Diabetes mellitus is the most common metabolic disorder in Western society and in older people can manifest as a severe disabling disorder (Sinclair et al, 2008); however, traditional macrovascular and microvascular complications of diabetes appear to account for less than half of the diabetes-related disability observed in older people (Maggi et al, 2004). In the last decade it has been recognised that frailty and sarcopenia (age-related loss of muscle and power) have emerged as new complications of diabetes, both of which are major risk factors for disability and share similar aetiology (Sinclair et al, 2017).
A focus on frailty
Frailty is not a new concept in diabetes. More than 15 years ago, diabetes was described as a “model of frailty” (Sinclair, 2000) but as the syndrome is now more widely described in older people in general (Clegg et al, 2013), health professionals engaged in the care of people with both frailty and diabetes are requesting guidance on management.
There are various international guidelines that have been published in the last decade that provide practical guidance on enhancing diabetes care for older people, including recommendations on sensible glucose targets, and how these should be matched to functional status and end-of-life care (Kirkman et al, 2012; Sinclair et al, 2012; Dunning et al, 2014). Detailed discussion of managing frailty in the context of diabetes care has been lacking, however. Furthermore, it was suggested that there was a need for a uniform approach to identifying and treating those with both frailty and diabetes, and details of the outcome measures that best serve the clinician in providing optimal overall care. These gaps in knowledge and understanding led to the development of the position statement “International Position Statement on the Management of Frailty in Diabetes Mellitus“ (Sinclair et al, 2017). In addition, the position statement firmly identified frailty as a pre-disability condition that creates opportunity for intervention to enhance functional performance.
The position statement had several important objectives:
- Derive a consensus approach on managing frailty in older people with diabetes.
- Develop recommendations in key areas that will support clinicians in everyday clinical practice.
- Provide a platform for commissioners of healthcare and policy makers to plan and coordinate care pathways in their local areas.
Development of the position statement
An international body of experts supported by the European Diabetes Working Party for Older People and the Hong Kong Geriatrics Society developed the recommendations over a period of 12 months using an evidence-based methodology. They produced guidance in nine separate areas including assessment, glucose regulation, treatments, hypoglycaemia, education, primary and community care, and exercise interventions.
Defining frailty
The definition of frailty was based on a summary concept of: a vulnerability state leading to adverse outcomes (e.g. falls, decline in physical performance), a decline in physiological reserve, and its pre-disability state. Several measures are available to screen for frailty and can easily be implemented by healthcare professionals (Sinclair et al, 2017). A key point to make is that the workforce should also screen for co-existing geriatric syndromes using a comprehensive geriatric evaluation system and to personalise diabetes management strategies. This approach has been shown to result in better functional outcomes, as well as reducing the need for healthcare and mortality (Rubenstein et al, 1984; Stuck et al, 1993; Van Craen et al, 2010).
Lowering glucose safely
The position statement advocates that glucose regulation should involve using glucose-lowering medications that have a low risk of hypoglycaemia, minor side effects profile and be cost-effective . The glycaemic goal should be personalised based on several factors, such as comorbid medical profile, as well as cognitive and functional status. In mild to moderate frail older adults, an HbA1c target range of 53–64 mmol/mol (7–8.0%) is appropriate depending on self-care management abilities and presence of additional risk factors for hypoglycaemia. In severe frailty, a HbA1c range of 59–69 mmol/mol (7.5–8.5%) is more protective.
Physical performance
As resistance training has been shown to have a positive influence on improving physical performance in frailty (Lopez et al, 2017), and the position statement clearly states that along with pharmacological and dietary interventions, physical training, including resistance and endurance training, is required for effective benefits to be realized. The NHS in the UK must now seriously consider how such programmes of exercise intervention can be implemented in a cost-effective feasible way.
Conclusion
The development of frailty in an older person with diabetes should be regarded as a part-failure of preventative care and a part-failure to recognise the clinical and social impact of frailty – this new International guidance provides a framework for change.
The International Position Statement on the Management of Frailty in Diabetes Mellitus is available to download as a pdf at: http://edwpop.org/resources
References
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Sinclair AJ, Abdelhafiz AH, Dunning T et al (2017) An International Position Statement on the Management of Frailty in Diabetes Mellitus: Summary of Recommendations 2017. J Frailty Aging, http://dx.doi.org/10.14283/jfa.2017.39
Sinclair AJ, Abdelhafiz AH, Rodríguez-Mañas L (2017) Frailty and sarcopenia – newly emerging and high impact complications of diabetes. J Diabetes Complications 31: 1465–73
Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ (1993) Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet 342: 1032–6
Van Craen K, Braes T, Wellens N et al (2010) The effectiveness of inpatient geriatric evaluation and management units: a systematic review and meta-analysis. J Am Geriatr Soc 58: 83–92
