Intricate relationships between frailty and diabetes: where do we go from here?
Authors: Gloria A Aguayo, Guy Fagherazzi
Journal: The Lancet Healthy Longevity (2020)

Population ageing is a public health, societal, and economic problem around the world.2Bloom DE Chatterji S Kowal P et al.Macroeconomic implications of population ageing and selected policy responses.Lancet. 2015; 385: 649-657Summary Full Text Full Text PDF PubMed Scopus (264) Google Scholar Frailty, defined as a state of vulnerability of older adults that increases health risks, can be considered a proxy of accelerated ageing. The prevalence of frailty increases with age in all individuals, but at different rates3Mitnitski AB Mogilner AJ Rockwood K Accumulation of deficits as a proxy measure of aging.Sci World J. 2001; 1: 323-336Crossref Scopus (1108) Google Scholar and has previously been associated with diabetes in the older population.4Veronese N Stubbs B Fontana L et al.Frailty is associated with an increased risk of incident type 2 diabetes in the elderly.JAMDA. 2016; 17: 902-907Google Scholar Due to the ageing population, frailty and diabetes are health outcomes that frequently co-occur and should therefore no longer be addressed independently. In The Lancet Healthy Longevity, Peter Hanlon and colleagues1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar did a systematic review and meta-analysis of observational studies of frailty in people with diabetes, examining prevalence and associations with general and diabetes-specific outcomes, which provides a very comprehensive overview of this research area. To our knowledge, this is the first study to review the different dimensions of frailty in relation with general and diabetic outcomes. Hanlon and colleagues1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar highlight that frailty is very common in people with diabetes and can affect the course and treatment of diabetes. For example, the prevalence of frailty has been shown to be higher when measured with the Frailty Index than with the frailty phenotype.5Fried LP Tangen CM Walston J et al.Frailty in older adults evidence for a phenotype.J Gerontol A Biol Sci. 2001; 56: m146-m157Crossref PubMed Google Scholar, 6Aguayo GA Donneau AF Vaillant MT et al.Agreement between 35 published frailty scores in the general population.Am J Epidemiol. 2017; 186: 420-434Crossref PubMed Scopus (90) Google Scholar This discrepancy can be due to the underlying concepts of each frailty instrument, but also to the different modes of categorisation (two categories in Frailty Index vs three categories in the frailty phenotype). It is known that frailty instruments cannot be directly compared,6Aguayo GA Donneau AF Vaillant MT et al.Agreement between 35 published frailty scores in the general population.Am J Epidemiol. 2017; 186: 420-434Crossref PubMed Scopus (90) Google Scholar which is why Hanlon and colleagues1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar discuss the difficulty of preventing frailty without a gold standard definition. One research question that still needs to be addressed is how diabetes management and glycaemic control can affect the development and evolution of frailty over time. Such research might clarify the role of diabetes in the acceleration of ageing. Another remaining research question is how glycated haemoglobin (HbA1c) levels are associated with diabetes outcomes in frail populations compared with those that are not frail. The question of a bidirectional association between frailty and diabetes is also yet to be addressed because while frailty is suspected to have a direct effect on diabetes management, medication, or glucose surveillance for those using medical devices such as continuous glucose monitoring, little information is available so far. In their Article, the authors mention that no study to date has examined the role of frailty as a determinant of HbA1c levels. The effect of frailty status on hypoglycaemia events remains a key question. Hanlon and colleagues1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar recommended extending frailty research to include younger people. We think this area is highly interesting; frailty at younger ages can be associated with poorer outcomes.7Aguayo GA Vaillant MT Donneau AF et al.Comparative analysis of the association between 35 frailty scores and cardiovascular events, cancer, and total mortality in an elderly general population in England: an observational study.PLoS Med. 2018; 15e1002543Crossref PubMed Scopus (29) Google Scholar, 8Hanlon P Nicholl BI Jani BD Lee D McQueenie R Mair FS Frailty and pre-frailty in middle-aged and older adults and its association with multimorbidity and mortality: a prospective analysis of 493 737 UK Biobank participants.Lancet Public Health. 2018; 3: e323-e332Summary Full Text Full Text PDF PubMed Scopus (182) Google Scholar Finally, the authors1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar highlight that only three (3%) of 118 studies originated from lower-middle-income countries and no studies were from low-income countries. More geographical and sociodemographic diversity in the study populations is needed. Frailty research has exponentially increased since 2001, when the frailty phenotype and the accumulation of deficit concepts were first developed and published, and so this Article is important and timely because it could now help to change some important aspects of diabetes care and management in elderly people. This work could also help health-care professionals in geriatrics, diabetology, or endocrinology to increase awareness regarding the intricate relationships between frailty and diabetes. In the community setting, health-care professionals are encouraged to screen for both frailty and diabetes and to fully integrate this screening in future diabetes care teams.9Sinclair AJ Abdelhafiz A Dunning T et al.An international position statement on the management of frailty in diabetes mellitus: summary of recommendations 2017.J Frailty Aging. 2018; 7: 10-20PubMed Google Scholar We think that this work also highlights the need for more innovative approaches to tackle both frailty and diabetes. The use of digital health technology in the assessment and treatment of frail older populations with diabetes is one promising option to improve health in these populations. There is a need for further development of specific functionalities to match the specific needs of those who are older, frail, or both, in terms of cognition, physical disability, or motivation for using digital health tools.10Wildenbos GA Peute L Jaspers M Aging barriers influencing mobile health usability for older adults: a literature based framework (MOLD-US).Int J Med Inform. 2018; 114: 66-75Crossref PubMed Scopus (92) Google Scholar Integrating new sources of information, such as vocal biomarkers, videos, or images, could help to move beyond the traditional smartphone applications with alerts and reminders and could contribute to identifying devices that are more effective than already existing ones and interventions for frail people with diabetes. Hanlon and colleagues1Hanlon P Fauré I Neave Corcoran 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. 2020; (published online Nov 19.)https://doi.org/10.1016/S2666-7568(20)30014-3Summary Full Text Full Text PDF Scopus (6) Google Scholar emphasised the need for frailty to be diagnosed, assessed and managed as early as possible in people with diabetes. This should be done in routine care in a more personalised fashion according to the level of frailty and the glycemic control of the individual. It is recommended that the choice of frailty instrument be based on its feasibility, depending on the context (clinical or general population), reliability, and external validity, ideally using a validated instrument and not an adapted version. Researchers should be aware that it is not possible to compare, nor to pool, findings of frailty status between studies that used instruments based on different underlying frailty concepts. However, the use of any frailty score can be useful for detecting at-risk populations and therefore for preventing frailty in high-risk groups, such as people with diabetes. We declare no competing interests. Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysisThe 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. Full-Text PDF Open Access