Both pre-frailty and frailty increase healthcare utilization and adverse health outcomes in patients with type 2 diabetes mellitus

Combined effect of diabetes and frailty on mortality among Chinese older adults: A follow-up study

BACKGROUND

Frailty and diabetes are two important health problems associated with aging in older individuals. This paper seeks to analyze the frailty in older adults suffering from diabetes and the combined effect of diabetes and frailty on mortality risk.

METHODS

The frailty index (FI) model was employed when evaluating frailty among the older adults based on the baseline data conducted in 2009; and death as outcome variables collected in 2020 were analyzed. The influence of diabetes on age-related changes in frailty in the older adults and resulting mortality rates was analyzed. Cox regression and Kaplan-Meier curves were applied to evaluate the influence on the risk of death and the 11-year survival of the older adults with varying diabetes and frailty statuses.

RESULTS

Ultimately, 1,213 older people aged between 60 and 101, with an average age of (74.79 ± 8.58) at baseline, were included in the analysis. By 2020, there had been 447 deaths with mortality at 36.9% (447/1,213); there were 271 cases of diabetes, with a prevalence of 22.3% (271/1,213). The mean FI value for older adults with diabetes was higher than that of those without regardless of age, and the average annual relative growth rate of the FI value for older adults with diabetes was higher than that of those without diabetes (β = 0.039 vs. β = 0.035, t = 8.367, P < 0.001). For all FI value levels, the mortality rate among older adults with diabetes was higher than that of those without. The Cox Regression analysis showed that, compared with those suffering from neither diabetes nor frailty, older adults with both had the higher mortality risk (HR = 1.760. P < 0.001), followed by older adults suffering from frailty alone (HR = 1.594, P = 0.006), and then by older adults suffering from only diabetes (HR = 1.475, P = 0.033). The survival analysis showed that the median survival of those suffering from diabetes and frailty to be the shortest at just 57.23 (95% CI: 54.05 to 60.41) months, lower than the 83.78 (95% CI: 79.33 to 88.23) months in those suffering from frailty alone, and 119.93 (95% CI: 113.84 to 126.02) months in those with only diabetes, and 124.39 (95% CI: 119.76 to 129.02) months in older adults with neither diabetes nor frailty (P < 0.001).

CONCLUSION

Frailty is common among older adults suffering from diabetes, and there is an increased risk of poor health outcomes, such as death, among older adults suffering from diabetes and frailty. When diagnosing, treating, and dealing with older adults with diabetes, attention should be paid to screening and assessing frailty in hopes of identifying it early so that appropriate measures of intervention can be taken to avoid or delay the resulting adverse effects.

Frailty Is Associated with Oxidative Stress in Older Patients with Type 2 Diabetes

Aging has increased the prevalence of frailty, and type 2 diabetes (T2D) has also increased in prevalence. Diabetes and oxidative stress (OS) have been shown to be related to frailty. However, the exact mechanism by which it occurs is not fully known. Our aim was to analyze body composition in community-dwelling older diabetic people treated in our center and to evaluate the possible relation between OS, frailty, and body composition. We included 100 adults older than 65 years with T2D. We found that 15% were frail and 57% were prefrail. The patients included in the nonrobust group showed increased levels of OS. Our study shows that the presence of T2D in the geriatric population is associated with a high prevalence of frailty and high OS levels, conditions that cause greater morbidity and mortality and that highlight the importance of the diagnosis of frailty in this population.

Hospitalizations and emergency department visits trends among elderly individuals in proximity to death: a retrospective population-based study

Acute healthcare services are extremely important, particularly during the COVID-19 pandemic, as healthcare demand has rapidly intensified, and resources have become insufficient. Studies on specific prepandemic hospitalization and emergency department visit (EDV) trends in proximity to death are limited. We examined time-trend specificities based on sex, age, and cause of death in the last 2 years of life. Datasets containing all hospitalizations and EDVs of elderly residents in Friuli-Venezia Giulia, Italy (N = 411,812), who died between 2002 and 2014 at ≥ 65 years, have been collected. We performed subgroup change-point analysis of monthly trends in the 2 years preceding death according to sex, age at death (65-74, 75-84, 85-94, and ≥ 95 years), and main cause of death (cancer, cardiovascular, or respiratory disease). The proportion of decedents (N = 142,834) accessing acute healthcare services increased exponentially in proximity to death (hospitalizations = 4.7, EDVs = 3.9 months before death). This was inversely related to age, with changes among the youngest and eldest decedents at 6.6 and 3.5 months for hospitalizations and at 4.6 and 3.3 months for EDVs, respectively. Healthcare use among cancer patients intensified earlier in life (hospitalizations = 6.8, EDVs = 5.8 months before death). Decedents from respiratory diseases were most likely to access hospital-based services during the last month of life. No sex-based differences were found. The greater use of acute healthcare services among younger decedents and cancer patients suggests that policies potentiating primary care support targeting these at-risk groups may reduce pressure on hospital-based services.

Sarcopenia, frailty and type 2 diabetes mellitus (Review)

Skeletal muscle is the largest and most energy‑consuming organ in the human body, which plays an important role in energy metabolism and glucose uptake. There is a notable decrease in glucose uptake in the skeletal muscle of patients with type 2 diabetes mellitus (DM). Endurance exercise can reduce hyperglycemia and improve insulin resistance in patients with type 2 DM. Insulin exerts a variety of effects, many of which are mediated by Akt, including increasing glucose uptake, promoting glycogen synthesis and inhibiting glycogen degradation, increasing free fatty acid uptake, increasing protein synthesis, promoting muscle hypertrophy and inhibiting protein degradation. Skeletal muscle mass progressively declines with aging, resulting in loss of muscle strength and physical function. Sarcopenia is a syndrome characterized by loss of skeletal muscle mass and muscle weakness or loss of physical function, and frailty is another syndrome that has received great interest in recent years. Decreased organ function results in vulnerability to external stress. Frailty is associated with falls, fractures and hospitalization; however, there is the reversibility of returning to a healthy state with appropriate interventions. Frailty is classified into three subgroups: Physical frailty, social frailty and cognitive frailty, whereby sarcopenia is the main component of physical frailty. The present review discusses the associations between sarcopenia, frailty and type 2 DM based on current evidence.

Dynamic Delirium Severity Trajectories and Their Association With 2-Year Healthcare Utilization and Mortality Outcomes

Supplemental Digital Content is available in the text.

Delirium severity has been associated with a higher risk of mortality and an increasing morbidity burden. Recently defined delirium severity trajectories were predictive of 30-day mortality in a critically ill patient population. No studies to date have examined associations between delirium severity trajectories and 2-year mortality and healthcare utilization outcomes.

Independent Determinants of Appetite Impairment among Patients with Stage 3 or Higher Chronic Kidney Disease: A Prospective Study

Protein-energy wasting (PEW) is an important complication resulting from chronic kidney disease (CKD). Appetite impairment contributes significantly to PEW in these patients, but risk factors associated with having appetite impairment in patients with CKD remain elusive. Patients with an estimated glomerular filtration rate <60 mL/min/1.73 m² for ≥2 times at least three months apart were prospectively enrolled during 2017, with their demographic features, comorbidities, anthropometric parameters, physical and performance indices, functional status, frailty, sensory organ integrity, and laboratory data collected. Their appetite status was measured using the Council on Nutrition Appetite Questionnaire (CNAQ). We examined independent determinants of appetite impairment in these CKD patients using multiple regression analyses. Among 78 patients with CKD, 42.3% had CNAQ-identified impaired appetite. Those with an impaired appetite also had poorer physical performance, a higher degree of functional impairment, higher frail severities, lower serum sodium levels, less intact oral cavity, and a trend toward having less intact nasal structures than those without. Multiple regression analyses revealed that a higher frail severity, in the forms of increasing Study of Osteoporotic Fractures (SOF) scores (odds ratio (OR), 2.74; 95% confidence interval (CI), 1.15–6.57) and a less intact nasal structure (OR, 0.96; 95% CI, 0.92–0.995) were associated with a higher probability of having an impaired appetite, while higher serum sodium (OR, 0.76; 95% CI, 0.6–0.97) correlated with a lower probability. Based on our findings, in patients with CKD, the severity of frailty, serum sodium, and nasal structural integrity might modify appetite status. Therapies targeting these factors might be beneficial for appetite restoration in patients with CKD.

