Skip to main content
SpringerLink
Log in

The Association of Frailty with Hospitalizations and Mortality Among Community Dwelling Older Adults with Diabetes

  • Original Research
  • Published:
The Journal of Frailty & Aging Aims and scope Submit manuscript

Abstract

Background

Diabetes (DM) is associated with an accelerated aging that promotes frailty, a state of vulnerability to stressors, characterized by multisystem decline that results in diminished intrinsic reserve and is associated with morbidity, mortality and utilization. Research suggests a bidirectional relationship between frailty and diabetes. Frailty is associated with mortality in patients with diabetes, but its prevalence and impact on hospitalizations are not well known.

Objectives

Determine the association of frailty with allcause hospitalizations and mortality in older Veterans with diabetes. Design: Retrospective cohort.

Setting

Outpatient.

Participants

Veterans 65 years and older with diabetes who were identified as frail through calculation of a 44-item frailty index.

Measurements

The FI was constructed as a proportion of healthcare variables (demographics, comorbidities, medications, laboratory tests, and ADLs) at the time of the screening. At the end of follow up, data was aggregated on all-cause hospitalizations and mortality and compared non-frail (robust, FI≤.10 and prefrail FI=>.10, <.21) and frail (FI≥.21) patients. After adjusting for age, race, ethnicity, median income, history of hospitalizations, comorbidities, duration of DM and glycemic control, the association of frailty with all-cause hospitalizations was carried out according to the Andersen-Gill model, accounting for repeated hospitalizations and the association with all-cause mortality using a multivariate Cox proportional hazards regression model.

Results

We identified 763 patients with diabetes, mean age 72.9 (SD=6.8) years, 50.5% were frail. After a median follow-up of 561 days (IQR=172), 37.0% they had 673 hospitalizations. After adjustment for covariates, frailty was associated with higher all-cause hospitalizations, hazard ratio (HR)=1.71 (95%CI:1.31–2.24), p<.0001, and greater mortality, HR=2.05 (95%CI:1.16–3.64), p=.014.

Conclusions

Frailty was independently associated with all-cause hospitalizations and mortality in older Veterans with diabetes. Interventions to reduce the burden of frailty may be helpful to improve outcomes in older patients with diabetes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146–56.

    Article  CAS  Google Scholar 

  2. Sinclair AJ, Abdelhafiz A, Dunning T, Izquierdo M, Rodriguez Manas L, Bourdel-Marchasson I, et al. An International Position Statement on the Management of Frailty in Diabetes Mellitus: Summary of Recommendations 2017. J Frailty Aging. 2018;7(1):10–20.

    CAS  PubMed  Google Scholar 

  3. Hubbard RE, Lang IA, Llewellyn DJ, Rockwood K. Frailty, body mass index, and abdominal obesity in older people. J Gerontol A Biol Sci Med Sci. 2010;65(4):377–81.

    Article  Google Scholar 

  4. Veronese N, Stubbs B, Fontana L, Trevisan C, Bolzetta F, De Rui M, et al. Frailty Is Associated with an Increased Risk of Incident Type 2 Diabetes in the Elderly. J Am Med Dir Assoc. 2016;17(10):902–7.

    Article  Google Scholar 

  5. Bouillon K, Kivimaki M, Hamer M, Shipley MJ, Akbaraly TN, Tabak A, et al. Diabetes risk factors, diabetes risk algorithms, and the prediction of future frailty: the Whitehall II prospective cohort study. J Am Med Dir Assoc. 2013;14(11):851 e1-6.

    Article  Google Scholar 

  6. Morley JE, Malmstrom TK, Rodriguez-Manas L, Sinclair AJ. Frailty, sarcopenia and diabetes. J Am Med Dir Assoc. 2014;15(12):853–9.

    Article  Google Scholar 

  7. Garcia-Esquinas E, Graciani A, Guallar-Castillon P, Lopez-Garcia E, Rodriguez-Manas L, Rodriguez-Artalejo F. Diabetes and risk of frailty and its potential mechanisms: a prospective cohort study of older adults. J Am Med Dir Assoc. 2015;16(9):748–54.

    Article  Google Scholar 

  8. Abdelhafiz AH, Koay L, Sinclair AJ. The effect of frailty should be considered in the management plan of older people with Type 2 diabetes. Future Sci OA. 2016;2(1):FSO102.

    Article  Google Scholar 

  9. Garcia-Esquinas E, Jose Garcia-Garcia F, Leon-Munoz LM, Carnicero JA, Guallar-Castillon P, Gonzalez-Colaco Harmand M, et al. Obesity, fat distribution, and risk of frailty in two population-based cohorts of older adults in Spain. Obesity (Silver Spring). 2015;23(4):847–55.

