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Type 2 Diabetes in the Older Adult: The Need for Assessment of Frailty

Coke, Lola A. PhD, RN, ACNS-BC, FAHA, FPCNA; Dennison Himmelfarb, Cheryl R. PhD, RN, ANP, FAHA, FPCNA, FAAN

The Journal of Cardiovascular Nursing: November/December 2017 - Volume 32 - Issue 6 - p 511–513
doi: 10.1097/JCN.0000000000000439
DEPARTMENTS: Progress in Prevention

Lola A. Coke, PhD, RN, ACNS-BC, FAHA, FPCNA Associate Professor, Adult Health and Gerontological Nursing, College of Nursing, Rush University, Chicago, Illinois.

Cheryl R. Dennison Himmelfarb, PhD, RN, ANP, FAHA, FPCNA, FAAN Professor, Department of Acute and Chronic Care, School of Nursing, Johns Hopkins University, and Division of Health Sciences Informatics, School ofMedicine, Johns Hopkins University, Baltimore, Maryland.

The authors have no funding or conflicts of interest to disclose.

Correspondence Lola A. Coke, PhD, RN, ACNS-BC, FAHA, FPCNA, Rush University Medical Center, Armour Academic Center, 600 S. Paulina St, Office 1056B, Chicago, IL 60612 (

In the United States, increased life expectancy means that people are living longer. The percentage of Americans aged 65 and older with diabetes is 26%, or 11.2 million seniors (diagnosed and undiagnosed).1 Among these adults, the prevalence of diabetes is estimated to be 14% of the population, and it is estimated that, by 2050, diabetes prevalence could be as high as 33% of the whole population in the United States.2

Older adults with diabetes have higher rates of premature death, functional disability, and comorbidities such as hypertension, coronary heart disease, and stroke than nondiabetic older adults. Diabetes is a disease associated with high levels of disability in older adults especially as geriatric syndromes, including polypharmacy, cognitive impairment, urinary incontinence, falls, neuropathic pain, and frailty, overlay the disease process of diabetes. Typically at the onset of diabetes diagnosis, many adults are overweight or obese.2 Assessments of medical, functional, mental, and social status are all important. The management plan includes lifestyle behavior changes to lose weight and increase physical activity, as well as medication management. However, as individuals age, especially after the age of 65 years, they experience a reduced appetite and decreased caloric need as energy consumption becomes less. The older adult begins to lose weight and becomes less active, and the potential for frailty occurs.

Frailty is regarded as a wasting disease in older adults caused by malnutrition, declining physical functioning, and sarcopenia or muscle wasting.3 It is characterized based on the presence of established phenotypes (weight loss, weakness, decreased physical activity, exhaustion, and slow gait speed). The presence of 0 to 1 phenotype is considered not frail, the presence of 2 phenotypes is considered prefrail, and the presence of 3 or more phenotypes is considered frail.4

In frail older adults (≥65 years old) with diabetes, sarcopenia, or the decline of skeletal muscle mass, is accelerated 2-fold because of an increase in catabolic state induced by insufficient amounts of insulin. In addition, poor dentition, dry mouth, reduced taste sensation, and decreased appetite, all normal changes of aging, contribute to declining nutritional state and potential malnutrition of frailty. As older adults lose weight and frailty develops, there is an increase in insulin sensitivity, and glucose tolerance once again improves as visceral fat is lost. The older adult with diabetes moves from a hyperglycemic state to a normoglycemic state. Finally, frailty is associated with all stages of chronic kidney disease (CKD), commonly associated with diabetes. Frailty occurs in 21% of older adults with a glomerular filtration rate (GFR) of less than 45 mL/min, with an approximately 2-fold increased risk of frailty in mild CKD (GFR, 60–89 mL/min) and 6-fold in persons with moderate to severe CKD (GFR, 15–29 mL/min) compared with those with normal kidney function.

Frailty is associated with weight loss and malnutrition in older age, which, among those with diabetes, may actually lead to normoglycemia, increased risk of hypoglycemia, and reduced needs for hypoglycemic medications. These physiological mechanisms suggest that healthcare providers need to consider frailty in their management plan as patients with type 2 diabetes advance in age.3 Other geriatric syndromes such as physical dysfunction and cognitive changes are also important to consider in older adults with diabetes because they impact medication adherence and lifestyle changes, which are important parts of the treatment plan.