Association of frailty with health service utilisation and health care expenditure in sub-Saharan Africa: evidence from Côte d'Ivoire

Background

Frailty, a syndrome resulting in heightened risk of negative outcomes for older adults, is increasing across the globe. However, little is known about the health service impacts of frailty in low-income countries (LICs), and in particular, sub-Saharan Africa (SSA). This study explores the relationship between frailty and health service 1) utilisation and 2) expenditure within Côte d’Ivoire.

Methods

Participants aged 50 years and over participated in the Living Condition, Health and Resilience among the Elderly study. Frailty was assessed using a 30-item Frailty Index (FI). The association between frailty and self-reported health service utilisation was analysed for general practitioners (GPs), specialists, overnight hospitalisations, traditional practitioners and self-medication. Expenditure over the previous month included consulting, medications, hospitalisations and total expenditure.

Results

Among participants [n = 860, mean age (SD) = 61.8 (9.7) years, 42.9% female], 60.0% were frail, 22.8% pre-frail and 17.2% robust. The mean (SD) FI was 0.28 (0.17). Increased health service utilisation was associated with frailty for GP attendance, traditional practitioners and self-medication but not specialists or overnight hospitalisation. Pre-frailty and frailty were associated with increased total health service expenditure, with frailty also associated with aggregate consulting costs and medications.

Conclusions

Although frailty is associated with health service utilisation and expenditure in a variety of contexts, the study results suggest that such impacts may vary across the globe. The experience of frailty in LICs is likely to differ from that experienced elsewhere due to cultural traditions, attitudes to the health system, and accessibility, with more research needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02377-6.

Risk factors associated with frailty in older adults with type 2 diabetes: A cross-sectional study

AIMS AND OBJECTIVES

The aims of the study were to (i) estimate the prevalence of frailty among older adults with type 2 diabetes, and (ii) investigate risk factors associated with frailty in the study group.

BACKGROUND

The high prevalence of frailty among older adults and its adverse health impacts including higher risks for physical disabilities and a higher mortality rate is quickly evolving to become an important public health issue.

DESIGN

A cross-sectional design.

METHODS

Data were collected from the Clinical Diabetes Centre of our study group. Frailty was assessed using the Chinese version of the Tilburg frailty indicator. Other questionnaires included Activities of Daily Living, Mini-Mental State Examination, Taiwan Geriatric Depression Scale and Instrumental Activities of Daily Living. Multivariable logistic regression was established to identify factors associated with frailty. The STrengthening the Reporting of OBservational studies in Epidemiology checklist was used preparing the manuscript.

RESULTS

A total of 248 subjects were recruited in this study, a total of 66 participants had frailty (26.6%). Our results showed that factors including age, number of chronic diseases, cerebrovascular accident, renal diseases, frequency of falling, frequency of hyperglycaemia, Activities of Daily Living, depression, Mini-Mental State Examination, and Instrumental Activities of Daily Living ≧1 task disability were correlated with frailty in older adults with type 2 diabetes. After adjusting for confounding factors, multivariate logistic regression analyses showed a significant increase in the probability of frailty by 1.72-times when comparing type 2 diabetes subjects with depression to those without depression.

CONCLUSION

This study revealed that depression is a significant factor associated with the occurrence of frailty among older adults with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Our results provided strong clinical evidence showing depression as an important factor associated with the risk of frailty in older individuals with type 2 diabetes. We recommend early detection via routine screenings for symptoms of depression during diabetes care to achieve early prevention or the delay of frailty and its implicated adverse health consequences.

Frailty is associated with a higher risk of developing delirium and cognitive impairment among patients with diabetic kidney disease: A longitudinal population-based cohort study

AIMS

Delirium, a form of acute brain failure, exhibits a high incidence among older adults. Recent studies have implicated frailty as an under-recognized complication of diabetes mellitus. Whether the presence of frailty increases the risk of delirium/cognitive impairment among patients with diabetic kidney disease (DKD) remains unclear.

METHODS

From the longitudinal cohort of diabetes patients (LCDP) (n = 840,000) in Taiwan, we identified adults with DKD, dividing them into those without and with different severities of frailty based on a modified FRAIL scale. Cox proportional hazard regression was utilized to examine the frailty-associated risk of delirium/cognitive impairment, identified using approaches validated by others.

RESULTS

Totally 149,145 patients with DKD (mean 61.0 years, 44.2% female) were identified, among whom 31.0%, 51.7%, 16.0% and 1.3% did not have or had 1, 2 and >2 FRAIL items at baseline. After 3.68 years, 6613 (4.4%) developed episodes of delirium/cognitive impairment. After accounting for demographic/lifestyle factors, co-morbidities, medications and interventions, patients with DKD and 1, 2 and >2 FRAIL items had a progressively higher risk of developing delirium/cognitive impairment than those without (for those with 1, 2 and >2 items, hazard ratio 1.18, 1.26 and 1.30, 95% confidence interval 1.08-1.28, 1.14-1.39 and 1.10-1.55, respectively). For every FRAIL item increase, the associated risk rose by 9%.

CONCLUSIONS

Frailty significantly increased the risk of delirium/cognitive impairment among patients with DKD. Frailty screening in these patients may assist in delirium risk stratification.

Muscle relaxant use and the associated risk of incident frailty in patients with diabetic kidney disease: a longitudinal cohort study

Background:

Patients with diabetic kidney disease (DKD) are at an increased risk of frailty. The exposure to muscle relaxants frequently leads to adverse effects despite their modest therapeutic efficacy, but whether muscle relaxants predispose users to frailty remains unclear.

Methods:

Patients with DKD from a population-based cohort, the Longitudinal Cohort of Diabetes Patients, were identified between 2004 and 2011 (N = 840,000). Muscle relaxant users were propensity score-matched to never-users in a 1:1 ratio based on demographic features, comorbidities, outcome-relevant medications, and prior major interventions. Incident frailty, the study endpoint, was measured according to a modified FRAIL scale. We used Kaplan–Meier analyses and Cox proportional hazard regression to analyze the association between cumulative muscle relaxant use (⩾ 28 days) and the risk of incident frailty.

Results:

Totally, 11,637 users and matched never-users were enrolled, without significant differences regarding baseline clinical features. Cox proportional hazard regression showed that patients with DKD and received muscle relaxants had a significantly higher risk of incident frailty than never-users [hazard ratio (HR) 1.26, 95% confidence interval (CI) 1.04–1.53]. This increase in frailty risk paralleled that in cumulative muscle relaxant dosages (quartile 1 versus 2 versus 3 versus 4, HR 0.91 versus 1.22 versus 1.38 versus 1.45, p = 0.0013 for trend) and in exposure durations (quartile 1 versus 2 versus 3 versus 4, HR 1.12 versus 1.33 versus 1.23 versus 1.34, p = 0.0145 for trend) of muscle relaxants.

Conclusion:

We found that cumulative muscle relaxant exposure might increase frailty risk. It is prudent to limit muscle relaxant prescription in patients with DKD.

Plain language summary

Does cumulative muscle relaxant exposure increase the risk of incident frailty among patients with diabetic kidney disease?

Background: Frailty denotes a degenerative feature that adversely influences one’s survival and daily function. Patients with diabetes and chronic kidney disease are at a higher risk of developing frailty, but whether concurrent medications, especially muscle relaxants, aggravate this risk remains undefined.

Methods: In this population-based study including 11,637 muscle relaxant users and matched never-users with diabetic kidney disease, we used a renowned frailty-assessing tool, FRAIL scale, to assess frailty severity and examined the incidence of frailty brought by muscle relaxant exposure.

