diabetes. This study aimed to investigate the impact of frailty on the prognosis of older adults with diabetes through a systematic review and meta-analysis, with the goal of offering insights for clinical decision-making.

METHODS

PubMed, Web of Science, Embase, Cochrane were systematically searched from inception to September 10th, 2023. Reviewers independently selected studies, extracted data and evaluated the quality of studies. Stata 15.1 Software was used to perform the meta-analysis. The primary outcomes of this study were mortality, hospitalization and disability, and the secondary outcomes were diabetes complications (including nephropathy, microvascular complications, macroangiopathy, cardiovascular events, hypoglycemia) and urolithiasis.

RESULTS

A total of 14 studies were included in this study, with low risk of bias and moderate to good quality. The results showed that frailty increased the risk of mortality (HR 1.91, 95% CI 1.55-2.35, P < .001), hospitalization (HR 2.19, 95% CI 1.53-3.13, P < .001), and disability in older adults with diabetes (HR 3.84, 95% CI 2.35-6.28, P < .001). In addition, frailty was associated with diabetes complications (including nephropathy, microvascular complications, macroangiopathy, cardiovascular events, hypoglycemia), urolithiasis.

CONCLUSIONS

Frailty is an important predictor of adverse outcomes, such as mortality, hospitalization, and disability in older adults with diabetes. Accurate assessment of the frailty in older adults with diabetes can help improve the adverse outcomes of patients.

Glycemic control and prescription profiles in internal medicine inpatients: The role of frailty

AIM

This work aims to characterize the clinical profile of individuals with frailty syndrome, diabetes mellitus (DM), and hyperglycemia during hospitalization in regard to glycemic control and treatment regimen.

METHODS

This cross-sectional multicentric study included patients with DM or hyperglycemia at admission. Demographic data, blood glucose values, treatment administered during hospitalization, and treatment indicated at discharge were analyzed. The sample was divided into three groups according to score on a frailty questionnaire. Generalized additive models were used to describe the relationship between either glycemic variability (GV) or minimum capillary blood glucose and hypoglycemia. Models were adjusted for age, comorbidity, and sarcopenia.

RESULTS

A total of 1,137 patients were analyzed. Patients with frailty syndrome had more comorbidity and sarcopenia, worse renal function, and lower albumin and lymphocyte levels. A GV between 21% and 60% was related to a higher probability of hypoglycemia, especially in patients with frailty. Regarding minimum capillary blood glucose, patients with frailty had the highest probability of hypoglycemia. This probability remained significant even in the group with frailty in which, with a reference value of 200 mg/dl, the adjusted odds ratio of a minimum capillary blood glucose of 151 mg/dL was 1.08 (95% confidence interval (1.12-1.05)). Baseline treatments showed a significant predominance of insulin use in the frailest groups.

CONCLUSIONS

Patients with frailty had more sarcopenia and undernourishment. These patients were managed in a similar manner during hospitalization to patients without frailty, despite their higher risk of hypoglycemia according to GV or minimum capillary blood glucose levels.

Social Vulnerability and Frailty in Hospitalized Older Adults

Background

Social vulnerability is the accumulation of disadvantageous social circumstances resulting in susceptibility to adverse health outcomes. Associated with increased mortality, cognitive decline, and disability, social vulnerability has primarily been studied in large population databases rather than frail hospitalized individuals. We examined how social vulnerability contributes to hospital outcomes and use of hospital resources for older adults presenting to the Emergency Department.

Methods

We analyzed patients 65 years of age or older admitted through the Emergency Department and consulted to internal medicine or geriatrics at a Canadian tertiary care hospital from July 2009 to September 2020. A 20-item social vulnerability index (SVI) and a 57-item frailty index (FI) were calculated, using a deficit accumulation approach. Outcomes were length of stay (LOS), extended hospital LOS designation, alternative level of care (ALC) designation, in-hospital mortality, and discharge to long-term care (LTC).