So, why is assessment for frailty so important in the diabetic older adult? First, with physiologic changes in the glycemic state, monitoring of fasting blood glucose and HbA1c and management of hypoglycemic medications become extremely important to prevent hypoglycemic episodes. Second, recurrent hospital admissions in older adults as a result of hypoglycemic episodes have been shown to cause further declines in cognition and physical function. Third, as malnutrition and sarcopenia progress and normoglycemic states occur, patients who continue to take their antidiabetes medications may experience hypoglycemic episodes resulting in occurrence of preventable falls. Finally, diabetes increases the rate of muscle mass loss and reduces muscle strength leading to a reduction in muscle function that impacts the older adult's ability to complete both basic (ie, bathing, dressing, getting up from a chair) and instrumental (ie, cooking, buying groceries, taking medications, housework) activities of daily living.5

All healthcare providers should complete a comprehensive geriatric assessment (CGA) on their older adult patients, especially the patients with diabetes. The definition of a CGA is a multidisciplinary diagnostic and treatment process that identifies medical, psychosocial, and functional limitations of a frail older adult to develop a coordinated plan to maximize overall health with aging.6 The CGA is typically performed by a team including the provider, social worker, pharmacist, physical and/or occupational therapist, and others as indicated based on the clinical picture of the patient. Assessment instruments are used to measure physical changes such as weight loss, dentition, ability to perform functional tasks and need for assistance, safe home environment to prevent falls, vision or hearing loss, and pain symptoms. In addition, balance and flexibility testing, handgrip strength, and gait speed are tested. Finally, cognition and mood disorders are tested, and medications are reviewed to determine whether polypharmacy is present. The CGA is obtained to determine patient baseline and is used then to measure decline and the development of frailty over time. Reimbursement of a GCA is possible if there is an underlying diagnosis such as cognitive decline or elder failure to thrive, and a good beginning point is a referral to a geriatrician. Medicare typically covers physical therapy, occupational therapy, and nutritional consults. Certainly, reimbursement is always a potential barrier and needs to be considered in the patient’s treatment plan.

What are the evidence-based strategies for caring for older adult patients with diabetes to reduce frailty and the complications of diabetes? Certainly, a key message is individualized assessment and management plans for each patient based on their mental, physical, social, and economic circumstances. Diabetes care for this population should include patient-centered care focused on minimizing cardiovascular risk and complications, managing CKD, and optimizing lifestyle behavior changes to decrease frailty and promote quality of life. An important evidence-based resource is the National Diabetes Education Program.7 This evidence-based program for healthcare professionals helps providers and teams to design and implement a management plan for the diabetic older adult. Specific objectives include the following:

  1. Optimization of provider and team behavior to manage pharmacological and/or lifestyle therapy
  2. Active support for patient behavior change including:
    • healthy lifestyle choices (physical activity, healthy eating, tobacco cessation, weight management, and effective coping);
    • disease self-management (taking and managing medication and self-monitoring of glucose and blood pressure); and
    • prevention of diabetes complications (self-monitoring of foot health, screening for eye, foot, and renal complications and immunizations).

The American Diabetes Association provides Standards of Medical Care in Diabetes.8 Glycemic targets should be individualized taking into consideration the individual’s overall health, presence of frailty, and expected life span. Current guidelines suggest relaxed glycemic control in frail older adults with diabetes as follows: (1) for healthy older adults with intact cognitive and functional status, a reasonable HbA1c is less than 7.5% with blood pressure control at less than 140/90 mm Hg. (2) For complex/intermediate older adults with coexisting chronic illnesses, instrumental activity of daily living impairments, and mild-to-moderate cognitive impairment, a reasonable HbA1c is less than 8.0% with blood pressure control at less than 140/90 mm Hg. (3) For very complex or older adults in poor health with end-stage chronic illnesses, the reasonable HbA1c is less than 8.5% with blood pressure control at less than 150/90 mm Hg. Regular medication review should be undertaken as patients get older with consideration of gradual reduction or even complete withdrawal when frailty and significant weight loss emerge.

Finally, patient-centered care of frail older adults with diabetes requires tailoring based on health disparities; ethnic, cultural, and sex differences; socioeconomic differences; and ability to access healthcare. Assessing each patient for their ability to pay for care and whether they have insurance coverage, presence of food insecurity, living conditions, and health literacy level is part of a comprehensive treatment plan. All providers should treat our frail older adults with kid glove care using the latest evidence-based guidelines.

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