Results: We found that users exhibited a 26% higher risk of developing incident frailty compared with never-users, and the probability increased further if users were prescribed higher doses or longer durations of muscle relaxants.

Conclusion: We concluded that in those with diabetic kidney disease, cumulative muscle relaxant use was associated with a higher risk of incident frailty, suggesting that moderation of muscle relaxant use in this population can be of potential importance.

Uremic Toxins and Frailty in Patients with Chronic Kidney Disease: A Molecular Insight

The accumulation of uremic toxins (UTs) is a prototypical manifestation of uremic milieu that follows renal function decline (chronic kidney disease, CKD). Frailty as a potential outcome-relevant indicator is also prevalent in CKD. The intertwined relationship between uremic toxins, including small/large solutes (phosphate, asymmetric dimethylarginine) and protein-bound ones like indoxyl sulfate (IS) and p-cresyl sulfate (pCS), and frailty pathogenesis has been documented recently. Uremic toxins were shown in vitro and in vivo to induce noxious effects on many organ systems and likely influenced frailty development through their effects on multiple preceding events and companions of frailty, such as sarcopenia/muscle wasting, cognitive impairment/cognitive frailty, osteoporosis/osteodystrophy, vascular calcification, and cardiopulmonary deconditioning. These organ-specific effects may be mediated through different molecular mechanisms or signal pathways such as peroxisome proliferator-activated receptor γ coactivator 1-α (PGC-1α), mitogen-activated protein kinase (MAPK) signaling, aryl hydrocarbon receptor (AhR)/nuclear factor-κB (NF-κB), nuclear factor erythroid 2-related factor 2 (Nrf2), heme oxygenase-1 (HO-1), Runt-related transcription factor 2 (RUNX2), bone morphogenic protein 2 (BMP2), osterix, Notch signaling, autophagy effectors, microRNAs, and reactive oxygen species induction. Anecdotal clinical studies also suggest that frailty may further accelerate renal function decline, thereby augmenting the accumulation of UTs in affected individuals. Judging from these threads of evidence, management strategies aiming for uremic toxin reduction may be a promising approach for frailty amelioration in patients with CKD. Uremic toxin lowering strategies may bear the potential of improving patients’ outcomes and restoring their quality of life, through frailty attenuation. Pathogenic molecule-targeted therapeutics potentially disconnect the association between uremic toxins and frailty, additionally serving as an outcome-modifying approach in the future.

Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease

Background

Patients with diabetic mellitus (DM) and chronic kidney disease (CKD) are at an increased risk of urinary tract infection (UTI) due to their altered immunological integrity. These patients are similarly prone to developing frailty, a state of cumulative health deficits involving multiple domains and leading to adverse outcomes. Whether frailty predisposes affected individuals to UTI among patients with DM and CKD remains unclear.

Methods

A population-based cohort of patients with DM and CKD (n = 79,887) were assembled from the Longitudinal Cohort of Diabetes Patients, with their baseline frailty status measured by a  modified FRAIL scale. We analyzed their risk of developing UTI depending on their severity of frailty, after accounting demographic profiles, lifestyle factors, comorbidities, concurrent medications, and major interventions. A secondary analysis focused on the risk of urosepsis related to frailty.

Results

Among all participants, 36.1 %, 50.3 %, 12.8 %, and 0.8 % did not have or had 1, 2, and ≥ 3 FRAIL items, respectively, at baseline. After 3.51 years, 11,175 UTI events occurred. Kaplan-Meier analysis showed that participants with DM, CKD and an increasing number of FRAIL items had successively higher incidence of UTI than those without any FRAIL items (log rank p < 0.001). Cox proportional hazard modeling revealed that after accounting for all confounders, those with more severe frailty exhibited a significantly higher risk of incident UTI (for groups of 1, 2, and ≥ 3 FRAIL items, hazard ratio 1.19, 1.24, and 1.43, respectively; all p < 0.001) than those without. An 11 % risk elevation for UTI could be observed for every FRAIL item increase. Participants with more severe frailty exhibited a trend of having higher risk of urosepsis as well.

Conclusions

Having frailty predicted a higher risk of developing UTI in the future in patients with DM and CKD. It would be prudent to screen for frailty in these patients and provide optimal frailty-directed management to attenuate their risk of UTI and improve their outcomes.

Frailty increases the risk for developing urinary tract infection among 79,887 patients with diabetic mellitus and chronic kidney disease

BACKGROUND

Patients with diabetic mellitus (DM) and chronic kidney disease (CKD) are at an increased risk of urinary tract infection (UTI) due to their altered immunological integrity. These patients are similarly prone to developing frailty, a state of cumulative health deficits involving multiple domains and leading to adverse outcomes. Whether frailty predisposes affected individuals to UTI among patients with DM and CKD remains unclear.

METHODS

A population-based cohort of patients with DM and CKD (n = 79,887) were assembled from the Longitudinal Cohort of Diabetes Patients, with their baseline frailty status measured by a  modified FRAIL scale. We analyzed their risk of developing UTI depending on their severity of frailty, after accounting demographic profiles, lifestyle factors, comorbidities, concurrent medications, and major interventions. A secondary analysis focused on the risk of urosepsis related to frailty.

RESULTS

Among all participants, 36.1 %, 50.3 %, 12.8 %, and 0.8 % did not have or had 1, 2, and ≥ 3 FRAIL items, respectively, at baseline. After 3.51 years, 11,175 UTI events occurred. Kaplan-Meier analysis showed that participants with DM, CKD and an increasing number of FRAIL items had successively higher incidence of UTI than those without any FRAIL items (log rank p < 0.001). Cox proportional hazard modeling revealed that after accounting for all confounders, those with more severe frailty exhibited a significantly higher risk of incident UTI (for groups of 1, 2, and ≥ 3 FRAIL items, hazard ratio 1.19, 1.24, and 1.43, respectively; all p < 0.001) than those without. An 11 % risk elevation for UTI could be observed for every FRAIL item increase. Participants with more severe frailty exhibited a trend of having higher risk of urosepsis as well.

CONCLUSIONS

Having frailty predicted a higher risk of developing UTI in the future in patients with DM and CKD. It would be prudent to screen for frailty in these patients and provide optimal frailty-directed management to attenuate their risk of UTI and improve their outcomes.

The risk trajectory of different cardiovascular morbidities associated with chronic kidney disease among patients with newly diagnosed diabetes mellitus: a propensity score-matched cohort analysis

Background

Chronic kidney disease (CKD) introduces an increased cardiovascular risk among patients with diabetes mellitus (DM). The risk and tempo of cardiovascular diseases may differ depending upon their type. Whether CKD differentially influences the risk of developing each cardiovascular morbidity in patients with newly diagnosed DM remains unexplored.

Methods

We identified patients with incident DM from the Longitudinal Cohort of Diabetes Patients (LCDP) cohort (n = 429,616), and uncovered those developing CKD after DM and their propensity score-matched counterparts without. After follow-up, we examined the cardiovascular morbidity-free rates of patients with and without CKD after DM, followed by Cox proportional hazard regression analyses. We further evaluated the cumulative risk of developing each outcome consecutively during the study period.

Results

From LCDP, we identified 55,961 diabetic patients with CKD and matched controls without CKD. After 4.2 years, patients with incident DM and CKD afterward had a significantly higher risk of mortality (hazard ratio [HR] 1.1, 95% confidence interval [CI] 1.06–1.14), heart failure (HF) (HR 1.282, 95% CI 1.19–1.38), acute myocardial infarction (AMI) (HR 1.16, 95% CI 1.04–1.3), and peripheral vascular disease (PVD) (HR 1.277, 95% CI 1.08–1.52) compared to those without CKD. The CKD-associated risk of mortality, HF and AMI became significant soon after DM occurred and remained significant throughout follow-up, while the risk of PVD conferred by CKD did not emerge until 4 years later. The CKD-associated risk of ischemic, hemorrhagic stroke and atrial fibrillation remained insignificant.

