Reference
Hanlon P, Fauré I, Corcoran N, Butterly E, Lewsey J, McAllister D, Mair FS. Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis. Lancet Healthy Longev. 2020 Dec;1(3):e106-e116.
Summary
Frailty is a condition that increases a person’s vulnerability to adverse health outcomes. In elderly subjects with diabetes mellitus, frailty is a critical factor in the evolution of the disease. The results of this meta-analytical review suggest that, in this patient population, procedures for identifying and assessing frailty should be incorporated into diabetes management protocols in order to improve treatment.
Context
Disability and its preceding condition, frailty, jeopardize healthy aging. While frailty is not universal among the elderly, and may also occur in younger populations with chronic diseases, it predisposes them to increased vulnerability to adverse health outcomes. Diabetes mellitus is a chronic multi-systemic disease affecting up to 30% of older people and is often associated with frailty and disability. Current recommendations call for less aggressive glycemic targets for elderly or frail patients with diabetes, owing to their lower life expectancy and increased risk of hypoglycemia. Standardizing the operational definitions of frailty, and assessing the link between frailty and clinical outcomes, can help improve the diagnosis and treatment of diabetes in the elderly.
Study characteristics
This study represents a systematic review and meta-analysis of observational studies focusing on frailty and its consequences in elderly patients with diabetes mellitus. The study evaluates the prevalence of frailty in this population, its incidence, and both generic outcomes (mortality) and diabetes-specific outcomes (hypoglycemia). Out of 3,038 initial publications, 118 studies were selected and used for this review. Results were assessed by meta-analysis where possible or were narratively described when obtained from overly heterogeneous populations.
Results obtained
The median age of the included populations was 72.8 years. Frailty measures were widely variable across the different studies, and 20 different measures were listed. The most commonly used frailty measure was the frailty phenotype (58%), frailty (14%) and the FRAIL scale (8%). Despite methodological discrepancies, frailty was common in patients with diabetes. In fact, using the phenotype of frailty, the median prevalence of frailty was 13%. In community-based studies, this prevalence ranged from 10-25% in diabetic people above 60 years old. Results showed that frailty is consistently associated with mortality (93%), hospitalization (100%) and disability (100%). In addition, associations were documented between frailty and hypoglycemic events, microvascular and macrovascular complications, reduced quality of life and cognitive deterioration.
Study limitations
Discrepancies exist in the current literature on this topic and the studies collected here show heterogeneity in terms of setting, demographics and inclusion criteria. Scant data exist in low- and middle-low income countries, which represents an important limitation when considering the increasing prevalence of diabetes and aging in many countries. Little attention was also paid to the relationship between glycated hemoglobin (HbA1c) and unfavorable outcomes in frail individuals, compared to non-frail persons, and only one study assessed the relationship between frailty and hypoglycemia.
What’s new
Current results suggest that diabetes is a risk factor for the development and progression of frailty. Identifying and assessing frailty should become a practice in diabetes management and treatment, particularly for elderly patients.
What are the prospects
Uncertainty exists regarding how to identify, measure and manage frailty, particularly in the context of diabetes. There is also a need for a more nuanced understanding of how frailty should be identified and characterized, including the implications of the choice of frailty measure. This is particularly important if clinicians are to identify people likely to benefit from guideline recommendations for managing diabetes in the context of frailty. In terms of glycemic goals, the scarcity of studies exploring the relationship between frailty, HbA1c, and clinical outcomes reflects a disparity in research that deserves further investigation. Since frailty is also prevalent in middle-aged people with diabetes, it is necessary to explore the clinical implications of frailty in a wider age group, as current guidelines are based on observations of older populations.
Edited by Paolo Marzullo