Results

In 1,146 patients (mean age 80.5±8.3, 54.0% female), mean SVI was 0.40±0.16 and FI was 0.44±0.14. The SVI scores were not associated with admission to hospital. Amongst those admitted, for every 0.1 unit increase in SVI, LOS increased by 1.15 days (p<.001) after adjusting for age, sex and FI. SVI was associated with staying over the expected LOS (aOR: 1.19, 1.05-1.34, p=.009) and ALC status (aOR 1.39, 1.12-1.74, p<.004). SVI was not associated with in-hospital mortality, but was associated with incident discharge to LTC (aOR 1.03, 1.02-1.04, p<.001).

Conclusion

Independent of frailty, being socially vulnerable was associated with increased LOS, designation as ALC, and being discharged to LTC from hospital. Consideration of social vulnerability's influence on prolonged hospitalization and long-term care needs has implications for screening and hospital resources.

[Study of the links between type 2 diabetes and geriatric criteria]

Type 2 diabetes in the elderly remains a major concern for all healthcare professionals and is itself considered a "global pandemic". Its prevalence is high and will continue to increase in years to come, becoming more and more prevalent in the elderly and very elderly. We offer a general summary of the work focusing on the links between type 2 diabetes and geriatric criteria.

The outcome of frailty in older people with diabetes as a function of glycaemic control and hypoglycaemic therapy: a review

INTRODUCTION

Frailty is an emerging and newly recognized complication of diabetes in older people. However, frailty is not thoroughly investigated in diabetes outcome studies.

AREAS COVERED

This manuscript reviews the effect of glycemic control and hypoglycemic therapy on the incidence of frailty in older people with diabetes.

EXPERT OPINION

Current studies show that both low glycemia and high glycemia are associated with frailty. However, most of the studies, especially low glycemia studies, are cross-sectional or retrospective, suggesting association, rather than causation, of frailty. In addition, frail patients in the low glycemia studies are characterized by lower body weight or lower body mass index (BMI), contrary to those in the high glycemia studies, who are either overweight or obese. This may suggest that frailty has a heterogeneous metabolic spectrum, starting with an anorexic malnourished (AM) phenotype at one end, which is associated with low glycemia and a sarcopenic obese (SO) phenotype on the other end, which is associated with high glycemia. The current little evidence suggests that poor glycemic control increases the risk of frailty, but there is a paucity of evidence to suggest that tight glycemic control would reduce the risk of incident frailty. Metformin is the only well-studied hypoglycemic agent, so far, to have a protective effect against frailty independent of glycemic control in the non-frail older people with diabetes. However, once frailty is developed, the choice of the best hypoglycemic agent for these patients will be affected by the metabolic phenotype of frailty. For example, sodium glucose transporter-2 (SGLT-2) inhibitors and glucagon-like peptide-1 receptor agonists (GLP-1RA) are appropriate in the SO phenotype due to their weight losing properties, while insulin therapy may be considered early in the AM phenotype due to its anabolic and weight gaining benefits. Future studies are still required to further investigate the metabolic effects of frailty on older people with diabetes, determine the most appropriate HbA1c target, and explore the most suitable hypoglycemic agent in each metabolic phenotype of frailty.

The Association Between the Clinical Frailty Scale and Adverse Health Outcomes in Older Adults in Acute Clinical Settings - A Systematic Review of the Literature

Background

Frail older adults experience higher rates of adverse health outcomes. Therefore, assessing pre-hospital frailty early in the course of care is essential to identify the most vulnerable patients and determine their risk of deterioration. The Clinical Frailty Scale (CFS) is a frailty assessment tool that evaluates pre-hospital mobility, energy, physical activity, and function to generate a score that ranges from very fit to terminally ill.

Purpose

To synthesize the evidence of the association between the CFS degree and all-cause mortality, all-cause readmission, length of hospital stay, adverse discharge destination, and functional decline in patients >65 years in acute clinical settings.