Conclusions

The cardiovascular risk profile among incident DM patients differs depending on disease type. These findings can facilitate the selection of an optimal strategy for early cardiovascular care for newly diagnosed diabetic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01279-6.

Frailty status changes are associated with healthcare utilization and subsequent mortality in the elderly population

BACKGROUND

This study determined (1) whether a change in frailty status after a 1 year follow up is associated with healthcare utilization and evaluated (2) whether a change in frailty status after a 1 year follow up and health care utilization are associated with all-cause mortality in a sample of Taiwan population.

METHODS

This work is a population-based prospective cohort study involving residents aged ≥65 years in 2009. A total of 548 elderly patients who received follow-ups in the subsequent year were included in the current data analysis. Fried frailty phenotype was measured at baseline and 1 year. Information on the outpatient visits of each specialty doctor, emergency care utilization, and hospital admission during the 2 month period before the second interview was collected through standardized questionnaires administered by an interviewer. Deaths were verified by indexing to the national database of deaths.

RESULTS

At the subsequent 1 year follow-up, 73 (13.3%), 356 (64.9%), and 119 (21.7%) elderly participants exhibited deterioration, no change in status, and improvement in frailty states, respectively. Multivariate logistic analysis showed the high risk of any type of outpatient use (odds ratios [OR] 1.94, 95% confidence interval [CI] 1.02-3.71) among older adults with worse frailty status compared with those who were robust at baseline and had unchanged frailty status after 1 year. After multivariate adjustment, participants with high outpatient clinic utilization had significantly higher mortality than those with low outpatient clinic visits among unchanged pre-frail or frail (hazard ratios [HR] 2.79, 95% CI: 1.46-5.33) and frail to pre-frail/robust group (HR 9.32, 95% CI: 3.82-22.73) if the unchanged robustness and low outpatient clinic visits group was used as the reference group.

CONCLUSIONS

The conditions associated with frailty status, either after 1 year or at baseline, significantly affected the outpatient visits and may have increased medical expenditures. Combined change in frailty status and number of outpatient visits is related to increased mortality.

Measuring frailty in younger populations: a rapid review of evidence

OBJECTIVES

Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

DESIGN

A rapid review of primary studies was conducted.

DATA SOURCES

Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

ELIGIBILITY CRITERIA

Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

DATA EXTRACTION AND SYNTHESIS

Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

RESULTS

We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

CONCLUSIONS

Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review

BACKGROUND

Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients.

METHODS

The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed.

RESULTS

Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients' race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies.

CONCLUSIONS

Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Protein intake is not associated with functional biomarkers of physical frailty: A cross-sectional analysis of community-dwelling older adults with type 2 diabetes mellitus

BACKGROUND AND AIM

Frailty has emerged as a third category of complication in patients with type 2 diabetes mellitus (T2DM). It has been suggested that adequate protein intake is an important dietary strategy for counteracting frailty. Therefore, we explored the association between protein intake and functional biomarkers of frailty in older adults with T2DM.

METHODS AND RESULTS

Frailty was operationalized as the presence of three of the following: exhaustion, low muscle strength, low physical activity, slow gait speed, and weight loss. Functional biomarkers included handgrip strength (HGS), chair stands, the short physical performance battery and gait speed. Eighty-seven older adults (71.2 ± 8.2 years; 66.7% males) were included. A total of n = 6 (~7%) and n = 32 (~37%) participants were identified as frail and pre-frail respectively. No significant difference was observed for protein intake across staging of frailty (pre-frail/frail: 1.3 ± 0.4 g/kg BW; non-frail: 1.4 ± 0.4 g/kg BW; P = 0.320). A significant association was observed for total protein intake and HGS (β = 0.44; 95% CI: 0.23-1.8; P = 0.01). However, this was no longer significant after adjusting for age, gender, physical activity, energy intake and total appendicular lean muscle (β = 0.03; 95% CI: -0.45-0.60; P = 0.78). Nil other associations were observed between total protein intake and functional biomarkers of frailty.

CONCLUSION

Adequate protein intake was not associated with functional biomarkers in older adults with T2DM. Future research should focus on the efficacy of protein on attenuating functional decline in vulnerable older adults with low protein intake.

Predictors of frailty among Chinese community-dwelling older adults with type 2 diabetes: a cross-sectional survey

OBJECTIVES

To assess the prevalence of frailty and identify predictors of frailty among Chinese community-dwelling older adults with type 2 diabetes.

DESIGN

A cross-sectional design.

SETTING

Two community health centres in central China.

PARTICIPANTS

291 community-dwelling older adults aged ≥65 years with type 2 diabetes.

MAIN OUTCOME MEASURES

Data were collected via face-to-face interviews, anthropometric measurements, laboratory tests and community health files. The main outcome measure was frailty, as assessed by the frailty phenotype criteria. The multivariate logistic regression model was used to identify the predictors of frailty.

RESULTS

The prevalence of prefrailty and frailty were 51.5% and 19.2%, respectively. The significant predictors of frailty included alcohol drinking (ex-drinker) (OR 4.461, 95% CI 1.079 to 18.438), glycated haemoglobin (OR 1.434, 95% CI 1.045 to 1.968), nutritional status (malnutrition risk/malnutrition) (OR 8.062, 95% CI 2.470 to 26.317), depressive symptoms (OR 1.438, 95% CI 1.166 to 1.773) and exercise behaviour (OR 0.796, 95% CI 0.716 to 0.884).

CONCLUSIONS

A high prevalence of frailty was found among older adults with type 2 diabetes in the Chinese community. Frailty identification and multifaceted interventions should be developed for this population, taking into consideration proper glycaemic control, nutritional instruction, depressive symptoms improvement and enhancement of self-care behaviours.

Use of the Patient-Generated Subjective Global Assessment to Identify Pre-Frailty and Frailty in Hospitalized Older Adults

OBJECTIVES

The Scored Patient-Generated Subjective Global Assessment (PG-SGA) and Edmonton Frail Scale (EFS) are widely used in acute care settings to assess nutritional and frailty status, respectively. We aimed to determine whether the scored PG-SGA can identify pre-frailty and frailty status, to simultaneously evaluate malnutrition and frailty in clinical practice.

DESIGN

Cross-sectional study.

SETTINGS AND PARTICIPANTS

A convenience sample of 329 consecutive patients admitted to an acute medical unit in South Australia.

MEASUREMENTS

Nutritional and frailty status were ascertained with scored PG-SGA and EFS, respectively. Optimal cut-off scores to identify pre-frailty and frailty were determined by calculating the Scored PG-SGA's sensitivity, specificity, positive and negative predictive values, Youden Index (YI), Liu index, Receiver Operator Curves (ROC) and Area Under Curve (AUC). Nutritional status and patient characteristics were analysed according to frailty categories.

RESULTS

The optimal cut-off PG-SGA score as determined by the highest YI, to identify both pre-frailty and frailty was >3, with a sensitivity of 0.711 and specificity of 0.746. The AUC was 0.782 (95% CI 0.731-0.833). In this cohort, 64% of the patients were well-nourished, 26% were moderately malnourished and 10% were severely malnourished. Forty-three percent, 24% and 33% of the patients were classified as robust, pre-frail and frail, respectively. Bivariate analysis showed that those robust were significantly younger than those who were pre-frail (-2.8, 95% CI -5.5 to -0.1, p=0.036) or frail (-3.4, 95% CI -5.9 to -1.0, p=0.002). Robust patients had significantly lower Scored PG-SGA than those who were pre-frail (-2.5, 95%CI -3.8 to -1.1, p<0.001) or frail (-4.9, 95% CI -6.1 to -3.7, p<0.001).

CONCLUSION

The Scored PG-SGA is moderately sensitive in identifying pre-frailty/frailty in older hospitalized adults and can be useful in identifying both conditions concurrently.

