Review Details Relationship Between Frailty, Diabetes in Older Populations

The identification and assessment of frailty, defined as a state of increased vulnerability to adverse health outcomes resulting from loss of physiological reserve, should become a routine aspect of diabetes care, authors of a systematic review and meta-analysis published in The Lancet Health Longevity argued.

Around 30% of individuals older than 65 have either type 1 or type 2 diabetes. Although the prevalence of frailty increases with age, frailty is not universal among those aged 65 and older and can also be identified in younger individuals suffering from long-term conditions, such as diabetes.

Among older individuals who are frail, more relaxed glycated hemoglobin (A1C) targets are recommended, as older or frail individuals are more likely to have lower life expectancy and greater risks of hypoglycemia.

“However, guidelines are not explicit about to whom these recommendations should be applied,” researchers explained. “Frailty is not a single homogeneous concept, and there is no single standard definition or measure. Instead, multiple operational definitions of frailty exist.”

To categorize frailty measures that have been used to identify frailty in those with diabetes, quantify this frailty, and to summarize the association between frailty and generic outcomes and diabetes-specific clinical outcomes, investigators searched MEDLINE, Embase and Web of Science databases for observational studies.

Any study published in English between January 2001 and November 2019 that assessed frailty in diabetes was included in the review. Researchers then extracted data from eligible studies while “studies reporting the relationship between frailty and clinical outcomes in diabetes were synthesized using a combination of narrative synthesis and random-effects meta-analysis.”

A total of 118 studies, consisting of 106 cohorts and samples, were included in the final narrative synthesis. Twenty different frailty measures were included in the studies, which collectively assessed 1,375,373 patients.

The majority of studies were community-based population studies (75%) and were conducted in high-income countries (75%). To measure frailty, the frailty phenotype was used in 58% of the studies, while the frailty index was used in 14% and FRAIL scale in 8%. Of the 69 studies that used the frailty phenotype, “the definition of one or more of the 5 frailty criteria differed from the original description from the Cardiovascular Health Study,” in 51 (74%) of these studies.

Analyses revealed:

• Median (IQR) community frailty prevalence using frailty phenotype was 13% (9–21).
• Frailty was consistently associated with mortality in 13 (93%) of 14 studies assessing this outcome (pooled hazard ratio [HR] 1.51 [95% CI, 1.30–1.76]), with hospital admission in 7 (100%) of 7, and with disability in 5 (100%) of 5 studies.
• Frailty was associated with hypoglycemia events in one study (<1%) and microvascular and macrovascular complications in 9 (82%) of 11 studies assessing complications.
• The condition was associated with 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 assessing glycated hemoglobin found no consistent relationship with frailty.
• Diabetes was associated with the development and progression of frailty.

“Across all measures used, frailty was prevalent in community and hospital-based settings and associated with various adverse clinical outcomes, including mortality, hospitalization, lower quality of life and disability,” authors wrote.

Specifically, in community-based settings, studies showed between 10% and 25% of individuals with diabetes aged 60 and older had frailty. Researchers argued a one-size-fits-all approach to frailty in this population will not be effective. Instead, “a nuanced approach that involves differentiating between levels of frailty and understanding individual patient needs and priorities within the context of frailty is likely to be important.”

Accelerated muscle loss, and neuropathic and inflammatory mechanisms may account for progression of frailty among those with diabetes. However, because all studies included in the review were observational, authors caution against drawing causal conclusions.

“The high prevalence and clinical importance of frailty in diabetes are clear, and there is therefore a need to advance our understanding of how frailty in diabetes should be managed,” researchers concluded.

Reference

Hanlon P, Fauré I, Cocoran N, et al. Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis. Lancet Healthy Longev. Published online November 19, 2020. doi:10.1016/S2666-7568(20)3001