Design

Systematic review with narrative synthesis.

Methods

Electronic databases (PubMed, EMBASE, CINAHL, Scopus) were searched for prospective or retrospective studies reporting a relationship between pre-hospital frailty according to the CFS and the outcomes of interest from database inception to April 2020.

Results

Our search yielded 756 articles, of which 29 studies were included in this review (15 were at moderate risk and 14 at low risk of bias). The included studies represented 26 cohorts from 25 countries (N = 44166) published between 2011 and 2020. All included studies showed that pre-hospital frailty according to the CFS is an independent predictor of all adverse health outcomes included in the review.

Conclusion

A primary purpose of the CFS is to grade clinically increased risk (i.e. risk stratification). Our results report the accumulated knowledge on the risk-predictive performance of the CFS and highlight the importance of routinely including frailty assessments, such as the CFS, to estimate biological age, improve risk assessments, and assist clinical decision-making in older adults in acute care. Further research into the potential of the CFS and whether implementing the CFS in routine practice will improve care and patients' quality of life is warranted.

Metabolic Impact of Frailty Changes Diabetes Trajectory

Diabetes mellitus prevalence increases with increasing age. In older people with diabetes, frailty is a newly emerging and significant complication. Frailty induces body composition changes that influence the metabolic state and affect diabetes trajectory. Frailty appears to have a wide metabolic spectrum, which can present with an anorexic malnourished phenotype and a sarcopenic obese phenotype. The sarcopenic obese phenotype individuals have significant loss of muscle mass and increased visceral fat. This phenotype is characterised by increased insulin resistance and a synergistic increase in the cardiovascular risk more than that induced by obesity or sarcopenia alone. Therefore, in this phenotype, the trajectory of diabetes is accelerated, which needs further intensification of hypoglycaemic therapy and a focus on cardiovascular risk reduction. Anorexic malnourished individuals have significant weight loss and reduced insulin resistance. In this phenotype, the trajectory of diabetes is decelerated, which needs deintensification of hypoglycaemic therapy and a focus on symptom control and quality of life. In the sarcopenic obese phenotype, the early use of sodium-glucose transporter-2 inhibitors and glucagon-like peptide-1 receptor agonists is reasonable due to their weight loss and cardio-renal protection properties. In the malnourished anorexic phenotype, the early use of long-acting insulin analogues is reasonable due to their weight gain and anabolic properties, regimen simplicity and the convenience of once-daily administration.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Metabolic phenotypes explain the relationship between dysglycaemia and frailty in older people with type 2 diabetes

BACKGROUND

Dysglycaemia (hyperglycaemia and hypoglycaemia) increase the risk of frailty in older people with diabetes, which appears contradictory. However, the characteristics of patients included in these studies are different and may reflect different metabolic phenotypes of frailty that may explain this apparent contradiction.

AIMS

To review the characteristics of frail patients included in clinical studies that reported an association between dysglycaemia and frailty in order to explore whether there is any metabolic differences in the profile of these patients.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Key words around older people, type 2 diabetes mellitus, frailty, hyperglycaemia and low glycaemia were used in the literature search.

RESULTS

Only 8 studies met the inclusion criteria. Four studies investigated the risk of frailty associated with low glycaemia. Two studies showed that hypoglycaemia increased the risk of frailty by 44% (HR 1.60, 95% CI 1.14 to 2.42) and predicted greater level of dependency (p < 0.001), respectively. The other two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.0% was associated with increased risk of disability (3.45, 1.02 to 11.6), respectively. Compared with non-frail patients, those with frailty tended to have lower body weight or body mass index (BMI), have features of malnutrition such as low serum albumin or low total cholesterol and suffer from more comorbidities including dementia. Four studies explored the association of high glycaemia with frailty. Higher HbA1c predicted frailty (OR 1.43, 95% CI 1.045 to 1.97) and positively correlated with Edmonton frail score (r = 0.44, p < 0.001), respectively in two studies. The other two studies found that subjects with HbA1c ≥ 6.5% had the greatest prevalence of frailty (70.3%) and subjects with higher HbA1c at baseline to have a higher frailty level throughout later life, respectively. Compared with non-frail patients, those with frailty tended to have higher body weight, waist circumference and BMI. They also have less physical activity, higher cholesterol level and have more comorbidities.