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.

Frailty modifies the association between opioid use and mortality in chronic kidney disease patients with diabetes: a population-based cohort study

The prevalence of chronic pain in patients with chronic kidney disease (CKD) and diabetes mellitus is high and correlates with higher frailty risk, but satisfactory pain control frequently fails, necessitating opioid initiation. We aimed to examine whether opioid use affected their outcomes and whether such a relationship was modified by frailty. From the longitudinal cohort of diabetes patients (n = 840,000), we identified opioid users with CKD (n = 26,029) and propensity score-matched them to opioid-naïve patients in a 1:1 ratio. We analyzed the associations between opioid use and long-term mortality according to baseline frailty status, defined by the modified FRAIL scale. Among all, 20.3% did not have any FRAIL items, while 57.2%, 20.6%, and 1.9% had 1, 2, and at least 3 positive FRAIL items, respectively. After 4.2 years, 16.4% died. Cox proportional hazard regression showed that opioid users exhibited an 18% higher mortality risk (HR 1.183, 95% CI 1.13-1.24) with a dose- and duration-responsive relationship, compared to opioid-naive ones. Furthermore, the mortality risk posed by opioids was observed only in CKD patients without frailty but not in those with frailty. In conclusion, opioid use increased mortality among patients with CKD, while this negative outcome influence was not observed among frail ones.

Low calf circumference is associated with frailty in diabetic adults aged over 80 years

BACKGROUND

Frailty is now seen as a significant factor in older people with diabetes, whose mortality and disability increased. This study aims to investigate the association between calf circumference (CC) with frailty in diabetic adults aged over 80 years.

METHODS

A cross-sectional analysis was performed on the data of 426 diabetic adults aged over 80 years. On admission, demographic data and laboratory parameters were recorded. CC was measured on the lower right leg at the point of the maximal circumference. All participants accepted frailty assessments. Frailty was mainly defined using the Fried frailty phenotype criteria.

RESULTS

The CC levels were significantly lower in the frail than the non-frail (26.7 ± 4.0 vs. 31.2 ± 4.0, P < 0.001). CC was negatively correlated with the Fried frailty phenotype index (P < 0.001). Logistic regression analysis of frailty revealed that age (Odds Ratio (OR), 1.368; 95% Confidential Interval (CI) 1.002-1.869; P = 0.049), CC (OR, 0.756; 95%CI 0.598-0.956; P = 0.019) were independent impact factors of frailty after adjusting all the potential confounders. Participants with low CC tertile had a significantly higher Fried frailty phenotype index than those with high CC tertiles. The best CC cut-off value for predicting frailty was 29.3 cm, its sensitivity was 75.0%, and the specificity was 78.6%, and areas under the curve (AUC) was 0.786 (P < 0.001).

CONCLUSIONS

CC was strongly related to frailty in diabetic adults aged over 80 years, suggesting that CC may be helpful for monitoring physical frailty in older adults in clinical and research settings.

Cachexia, muscle wasting, and frailty in cardiovascular disease

The last several years have seen increasing interest in understanding cachexia, muscle wasting, and physical frailty across the broad spectrum of patients with cardiovascular illnesses. This interest originally started in the field of heart failure, but has recently been extended to other areas such as atrial fibrillation, coronary artery disease, peripheral artery disease as well as to patients after cardiac surgery or transcatheter aortic valve implantation. Tissue wasting and frailty are prevalent among many of the affected patients. The ageing process itself and concomitant cardiovascular illness decrease lean mass while fat mass is relatively preserved, making elderly patients particularly prone to develop wasting syndromes and frailty. The aim of this review is to provide an overview of the available knowledge of body wasting and physical frailty in patients with cardiovascular illness, particularly focussing on patients with heart failure in whom most of the available data have been gathered. In addition, mechanisms of wasting and possible therapeutic targets are discussed.

Association between frailty and risk of fall among diabetic patients

BACKGROUND

Several epidemiological studies have demonstrated the risk factors for fall, while few studies investigated the association between frailty and risk of fall in diabetic patients aged ≥45 years.

METHODS

In this multicity observational study, participants with type 2 diabetes aged ≥45 years were enrolled. Frailty status was measured by a frailty index (FI) of deficit accumulation. We used multivariable regression models to examine the relationship between frailty and fall in diabetic patients, and further investigated the associations between frailty and fall in varied subgroups.

RESULTS

A total of 2049 participants with type 2 diabetes were identified in our study. Our results showed a per-s.d. and a per-0.01 increment of FI were associated with an increased risk of fall, with a fully adjusted OR of 1.89 (95% CI: 1.50, 2.38), 1.06 (95% CI: 1.04, 1.09), respectively. The effects were magnified when frailty was considered as dichotomous, with an OR of 3.08 (95% CI: 2.18, 4.34). In further subgroup analyses, we found that the females, the older, rural residents, individuals with no sitting toilet, people with poor balance performance and those in poor health status were susceptible to fall. Especially, for the risk of fall in the older, a per-s.d. increase of FI corresponded to an OR of 2.46 (95% CI: 1.68, 3.62). When frailty was regarded as a binary variable, the effect increased to 4.62 (95% CI: 2.54, 8.38) in the older subgroup.

CONCLUSION

Frailty was associated with a higher risk of fall in people with type 2 diabetes, and the effects were higher in vulnerable groups. This evidence suggested that more attention should be paid to vulnerable groups for fall prevention.

Elevated Red Cell Distribution Width Is Independently Associated With a Higher Frailty Risk Among 2,932 Community-Dwelling Older Adults

Background: Older adults are at an increased risk of frailty, but laboratory surrogates for identifying frailty in this population remain controversial and clinicians frequently encounter difficulty during frailty screening. We examined whether having a high red cell distribution width (RDW) was associated with an increased probability of frailty in older adults.

Methods: We prospectively included community-dwelling older adults between 2013 and 2016 from a single institute, with their clinical features/laboratory parameters documented. We used the Study of Osteoporotic Fractures index (malnutrition, poor physical performance, and fatigue) to delineate frailty, and harnessed multiple logistic regression to investigate whether having a high RDW (≥ 15.7%) was associated with an increased risk of having frailty among these participants.

Results: A total of 2,932 older adults (mean 73.5 ± 6.7 years; 44.6% male) were included, among whom 113 (3.9%) and 76 (2.6%) had a high RDW and presented frailty, respectively. Older adults with a high RDW were more likely to be frail (p = 0.002) and had more positive SOF items than those with normal RDW levels (p = 0.013). Those with a high RDW exhibited a significantly higher risk of having frailty (odds ratio [OR] 2.689, 95% confidence interval [CI] 1.184–6.109) compared to those without. Sensitivity analyses using RDW as a continuous variable similarly showed that RDW levels were positively associated with frailty risk (OR 1.223 per 1% RDW higher).

Conclusions: In older adults, higher RDW can be regarded as a frailty indicator, and the readiness in RDW assessment supports its screening utility.

The impact of frailty on the economic evaluation of geriatric surgery: hospital costs and opportunity costs based on meta-analysis

Objectives: We used a systematic review and meta-analysis to analyze the difference in costs between surgery for frail and non-frail elderly patients. The opportunity cost of frailty in geriatric surgery is estimated using the results.Methodology: Two literature reviews were carried out between 2000 and 2019: (1) studies comparing total hospital costs of frail and non-frail surgical patients; (2) studies evaluating the length of hospital stay and cost for surgical geriatric patients. We performed a meta-analysis of the items selected in the first review. We subsequently calculated the opportunity cost of frail patients, based on the design of a cost/time variable.Results: Twelve articles in the first review were selected (272,717 non-frail and 16,461 frail). Fourteen articles were selected from the second review. Frail patients had higher hospital costs than non-frail patients (22,282.541 € and 16,388.844, p < .001) and a longer hospital stay (10.16 days and 8.4 (p < .001)). The estimated opportunity cost in frail patients is 1,019.56 € (cost/time unit factor of 579.30 €/day).Conclusions: Frail surgical geriatric patients generate a higher total hospital cost, and an opportunity cost arising from not operating in the best possible state of health. Preoperatively treating the frailty of elderly patients will improve the use of health resources.

