Management of Frailty 'Key to Diabetes Care in Older Adults'

Peter Russell

June 14, 2019

A position statement aimed at improving management of frail older people with diabetes has been released.

The authors acknowledged that frailty was emerging as a new complication of diabetes, contributing to poorer health and shorter lifespan.

They said that as there was little high quality research evidence to draw on, their guidance represented "best clinical practice viewpoints".

In planning the statement, the Association of British Clinical Diabetologists (ABCD) said research had suggested that frailty might be present in between 32% and 48% of adults aged 65 years and over who had diabetes.

It featured examples to help healthcare professionals detect and manage frailty in several key areas.

It dealt with:

  • The definitions and clinical importance of frailty

  • A summary of the key areas of management including glucose regulation, blood pressure management, lipid-lowering agents, chronic kidney disease, avoiding hypoglycaemia, and the role of exercise interventions

  • Clinical audit aspects of frailty management, and the development of a frailty care pathway in the NHS

Emphasis was placed on the importance of individualised frailty care becoming the norm and being part of routine diabetes management once patients reached the age of 70.

The position statement was written by Prof Alan Sinclair from the Foundation for Diabetes Research in Older People, a research arm of Diabetes Frail, and Dr Alison Gallagher of University Hospitals Leicester NHS Trust.

Prof Alan Sinclair

Prof Sinclair spoke to Medscape News UK about the recommendations, and the background to a new assessment of frailty and its association with diabetes in older adults.

Q&A

Prof Sinclair: Frailty, as a visual concept, has been around for a very long time. People used to make visual diagnoses that somebody, usually an older individual who was walking with the aid of a walking stick, stooped, obviously looking weak, and so on, was frail. But people would use the word interchangeably with other, perhaps, more negative descriptions.

It was only in about 2001 [things changed] when an American scientist called Linda Fried and her group looked at a group of older people in the Cardiovascular Health Study – a big prospective study in the United States.

She was able to demonstrate that five parameters of interest were very highly predictive of something happening to an individual at a year, or 2 years, or 3 years. In other words, they were able to demonstrate that these five domains fitted a picture of frailty, and that they were able to predict outcomes from this.

It was recognised by Dr Fried, from an objective point of view, that you actually can, in essence, diagnose frailty using phenotypic descriptors. These involved domains such as lost weight, weakness, low walk speed, low grip strength, and so on. And this, in a sense, started a bit of a revolution and resurgence of interest in the concept of frailty.

Why was that an important milestone for diabetes care?

Disability in diabetes is something that up to a relatively short period of time ago, people were not measuring properly, or had little interest in.

The interest seemed to be in eyes, kidneys, feet, and so on.

But it was recognised that, in fact, it was the disability that resulted from those complications that was causing most of the distress and the reduction in quality of life of many individuals with diabetes, particularly older people.

It was also disability that was causing the excess healthcare expenditure.

Frailty became very important because frailty being pre-disability means that frailty might be subject to reversibility.

Has that altered thinking about frailty and diabetes care?

Up until fairly recently we hadn't done any studies on how you manage people. Are there any interventions that make a difference for people with frailty, or pre-frailty?

Another step before frailty is the 'pre-frail' stage where on the scoring system, whichever you use, the scores are not so high, but they're highly suggestive that the individual will have a high risk of developing full-blown frailty.

About 5 years ago, working with a colleague from Madrid, we submitted an application to do a randomised controlled trial in older people with diabetes and frailty.

This was called the MID-Frail Study. That was a study of nearly a thousand subjects across Europe who were above the age of 70, had type 2 diabetes, and were either frail or pre-frail, according to Linda Fried's criteria.

We have demonstrated that one year after [an intervention of] resistance training twice a week [for 16 weeks], and nutritional education, compared with a group that just had usual primary care treatment, [they demonstrated] a significant increase in physical performance, and some reversibility of frailty.

We also showed a decrease in healthcare costs.

How do you see the future of care for diabetes and frailty?

What I think is very important is that people understand what frailty is.

People think that frailty is an end of the line, a pathway of deterioration, and that it's not reversible.

I think what we need to do is develop proper pathways.

We've developed a pathway for hospitals, and we've developed a pathway for the management of diabetes in a sense from an outpatient point of view through the ABCD. But I think there's a need to continue this to develop pathways in primary care so that GPs, nurses, and others involved are able to detect frailty easily.

There's two very important points.

Firstly, someone who is frail but not disabled should be given the opportunity to have that frailty reversed, or managed, so that they don't become disabled – because that's when quality of life will significantly fall, and healthcare costs will increase.

The second thing to recognise – and this is what most people don't know – is that apart from age and sex, when you're above 70 with diabetes, frailty is the most important determinant of your future[, more] than any of the other classic complications of diabetes.

Managing frailty and associated comorbidities in older adults with diabetes: Position

Statement on behalf of the Association of British Clinical Diabetologists (ABCD), Sinclair, Gallagher.

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