CONCLUSIONS

Dysglycaemia increases the risk of frailty but the characteristics of patients in these studies suggest different metabolic phenotypes of frailty. Therefore, these metabolic differences in frailty should be taken into consideration in the management of older people with diabetes.

Adherence to Medication in Older Adults with Type 2 Diabetes Living in Lubuskie Voivodeship in Poland: Association with Frailty Syndrome

Purpose: Diabetic patients aged 65 years or older are more likely to be frail than non-diabetic older adults. Adherence to therapeutic recommendations in the elderly suffering from diabetes and co-existent frailty syndrome may prevent complications such as micro- or macroangiopathy, as well as significantly affect prevention and reversibility of frailty. The study aimed at assessing the impact of frailty syndrome (FS) on the level of adherence to medication in elderly patients with type 2 diabetes (DM2). Patients and Methods: The research was carried out among 175 DM2 patients (87; 49.71% women and 88; 50.29% men) whose average age amounted to 70.25 ± 6.7. Standardized research instruments included Tilburg frailty indicator (TFI) to assess FS and adherence in chronic disease scale questionnaire (ACDS) to measure adherence to medications. Results: The group of 101 (57.71%) patients displayed medium, 39 (22.29%)—low, and 35 (20.00%)—high adherence. As many as 140 of them (80.00%) were diagnosed with frailty syndrome. The median of the average result of TFI was significantly higher in the low adherence group (p ˂ 0.001) (Mdn = 9, Q1–Q3; 7–10 pt.) than in the medium (Mdn = 6, Q1–Q3; 5–9 pt.) or high adherence (Mdn = 6.00, Q1–Q3; 4.5–8 pt.) ones. The independent predictors of the chance to be qualified to the non-adherence group included three indicators: TFI (OR 1.558, 95% CI 1.245–1.95), male gender (OR 2.954, 95% CI 1.044–8.353), and the number of all medications taken daily (each extra pill decreased the chance of being qualified to the non-adherence group by 15.3% (95% CI 0.728–0.954). Conclusion: Frailty syndrome in elderly DM2 patients influenced medical adherence in this group. The low adhesion group had higher overall TFI scores and separately higher scores in the physical and psychological domains compared to the medium and high adhesion groups.

Low glycaemic state increases risk of frailty and functional decline in older people with type 2 diabetes mellitus - Evidence from a systematic review

AIMS

To explore risk of frailty and functional decline associated with low glycaemia in older people with type 2 diabetes.

METHODS

Systematic review.

RESULTS

11 studies included. Six studies investigated risk of frailty or physical decline with hypoglycaemia. Hypoglycaemia increased risk of incident frailty (HR 1.60, 95% CI 1.14 to 2.42) in one study and risk of fractures in four studies (2.24, 1.56 to 3.21, 1.24, 1.13 to 1.37, 1.94, 1.67 to 2.24 and 1.71, 1.35 to 2.16 respectively). In sixth study, hypoglycaemia associated with dependency (P < 0.001). Five studies explored association of low blood glucose/HbA1c with frailty. One study showed that mean blood glucose decreased with increasing frailty (p = 0.003). Two studies reported that HbA1c inversely correlated with clinical frailty scale (r = -0.31, p < 0.01) and HbA1c < 6.9% increased risk of frailty (HR, 1.41 95% CI 1.12 to 1.78) respectively. Last two studies showed that HbA1c < 6.5% associated with risk of any fracture (HR 1.08, 95% CI 1.06 to 1.11) and HbA1c < 6.0% associated with increased risk of care need (3.45, 1.02 to 11.6) respectively.