Changes in Cognitive Function and in the Levels of Glycosylated Haemoglobin (HbA1c) in Older Women with Type 2 Diabetes Mellitus Subjected to a Cardiorespiratory Exercise Programme

Ageing and diabetes are recognised as important risk factors for the development of cognitive deterioration. The aim was to analyse the effects of a walking-based training programme on cognitive deterioration and glycosylated haemoglobin (HbA1c) in older women with type 2 diabetes. This was a six-month experimental and longitudinal study with an experimental group (EG) (n = 57) and a control group (CG) (n = 52). All participants were diabetic with hypoglycaemic treatment. EG carried out a walking-based training program. After the training, we evaluated the diabetic state (HbA1c), cognitive functioning with the Mini-Mental State Examination (MMSE), cardiorespiratory fitness (VO2max) and body mass index (BMI). Results: EG obtained better results than CG in all the analysed variables. EG showed a significant improvement in the levels of HbA1c (−4.5%; p < 0.001), VO2max (+5.9%; p < 0.001) and BMI (−5.4%; p < 0.001); it also obtained increases in the scores of cognitive functioning, which were statistically significant in all dimensions, except for calculation (p = 0.384) and language (p = 0.168). Conclusion: The aerobic treatment produced significant improvements in the diabetic state and cognitive functioning in older women with type 2 diabetes.

Chronic kidney disease-related osteoporosis is associated with incident frailty among patients with diabetic kidney disease: a propensity score-matched cohort study

Chronic kidney disease (CKD)-related osteoporosis is a major complication in patients with CKD, conferring a higher risk of adverse outcomes. We found that among those with diabetic kidney disease, this complication increased the risk of incident frailty, an important mediator of adverse outcomes.

INTRODUCTION

Renal osteodystrophy and chronic kidney disease (CKD)-related osteoporosis increases complications for patients with diabetic kidney disease (DKD). Since musculoskeletal degeneration is central to frailty development, we investigated the relationship between baseline osteoporosis and the subsequent frailty risk in patients with DKD.

METHODS

From the Longitudinal Cohort of Diabetes Patients in Taiwan (n = 840,000), we identified 12,027 patients having DKD with osteoporosis and 24,054 propensity score-matched controls having DKD but without osteoporosis. The primary endpoint was incident frailty on the basis of a modified FRAIL scale. Patients were prospectively followed-up until the development of endpoints or the end of this study. The Kaplan-Meier technique and Cox proportional hazard regression were used to analyze the association between osteoporosis at baseline and incident frailty in these patients.

RESULTS

The mean age of the DKD patients was 67.2 years, with 55.4% female and a 12.6% prevalence of osteoporosis at baseline. After 3.5 ± 2.2 years of follow up, the incidence rate of frailty in patients having DKD with osteoporosis was higher than that in DKD patients without (6.6 vs. 5.7 per 1000 patient-year, p = 0.04). A Cox proportional hazard regression showed that after accounting for age, gender, obesity, comorbidities, and medications, patients having DKD with osteoporosis had a significantly higher risk of developing frailty (hazard ratio, 1.19; 95% confidence interval, 1.02-1.38) than those without osteoporosis.

CONCLUSIONS

CKD-related osteoporosis is associated with a higher risk of incident frailty in patients with DKD.

Activity behavior and cognitive performance in older adults living in a senior housing facility: the impact of frailty status

BACKGROUND

Frailty, a condition characterized by a reduced physiological reserve and resilience, is highly prevalent among older adults.

AIMS

This study examined differences in physical activity (PA) level, sedentary behavior (SB) time, and cognitive performance in older adults living in a senior housing facility (SHF) as a function of frailty status.

METHODS

This study assessed 100 older adults from a SHF in the Midwest area of the United States. Participants were categorized as frail or non-frail according to scores observed in the short physical performance battery (SPPB), using the cutoff of nine previously stated in the literature. PA level and SB time were self-reportedly assessed using the physical activity scale for the elderly (PASE) and SB using a specific questionnaire developed for the older adult population. Cognitive performance was assessed using a collection of tests measuring cognitive processing speed, verbal learning, visuospatial memory, and verbal fluency.

RESULTS

Frail and non-frail older adults reported similar PA level and SB time (P > .05). Frail older adults performed significantly (P < .05) worse than their counterparts, non-frail in all measures of cognitive function. However, after controlling the analysis for age, only processing speed (SDMT scores) remained statistically different (P < .05) between groups.

DISCUSSION/CONCLUSION

Older adults living in a SHF with different frailty status (i.e., frail vs. non-frail) report similar levels of PA level and SB time; but our findings suggest that non-frail older adults appear to have better cognitive function in terms of processing speed compared to the frail group.

Hypoglycemic episodes are associated with an increased risk of incident frailty among new onset diabetic patients

AIMS

Patients with diabetes mellitus (DM) are at risk for developing frailty due to the complex interplay between different cardiometabolic factors. We examined whether hypoglycemia could independently increase frailty risk besides these factors.

METHODS

From the Longitudinal Cohort of Diabetic Patients, 210,254 patients with new onset DM between 2004 and 2011 were identified, among whom 2119 non-frail patients had at least 1 hypoglycemic episode within 3 years of DM diagnosis. They were propensity score-matched to 8432 non-frail ones without hypoglycemia throughout the study period. Both groups were followed up longitudinally for incident physical frailty according to a modified FRAIL scale (Fatigue, Resistance, Ambulation, Illness, and Loss of weight). We analyzed the risk of frailty (primary) and mortality (secondary outcome) introduced by hypoglycemia, adjusted for known risk factors of frailty.

RESULTS

The mean age of patients (46.2% male) was 65.9 ± 14 years; diabetic patients with hypoglycemia had significantly higher comorbidity burden than those without. After 2.68 years, 172 (1.6%) patients with hypoglycemia developed incident frailty, representing a 60% higher risk (hazard ratio [HR] 1.599, 95% confidence interval [CI] 1.14-2.42). After adjusting for other risk factors, those with hypoglycemia had a significantly higher risk of frailty than those without (HR 1.443, 95% CI 1.01-2.05). Additionally, the mortality of those with hypoglycemia was 2-fold higher than those without, and the risk persisted despite confounder adjustment (HR 1.462, 95% CI 1.3-1.65).

CONCLUSION

In this population-based cohort, hypoglycemic episodes among diabetic patients increased the risk of incident frailty and mortality.

Changes and Risk Factors of Skeletal Muscle Mass and Strength in Patients with Type 2 Diabetes over 60 Years Old: A Cross-Sectional Study from China

OBJECTIVE

The accelerate loss of skeletal muscle mass, strength, and function, named sarcopenia, is a progressive and generalised skeletal muscle disorder, and it is always associated with increased outcomes including falls, frailty, and disability. Diabetes mellitus is associated with significant muscle and physical complications. We aimed at clarifying the changes and risk factors of skeletal muscle mass and strength in elderly with type 2 diabetes.

METHODS

The study consisted of patients with type 2 diabetes (n = 120) and an older general population (n = 126). The skeletal muscle mass and muscle strength, as well as the serum levels of chronic inflammation, oxidative stress, homocysteine, and insulin-like factor-1 were assessed, and the correlation and regression analysis were conducted to evaluate outcomes.

RESULTS

T2DM patients exhibited lower muscle strength compared with the non-T2DM subjects (P < 0.01). Among T2DM patients, serum IGF-1 levels were positively correlated with muscle strength (r = 0.255, P < 0.01) and muscle mass (r = 0.209, P < 0.05), levels of 8-OHdG were inversely correlated with muscle strength (r = -0.252, P < 0.01), and there was a negative association between HCY and muscle mass (r = -0.185, P < 0.05). Muscle mass and strength of patients with higher education level were significantly higher than those with lower education level (P < 0.05), in male patients, muscle mass and muscle strength were significantly lower in smokers (P < 0.01), and muscle mass was lower in chronic drinkers (P < 0.05).

