Frailty has become a highly relevant geriatric syndrome in older people with diabetes since it constitutes a variable that defines treatment goals and can influence adherence to diabetes management and their quality of life [5,6,7, 31]. Literature have described that the coexistence of diabetes and frailty increases the risk of cardiovascular complications, hypoglycemia, deterioration in the quality of life, functional disability, increased risk of falls and fractures, and cognitive deterioration [20], in addition to being associated with greater use of the health system, risk of hospitalization for all causes and mortality [21, 22]. Few studies evaluated the prevalence of frailty in older people with diabetes, finding in the present study a prevalence of 22.4%, considered within data reported in other studies (20 and 30%) [32, 33].
In this study, we didn’t find a significant association in older people that had diabetes and frailty with dependent variables, but still there was a significant association in people with diabetes without concurrent frailty with poorer self-rated health and fear of falling. Similarly, frail elderly without diabetes, was consistently associated with poorer self-rated health, recurrent falls, and fear of falling. This unexpected finding may suggest potential measurement bias, or a limited sample size within this subgroup (people with diabetes and frailty) limiting the statistical power to detect associations and demanding further investigation and longitudinal studies. Additionally, our findings highlight the association of frailty and adverse health outcomes, independently of chronic diseases such as diabetes [24, 34].
Older people with diabetes in the present study were predominantly women, between 60 and 69 years old, which is striking in addition to the fact that there was a greater chance of having some geriatric syndrome. Within geriatric syndromes, fear of falling and recurrent falls had been highly associated to older people with diabetes, possibly related to the micro and macrovascular complications of diabetes, such as peripheral neuropathy that is poorly screened in the diabetic population, in addition to visual impairment due to refractive problems or retinopathy. Additionally, fear of falling has recently been described as a manifestation of anxiety disorder [35, 36], which can even occur in people who have not previously had falls, and had been related to the life-space limitation, promoting a sedentary lifestyle, greater chronic non-communicable diseases, and poor adherence to their management, also, feeling of loneliness and deterioration in the quality of life. Additionally, the fear of falling has been linked lately as one of the possible predictors of cognitive deterioration [37, 38], which in the context of older people with diabetes, could be one of the early markers for their referral to geriatrics and for adjustments in diabetes management, being more flexible with the goals and to simplify treatment scheme, to have a cognitive and affective evaluation and supporting older people in multidimensional management.
A poor perception of oral health in older people with diabetes was obtained using the GOHAI scale. It is noticeable that those with diabetes did not show a significant association with malnutrition, and this may suggest that the score of poor self-rated of oral health could be related to a greater extent with the swallowing capacity, perception of teeth and social behavior, considering that the mininutritional assessment has limitations to evaluate people with overweight and obesity. Polypharmacy continues to be present in older people with diabetes, a geriatric syndrome that may be necessary to achieve metabolic control and the rest of comorbidities, always individualizing management and avoiding inappropriate prescription of them.
Additionally, results from this study related to social domain, describe that people with diabetes had a greater association with having low personal income, which could increase the incidence of multimorbidity, geriatric syndromes, unhealthy diets, low protein consumption promoting incidence of diabetes and influencing diabetes’ control and development of sarcopenia and frailty. This allows for future research ideas and the creation of public health policies in this vulnerable population.
This work highlights the creation of a modified version of the Frailty Phenotype proposed by Fried and colleagues for cross-sectional studies, using questions from the SABE Colombia Study. Moreover, included the assessment of diabetes and frailty status, allowing to explore their independent and combined effects. Early identification and intervention of frailty may reduce the risk of adverse outcomes regardless of diabetes status. There is important to promote worldwide a comprehensive and individualized management of the older people with diabetes and the screening, diagnosis, and early management of frailty in this population, as well as proper and timely referral for a geriatric assessment.
Likewise, this study has some limitations, data were obtained and analyzed from a cross-sectional study, therefore, causality cannot be established. Also, the prevalence of diabetes and comorbidities were obtained by self-report, therefore, could exist memory bias related to study design, we couldn’t know about diabetes severity and specified pharmacological treatment and potential residual confounding couldn’t be ruled out despite adjustments. Additionally, anthropometric measurements and information to assess sarcopenia and frailty were obtained from a subsample of the surveyed population. Even so, statistically significant associations were obtained between the variables evaluated.
Finally, we consider it is relevant to promote the development of longitudinal observational studies to explore causal pathways, verify the associations found and based on the results obtained, there is a necessity to improve education in the identification and early intervention of frailty in older people with diabetes and others chronical conditions at different levels of care in health, to make a timely referral to geriatricians, promoting an individualized and comprehensive assessment, determine real metabolic goals, adjust diabetes management, reduce adverse outcomes, and promote quality of life.
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