CONCLUSIONS

Low glycaemia increases risk of frailty and functional decline in older people with type 2 diabetes. Management should minimise incidence of low glycaemia in these patients.

Effects of a Tailored Exercise Intervention in Acutely Hospitalized Oldest Old Diabetic Adults: An Ancillary Analysis

OBJECTIVE

To analyze the effects of a tailored exercise intervention in acutely hospitalized elderly diabetic patients.

RESEARCH DESIGN AND METHODS

This is an ancillary analysis of a randomized controlled trial (RCT). A total of 103 acutely hospitalized elderly adults (mean age ~87 years) with type II diabetes were randomized to an intervention (exercise, n = 54) or control group (usual care, n = 49). The primary endpoint was change in functional status from baseline to hospital discharge as assessed with the Barthel Index and the Short Physical Performance Battery (SPPB). Secondary endpoints comprised cognitive function and mood status, quality of life (QoL), incidence of delirium, and handgrip strength. Exercise-related side effects, length of hospital stay, and incidence of falls during hospitalization were also assessed, as well as transfer to nursing homes, hospital readmission, and mortality during a 3-month follow-up.

RESULTS

The median length of stay was 8 days (interquartile range, 4) for both groups. The intervention was safe and provided significant benefits over usual care on SPPB (2.7 [95% confidence interval (CI) 1.8, 3.5]) and Barthel Index (8.5 [95% CI: 3.9, 13.1]), as well as on other secondary endpoints such as cognitive status, depression, QoL, and handgrip strength (all P < 0.05). No significant between-group differences were found for the remainder of secondary endpoints.

CONCLUSIONS

An in-hospital individualized multicomponent exercise intervention was safe and effective for the prevention of functional and cognitive decline in acutely hospitalized elderly diabetic patients, although it had no influence on other endpoints assessed during hospitalization or at the 3-month follow-up after discharge.

Anticoagulant Therapy for Frail Patients with Atrial Fibrillation

The prevalence of atrial fibrillation (AF) increases with age, as does the proportion of patients with frailty. AF patients with frailty have a higher risk of stroke than those without frailty, and progressive frailty caused by stroke is also associated with a worse prognosis. Despite this, anticoagulant therapy tends to not be used in frail patients because of the risk of falls and bleeding complications. However, some studies have shown that anticoagulant therapy improves the prognosis in patients with frailty. An accurate assessment of the "net-clinical-benefits" is needed in patients with frailty, with the aim of improving the prognoses of patients with frailty by selecting those who will benefit from anticoagulant therapy and actively reducing the risk of bleeding. A comprehensive intervention that includes a team of doctors and social resources is required. We herein review the effectiveness and bleeding risk associated with anticoagulant therapy in frail patients investigated in clinical studies.

Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis

Background

Frailty, a state of increased vulnerability to adverse health outcomes, is important in diabetes management. We aimed to quantify the prevalence of frailty in people with diabetes, and to summarise the association between frailty and generic outcomes (eg, mortality) and diabetes-specific outcomes (eg, hypoglycaemia).

Methods

In this systematic review and study-level meta-analysis, we searched MEDLINE, Embase, and Web of Science for observational studies published between Jan 1, 2001 (the year of the original publication of the Fried frailty phenotype), to Nov 26, 2019. We included studies that assessed and quantified frailty in adults with diabetes, aged 18 years and older; and excluded conference abstracts, grey literature, and studies not published in English. Data from eligible studies were extracted using a piloted data extraction form. Our primary outcome was the prevalence of frailty in people with diabetes. Secondary outcomes were incidence of frailty and generic and diabetes-specific outcomes. Data were assessed by random-effects meta-analysis where possible and by narrative synthesis where populations were too heterogeneous to allow meta-analysis. This study is registered with PROSPERO, CRD42020163109.