CONCLUSIONS

These findings suggest that diabetic patients may be more susceptible to sarcopenia at an older age. And it also provides evidences that among elderly with diabetes mellitus, oxidative damage and HCY as well as IGF-1 are important predictors of age-dependent sarcopenia.

Frailty predicts a higher risk of incident urolithiasis in 525 368 patients with diabetes mellitus: a population-based study

OBJECTIVE

Patients with diabetes have an increased risk for urolithiasis, but the associated risk factors remain an active area of research. We investigated whether frailty influenced the probability of patients with diabetes developing urolithiasis.

RESEARCH DESIGN AND METHODS

Using data from the Longitudinal Cohort of Diabetic Patients from 2004 to 2010, we identified those without and with frailty based on a validated, modified FRAIL scale. Patients were followed until they developed urolithiasis, and we used Kaplan-Meier and Cox proportional hazard regression analyses to examine the relationship between frailty, its severity, and the risk of urolithiasis, accounting for demographic profiles, comorbidities, frailty status changes over follow-up, and medications, with risk competition by mortality.

RESULTS

Among 525 368 patients with diabetes, 64.4% were not frail, while 28.5%, 6.6%, and 0.6% had 1, 2, and ≥3 FRAIL items at baseline. After 4.2 years of follow-up, 13.4% experienced incident urolithiasis. Cox proportional hazard regression analysis showed that patients with diabetes having at least one FRAIL criterion exhibited a significantly higher risk for urolithiasis compared with non-frail patients (for 1, 2, and ≥3 items, hazard ratio (HR)s: 1.04, 1.23, and 1.46; 95% confidence intervals (CIs) 0.99 to 1.09, 1.12 to 1.35, and 1.12 to 1.91, respectively). This increase in urolithiasis risk remained significant if we restricted analyses to renal stones or recurrent urolithiasis as the study outcomes.

CONCLUSIONS

Frailty may pose a risk for incident urolithiasis in patients with diabetes. Treating frailty may potentially reduce their risk for urolithiasis.

Frailty Predicts an Increased Risk of End-Stage Renal Disease with Risk Competition by Mortality among 165,461 Diabetic Kidney Disease Patients

To examine the effect of frailty on diabetic kidney disease patients’ risk of progression to end-stage renal disease (ESRD), mortality, and adverse episodes, as whether frailty modifies their risk of developing ESRD and other adverse outcomes remains unclear. We identified 165,461 DKD patients from the Longitudinal Cohort of Diabetes Patients in Taiwan (n=840,000) between 2004 and 2010, classifying them into those without frailty or with 1, 2 and ≥3 frailty components based on a modified version of FRAIL scale. Using Cox proportional hazard regression analysis, we examined the long-term risk of developing ESRD along with their risk of mortality, supplemented by a competing risk analysis against mortality. Among all participants, 66.2% (n=109,586), 27.2% (n=44,986), 5.9% (n=9,799), and 0.7% (n=1090) patients did not have or had 1, 2, and ≥3 frailty components, respectively. After a 4.1-year follow-up, 4.2% patients developed ESRD and 18.5% died. Cox proportional hazard modeling revealed that patients with 1, 2, and ≥3 frailty components had increased risks of developing ESRD (for 1, 2, and ≥3 components, hazard ratio [HR] 1.13, 1.18, and 1.2, respectively) and mortality (HR 1.25, 1.41, and 1.34, respectively), with. 9% and 16% risk elevations for ESRD and mortality per component increase. Competing risk analysis showed that frailty-induced ESRD risk was attenuated partially by mortality in those with moderate frailty. The receipt of palliative care did not attenuate this risk. Frailty increased the risk of ESRD based on a dose-response relationship among DKD patients with risk competition by mortality.

Rationale and design of a cross-sectional study to investigate and describe the chronotype of patients with type 2 diabetes and the effect on glycaemic control: the CODEC study

INTRODUCTION

A person's chronotype is their entrained preference for sleep time within the 24 hours clock. It is described by the well-known concept of the 'lark' (early riser) and 'owl' (late sleeper). Evidence suggests that the 'owl' is metabolically disadvantaged due to the standard organisation of our society which favours the 'lark' and places physiological stresses on this chronotype. The aim of this study is to explore cardiometabolic health between the lark and owl in a population with an established metabolic condition - type 2 diabetes.

METHODS

This cross-sectional, multisite study aims to recruit 2247 participants from both secondary and primary care settings. The primary objective is to compare glycaemic control between late and early chronotypes. Secondary objectives include determining if late-chronotype is associated with poorer cardiometabolic health and other lifestyle factors, including well-being, compared with early-chronotype; describing the prevalence of the five different chronotypes in this cohort and examining the trends in glycaemic control, cardiometabolic health, well-being and lifestyle factors across chronotype.

ANALYSIS

The primary outcome (glycated haemoglobin (HbA1c)), linear regression analysis will compare HbA1c between early and late chronotypes, with and without adjustment for confounding variables. Chronotype will be modelled as a categorical variable with all five levels (from extreme-morning to extreme-late type), and as a continuous variable to calculate p for trend across the five categories. A number of models will be created; unadjusted through to adjusted with age, sex, ethnicity, body mass index, duration of diabetes, family history of diabetes, current medication and dietary habits. All secondary outcomes will be analysed using the same method.

ETHICS

Ethical approval from the West Midlands - Black Country Research Ethics Committee (16/WM/0457).

DISSEMINATION

The results will be disseminated through publication in peer-reviewed medical journal, relevant medical/health conferences and a summary report sent to patients.

TRIAL REGISTRATION NUMBER

NCT02973412 (Pre-Results).

Advanced Age and Chronic Kidney Disease Modify the Association Between Metabolic Syndrome and Frailty Among Community-Dwelling Elderly

Metabolic syndrome (MetS) predisposes older adults to the development of frailty. However, previous studies have not explored factors that may influence the association between MetS and the risk of frailty in this population. Community-dwelling older adults (≥65 years of age) were prospectively identified and enrolled between 2013 and 2016. MetS and frailty were defined based on the American Association of Clinical Endocrinologists and Study of Osteoporotic Fractures criteria, respectively. Multiple logistic regression with frailty/prefrailty as the dependent variable was used to examine the relationship between MetS and frailty/prefrailty, supplemented by subgroup analyses of the influence of aging and chronic kidney disease (CKD). Among 2862 elderly (73.4 ± 6.7 years), 17.5% and 17.3%, respectively, had MetS and frailty/prefrailty, among whom 74 (2.6%) and 420 (14.7%) had frailty and prefrailty. The presence of MetS (odds ratio [OR] 2.53, p < 0.001), higher age (OR 1.05, p < 0.001), and CKD (OR 1.42, p = 0.006) were associated with a significantly higher risk of frailty/prefrailty. Furthermore, among those ≥80 years of age, the association between MetS and frailty/prefrailty disappeared (p = 0.329). Among those with CKD, the presence of MetS was significantly associated with a progressively higher risk of frailty/prefrailty (for stage 3 or higher and for stage 3b or higher, OR 6.4 and 12.4, p < 0.001 and = 0.009, respectively). In conclusion, aging and CKD modified the association between MetS and frailty. These findings may assist in devising case-specific care plans for elderly with MetS by refocusing our attention on those at high risk of developing frailty/prefrailty.

Relationship between frailty and mortality, hospitalization, and cardiovascular diseases in diabetes: a systematic review and meta-analysis

Background

In patients with diabetes, death and cardiovascular diseases are attributed to classical risk factors such as hypertension, dyslipidemia, and smoking habit, whereas these events are attributed to frailty in the remaining patients. In this meta-analysis, we examined the relationship between frailty and mortality, hospitalization, and cardiovascular diseases in patients with diabetes.

