Identification and prevalence of frailty in diabetes mellitus and association with clinical outcomes: a systematic review protocol

Prevalence, characteristics, and impact on health outcomes of frailty in elderly outpatients with diabetes: A cross-sectional study

The aims of this study were to determine the prevalence of frailty and its relationship with health outcomes in elderly outpatients attending a Diabetes Specialist Clinic. This study was a cross-sectional study. A total of 168 elderly patients (aged 65 years and above) attending the Diabetes Specialist Clinic of a Three-A hospital of Sichuan province were recruited from January 2021 to February 2021, and follow-up was conducted 1 year after day of screening. Baseline characteristics of patients were collected and frail status were assessed at recruitment. The longitudinal outcomes included hospitalization, fall, mortality, emergency visit, and clinic visit. The presence of frailty was determined by the 5-item FRAIL scale, which ranges from 0 to 5 and are categorized as frail (3-5), prefrail (1-2), and robust (0). A phone questionnaire was carried out to obtain health outcomes. Logistic regression analyses was used to evaluate adverse health outcomes at 1 year follow-up. Of the 168 outpatients, 28.0% was robust, 49.4% was prefrail, and 22.6% was frail. Frailty (both prefrail and frail status) was more prevalent in those patients, which were 75 years old and above (57.0%; P < .001), insulin dependent (45.6%; P = .008), and those had diabetic complications (43.8%; P = .005), previous admission (68.6%; P = .016), and co-morbidities (36.4%; P = .001). In the following year after recruitment, 19.1% of robust patients were hospitalized, while the proportion was 45.8% for prefrail patients and 65.8% for frail patients. Prefrail (OR [odds ratio] = 2.35, 95% confidence interval (CI) 1.63-2.88; P = .028) and frail (OR = 4.63, 95% CI 2.52-5.81; P = .005) patients were more likely to be hospitalized. Frail (OR = 3.37, 95% CI 2.68-4.04; P < .001) patients were more inclined to fall while prefrail patients (OR = 1.03, 95% CI 0.82-1.56; P = .371) were not. Moreover, prefrail (OR = 3.37, 95% CI 2.31-5.72; P = .017) and frail (OR = 4.29, 95% CI 3.16-5.54; P = .006) patients were more likely to return to the clinic. There is a high incidence of frailty among elderly patients attending a Diabetes Specialist Clinic. Frailty is a predictor of hospitalization, fall, and clinic visits within 1 year.

Frailty in people with rheumatoid arthritis: a systematic review of observational studies

Background: Frailty, an age-related decline in physiological reserve, is an increasingly important concept in the management of chronic diseases. The implications of frailty in people with rheumatoid arthritis are not well understood. We undertook a systematic review to assess prevalence of frailty in people with rheumatoid arthritis, and the relationship between frailty and disease activity or clinical outcomes. Methods: We searched four electronic databases (January 2001 to April 2021) for observational studies assessing the prevalence of frailty (any frailty measure) in adults (≥18 years) with rheumatoid arthritis, or analysing the relationship between frailty and disease activity or clinical outcomes (e.g. quality of life, hospitalisation or mortality) in people with rheumatoid arthritis. Study quality was assessed using an adapted Newcastle-Ottawa Scale. Screening, quality assessment and data extraction were performed independently by two reviewers. We used narrative synthesis. Results: We identified 17 analyses, from 14 different populations. 15/17 were cross-sectional. Studies used 11 different measures of frailty. Frailty prevalence ranged from 10% (frailty phenotype) to 36% (comprehensive rheumatologic assessment of frailty) in general adult populations with rheumatoid arthritis. In younger populations (<60 or <65 years) prevalence ranged from 2.4% (frailty phenotype) to 19.9% (Kihon checklist) while in older populations (>60 or >65) prevalence ranged from 31.2% (Kihon checklist) to 55% (Geriatric 8 tool). Frailty was cross-sectionally associated with higher disease activity (10/10 studies), lower physical function (7/7 studies) and longer disease duration (2/5 studies), and with hospitalization and osteoporotic fractures (1/1 study, 3.7 years follow-up). Conclusion: Frailty is common in rheumatoid arthritis, including those aged <65 years, and is associated with a range of adverse features. However, these is heterogeneity in how frailty is measured. We found few longitudinal studies making the impact of frailty on clinical outcomes over time and the extent to which frailty is caused by rheumatoid arthritis unclear.

Frailty in people with rheumatoid arthritis: a systematic review of observational studies

Background: Frailty, an age-related decline in physiological reserve, is an increasingly important concept in the management of chronic diseases. The implications of frailty in people with rheumatoid arthritis are not well understood. We undertook a systematic review to assess prevalence of frailty in people with rheumatoid arthritis, and the relationship between frailty and disease activity or clinical outcomes. Methods: We searched four electronic databases (January 2001 to April 2021) for observational studies assessing the prevalence of frailty (any frailty measure) in adults (≥18 years) with rheumatoid arthritis, or analysing the relationship between frailty and disease activity or clinical outcomes (e.g. quality of life, hospitalisation or mortality) in people with rheumatoid arthritis. Study quality was assessed using an adapted Newcastle-Ottawa Scale. Screening, quality assessment and data extraction were performed independently by two reviewers. We used narrative synthesis. Results: We identified 17 analyses, from 14 different populations. 15/17 were cross-sectional. Studies used 11 different measures of frailty. Frailty prevalence ranged from 10% (frailty phenotype) to 36% (comprehensive rheumatologic assessment of frailty) in general adult populations with rheumatoid arthritis. In younger populations (<60 or <65 years) prevalence ranged from 2.4% (frailty phenotype) to 19.9% (Kihon checklist) while in older populations (>60 or >65) prevalence ranged from 31.2% (Kihon checklist) to 55% (Geriatric 8 tool). Frailty was cross-sectionally associated with higher disease activity (10/10 studies), lower physical function (7/7 studies) and longer disease duration (2/5 studies), and with hospitalization and osteoporotic fractures (1/1 study, 3.7 years follow-up). Conclusion: Frailty is common in rheumatoid arthritis, including those aged <65 years, and is associated with a range of adverse features. However, these is heterogeneity in how frailty is measured. We found few longitudinal studies making the impact of frailty on clinical outcomes over time and the extent to which frailty is caused by rheumatoid arthritis unclear.

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.