Findings

Of the 3038 studies we identified, 118 studies using 20 different frailty measures were eligible for inclusion (n=1 375 373). The most commonly used measures of frailty were the frailty phenotype (69 [58%] of 118 studies), frailty (16 [14%]), and FRAIL scale (10 [8%]). Studies were heterogenous in setting (88 studies were community-based, 18 were outpatient-based, ten were inpatient-based, and two were based in residential care facilities), demographics, and inclusion criteria; therefore, we could not do a meta-analysis for the primary outcome and instead summarised prevalence data using a narrative synthesis. Median community frailty prevalence using frailty phenotype was 13% (IQR 9-21). Frailty was consistently associated with mortality in 13 (93%) of 14 studies assessing this outcome (pooled hazard ratio 1·51 [95% CI 1·30-1·76]), with hospital admission in seven (100%) of seven, and with disability in five (100%) of five studies. Frailty was associated with hypoglycaemia events in one study (<1%), microvascular and macrovascular complications in nine (82%) of 11 studies assessing complications, lower quality of life in three (100%) of three studies assessing quality of life, and cognitive impairment in three (100%) of three studies assessing cognitive impairment. 13 (11%) of 118 studies assessed glycated haemoglobin finding no consistent relationship with frailty.

Interpretation

The identification and assessment of frailty should become a routine aspect of diabetes care. The relationship between frailty and glycaemia, and the effect of frailty in specific groups (eg, middle-aged [aged <65 years] people and people in low-income and lower-middle-income countries) needs to be better understood to enable diabetes guidelines to be tailored to individuals with frailty.

Funding

Medical Research Council.

Management of Inpatient Hyperglycemia and Diabetes in Older Adults

Diabetes is one of the world's fastest growing health challenges. Insulin therapy remains a useful regimen for many elderly patients, such as those with moderate to severe hyperglycemia, type 1 diabetes, hyperglycemic emergencies, and those who fail to maintain glucose control on non-insulin agents alone. Recent clinical trials have shown that several non-insulin agents as monotherapy, or in combination with low doses of basal insulin, have comparable efficacy and potential safety advantages to complex insulin therapy regimens. Determining the most appropriate diabetes management plan for older hospitalized patients requires consideration of many factors to prevent poor outcomes related to dysglycemia.

Impact of Diabetes Mellitus and Frailty on Long-Term Outcomes in Elderly Patients with Acute Coronary Syndromes

OBJECTIVES

Diabetes mellitus (DM) and frailty are common in older patients with acute coronary syndromes (ACS). No data exists about its prognostic impact on long-term outcomes and their possible interaction in this setting.

DESIGN

Observational prospective study.

SETTING

Multicenter registry conducted in 44 hospitals in Spain.

PARTICIPANTS

Consecutive patients with ACS aged 80≥years.

MEASUREMENTS

A comprehensive geriatric evaluation was performed during hospitalization, including frailty assessment by the FRAIL score. The impact of DM and frailty on the incidence of mortality/readmission at 24 months was analysed by a Cox regression model.

RESULTS

A total of 498 patients were included (mean age 84.3 years). Prevalence of previous DM was 199/498 (40.0%). The rate of frail patients was 135/498 (27.1%). The incidence of mortality/readmission was higher frail patients (HR 2.49) (both p<0.001). In contrast, DM was not significantly associated to a higher rate of outcomes (HR 1.23, p=0.060) in the whole cohort. Among non-frail patients, patients with DM had a similar incidence of mortality or readmission (p=0.959). In contrast, among frail patients, DM was significantly associated with a higher incidence of events (HR 1.51, p=0.034).

CONCLUSIONS

Unlike frailty status, DM was not associated to poorer long-term outcome in elderly patients with ACS. Among frail patients the presence of DM seems to provide additional prognostic information.