Methods

Literature search was conducted using databases such as MEDLINE, Cochrane Controlled Trials Registry, and ClinicalTrials.gov. Studies that examined the relationship between frailty and mortality, hospitalization, and cardiovascular disease and included hazard ratios (HRs), odds ratios (ORs), and 95% confidence intervals (CIs) were included. Statistical analysis was performed using a random effects model, and pooled HRs, pooled ORs, and 95% CIs were calculated.

Results

The literature search extracted 8 studies (565,039 patients) that met our inclusion criteria, which were included in this meta-analysis. The pooled HR of prefrailty and frailty related to mortality was 1.09 (95% CI 1.01–1.17; P = 0.02) and 1.35 (95% CI 1.05–1.74; P = 0.02), respectively, indicating a significant relationship between them. The pooled OR of prefrailty and frailty related to hospitalization was 2.15 (95% CI 1.30–3.54; P = 0.003) and 5.18 (95% CI 2.68–9.99; P < 0.001), respectively, indicating a significant relationship. Although a significant relationship was found between frailty and cardiovascular diseases, we found only few related studies; thus, robust results could not be obtained.

Conclusions

In patients with diabetes, a significant relationship was observed between frailty and mortality and hospitalization. However, only few heterogeneous studies were included, warranting further examination.

Applicability of laboratory deficit-based frailty index in predominantly older patients with end-stage renal disease under chronic dialysis: A pilot test of its correlation with survival and self-reported instruments

AIM

Laboratory deficit-based frailty index (LFI) exhibited outcome-prediction ability in the elderly, but not in those with end-stage renal disease (ESRD). We hypothesized that LFI results might have outcome correlation and correlate closely with other instruments in ESRD patients.

METHODS

We prospectively enroled ESRD patients between 2014 and 2015 and administered self-report frailty instruments (Strawbridge questionnaire, Edmonton frail scale (EFS), Groningen frailty indicator (GFI), Tilburg frailty indicator, G8 questionnaire and FRAIL scale), and Cardiovascular Health Study (CHS) scale, with two types of LFI calculated. They were followed up until June 30, 2017. Correlations between the results of six instruments, CHS scale, and those of LFI were identified, followed by Kaplan-Meier survival analyses and logistic regression analyses to compare those with high and low LFI.

RESULTS

The frailty prevalence was 33.3% (CHS), 78.8% Strawbridge questionnaire, 45.5% (EFS), 57.6% (GFI), 27.3% (Tilburg frailty indicator), 84.8% (G8) and 18.2% (FRAIL) among ESRD participants. LFI-1 results were significantly correlated with those of LFI-2 (P < 0.01), EFS (P = 0.04) and GFI (P < 0.01), while LFI-2 results were not. Those with CHS or GFI-identified frailty had significantly lower 1,25-(OH)₂ -D levels than those without. After 32.3 ± 5.4 months, patients with high LFI-1 scores, but not LFI-2, had a significantly higher mortality than those with lower scores. GFI and EFS scores were also independently associated with LFI-1, while CHS scores exhibited borderline association only.

CONCLUSION

Among a group of predominantly older ESRD patients, LFI differentiates patients with good and poor outcomes, supporting its applicability in these patients.

Risk Factors for Poor Functional Recovery, Mortality, Recurrent Fractures, and Falls Among Patients Participating in a Fracture Liaison Service Program

OBJECTIVE

A fracture liaison service (FLS) for patients with fractures is a promising approach for improving outcomes, but barriers to the successful implementation of an FLS remain. The factors influencing the outcomes of patients already receiving FLS care are unclear.

DESIGN

A prospective multicenter cohort study.

SETTINGS AND PARTICIPANTS

Patients with incident hip and clinical vertebral fractures treated at 2 institutions between January 2014 and June 2016 were prospectively enrolled. Demographic profiles, comorbidities, prior fracture experiences, T scores, Fracture Risk Assessment Tool (FRAX) scores, and serum markers were examined.

MEASURES

Self-reported functional status (at the 4th month), mortality, recurrent fractures, and falls (at the 2-year follow-up).

RESULTS

Of 712 patients screened for eligibility, 600 (84%) participants (age 78 ± 10 years) were enrolled in the FLS program. At 4 months, 58%, 53%, and 60% of the participants reported improved mobility, self-care, and daily activities after FLS care, respectively. After 2 years, 85 (14%) died, 36 (6%) developed recurrent fractures, and 199 (33%) had 1 or more fall episodes. Multivariate logistic regression showed that neurologic disorders, heart disease, and diabetes were associated with a decreased probability of functional recovery. Cox regression showed that older age and chronic kidney disease (CKD) were predictive of increased mortality, whereas heart disease was correlated with an increased refracture risk. Older age and cancer or osteoarthritis were associated with a higher risk of falls. Importantly, a higher body mass index predicted a lower risk of mortality and a higher probability of improved self-care but a higher risk of fall at follow-up.

CONCLUSIONS/IMPLICATIONS

We discovered that comorbidities including CKD, heart disease, cancer, and osteoarthritis could influence short-term functional changes, survival, and the risk of refractures or falls among patients participating in FLSs. These factors are expected to aid in prognosis estimation and management planning for those with fractures.

N-Terminal Pro-Brain Natriuretic Peptide Predicts Long-Term Technique Failure in Patients Undergoing Peritoneal Dialysis

It is unclear whether N-terminal pro-brain type natriuretic peptide (NT-proBNP) level can be a biomarker for technique failure among long-term peritoneal dialysis (PD) patients. We prospectively included end-stage renal disease patients undergoing PD from a single center between December 2011 and December 2017. We divided the cohort into high or low NT-proBNP groups and analyzed the risk factors associated with the incidence of technique failure using Cox proportional hazard regression analysis. A total of 258 chronic PD patients (serum NT-proBNP, 582 ± 1216 ng/mL) were included. After a mean follow-up of 3.6 years, 49.6% of PD patients developed technique failure and switched to hemodialysis, while 15.5% died. Cox proportional hazard regression analyses accounting for age, gender, diabetes, renal clearance, C-reactive protein, and hydration status, showed that higher natural log transformed NT-proBNP levels (hazard ratio [HR] 1.13, p < 0.01) were predictive of an increased risk of technique failure, and were also predictive of an increased risk of mortality (HR 1.56, p < 0.01). Consequently, NT-proBNP might be an under-recognized biomarker for estimating the risk of technique failure, and regular monitoring NT-proBNP levels among PD patients may assist in their care.

10-Year Renal Function Trajectories in Community-Dwelling Older Adults: Exploring the Risk Factors for Different Patterns

Longitudinal changes of renal function help inform patients’ clinical courses and improve risk stratification. Rare studies address risk factors predicting changes in estimated glomerular filtration rate (eGFR) over time in older adults, particularly of Chinese ethnicity. We identified prospectively enrolled community-dwelling older adults (≥65 years) receiving annual health examinations between 2005 and 2015 with serum creatinine available continuously in a single institute, and used linear regression to derive individual’s annual eGFR changes, followed by multivariate logistic regression analyses to identify features associated with different eGFR change patterns. Among 500 elderly (71.3 ± 4.2 years), their mean annual eGFR changes were 0.84 ± 1.67 mL/min/1.73 m²/year, with 136 (27.2%) and 238 (47.6%) classified as having downward (annual eGFR change <0 mL/min/1.73 m²/year) and upward eGFR (≥1 mL/min/1.73 m²/year) trajectories, respectively. Multivariate logistic regression showed that higher age (odds ratio (OR) 1.08), worse renal function (OR 13.2), and more severe proteinuria (OR 9.86) or hematuria (OR 3.39) were predictive of a declining eGFR while greater waist circumference (OR 1.06) and higher leukocyte counts (OR 1.21) were predictive of an uprising 10-year eGFR. These findings elucidate important features associated with geriatric renal function variations, which are expected to improve their renal care.