A framework for modern-day management and assessment of frailty

Strain WD, Hope SV, Green A, Kar P, Valabhji J, Sinclair AJ (2018) Type 2 diabetes mellitus in older people: a brief statement of key principles of modern day management including the assessment of frailty. A national collaborative stakeholder initiative. Diabet Med 35: 838–45

• This collaborative stakeholder initiative from the UK presents a framework for assessing frailty status in older people and guidelines for the management of diabetes according to frailty status.
• The frailty assessment pathway begins with clinical review and a validated frailty assessment tool in primary care, with opportunity for referral if required. An initial management plan can then be agreed with the patient with input from diabetes specialists and geriatricians.
• The features of a modern-day diabetes service for older people are then outlined, including inter-professional working, a strategy to minimise medication risk, an active deprescribing policy, review of diabetes and frailty status at the time of care home residency, an easy-access end-of-life care pathway and use of additional clinical outcomes in audit.
• The proposed treatment guidelines suggest targets of 58, 64 and 70 mmol/mol (7.5%, 8.0% and 8.5%) in fit older adults, moderate frailty and severe frailty, respectively, while the thresholds for deprescribing are 53, 58 and 64 mmol/mol (7.0%, 7.5% and 8.0%).
• In general, with increasing frailty, deprescribing should involve stopping sulfonylureas and short-acting insulins. Pioglitazone should be avoided because of heart failure risk. Metformin use should take renal function into account.
• In people with severe frailty, therapies that promote weight loss should be avoided as they may exacerbate sarcopenia.

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