    Article  Google Scholar 

  10. Adame Perez SI, Senior PA, Field CJ, Jindal K, Mager DR. Frailty, Health-Related Quality of Life, Cognition, Depression, Vitamin D and Health-Care Utilization in an Ambulatory Adult Population With Type 1 or Type 2 Diabetes Mellitus and Chronic Kidney Disease: A Cross-Sectional Analysis. Can J Diabetes. 2019;43(2):90–7.

    Article  Google Scholar 

  11. Orkaby AR, Nussbaum L, Ho YL, Gagnon D, Quach L, Ward R, et al. The Burden of Frailty Among U.S. Veterans and Its Association With Mortality, 2002–2012. J Gerontol A Biol Sci Med Sci. 2018.

    Google Scholar 

  12. Liu Y, Sayam S, Shao X, Wang K, Zheng S, Li Y, et al. Prevalence of and Trends in Diabetes Among Veterans, United States, 2005–2014. Prev Chronic Dis. 2017; 14:170230.

    Article  Google Scholar 

  13. Benjamin SM, Wang J, Geiss LS, Thompson TJ, Gregg EW. The Impact of Repeat Hospitalizations on Hospitalization Rates for Selected Conditions Among Adults With and Without Diabetes, 12 US States, 2011. Prev Chronic Dis. 2015; 12:150274.

    Article  Google Scholar 

  14. Chang SF, Lin HC, Cheng CL. The Relationship of Frailty and Hospitalization Among Older People: Evidence From a Meta-Analysis. J Nurs Scholarsh. 2018;50(4):383–91.

    Article  Google Scholar 

  15. De Berardis G, D’Ettorre A, Graziano G, Lucisano G, Pellegrini F, Cammarota S, et al. The burden of hospitalization related to diabetes mellitus: a population-based study. Nutr Metab Cardiovasc Dis. 2012;22(7):605–12.

    Article  CAS  Google Scholar 

  16. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5):373–83.

    Article  CAS  Google Scholar 

  17. Rockwood K, Song X, MacKnight C, Bergman H, Hogan DB, McDowell I, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ. 2005;173(5):489–95.

    Article  Google Scholar 

  18. Cesari M, Gambassi G, van Kan GA, Vellas B. The frailty phenotype and the frailty index: different instruments for different purposes. Age Ageing. 2014;43(1):10–2.

    Article  Google Scholar 

  19. Searle SD, Mitnitski A, Gahbauer EA, Gill TM, Rockwood K. A standard procedure for creating a frailty index. BMC Geriatr. 2008;8:24.

    Article  Google Scholar 

  20. Maynard C. Ascertaining Veterans’ Vital Status: VA Data Sources for Mortality Ascertainment and Cause of Death. [Internet]. Washington, DC: VA Health Services Research & Development (HSRD); 2017 [updated March 6, 2017; cited 2019. Available from: https://www.hsrd.research.va.gov/for_researchers/cyber_seminars/archives/video_archive.cfm?SessionID=1242.

    Google Scholar 

  21. American Diabetes Association. 11. Older Adults: Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41(Suppl 1):S119–S125.

    Article  Google Scholar 

  22. Walston J, McBurnie MA, Newman A, Tracy RP, Kop WJ, Hirsch CH, et al. Frailty and activation of the inflammation and coagulation systems with and without clinical comorbidities: results from the Cardiovascular Health Study. Arch Intern Med. 2002;162(20):2333–41.

    Article  Google Scholar 

  23. Miller EA, Weissert WG. Predicting elderly people’s risk for nursing home placement, hospitalization, functional impairment, and mortality: a synthesis. Med Care Res Rev. 2000;57(3):259–97.

    Article  CAS  Google Scholar 

  24. Torisson G, Stavenow L, Minthon L, Londos E. Importance and added value of functional impairment to predict mortality: a cohort study in Swedish medical inpatients. BMJ Open. 2017;7(5):e014464.

    Article  Google Scholar 

  25. Romero-Ortuno R, Forsyth DR, Wilson KJ, Cameron E, Wallis S, Biram R, et al. The Association of Geriatric Syndromes with Hospital Outcomes. J Hosp Med. 2017;12(2):83–9.

    Article  Google Scholar 

  26. Callahan KE, Lovato JF, Miller ME, Easterling D, Snitz B, Williamson JD. Associations Between Mild Cognitive Impairment and Hospitalization and Readmission. J Am Geriatr Soc. 2015;63(9):1880–5.

    Article  Google Scholar 

  27. McGuire LC, Ford ES, Ajani UA. The impact of cognitive functioning on mortality and the development of functional disability in older adults with diabetes: the second longitudinal study on aging. BMC Geriatr. 2006;6:8.

    Article  Google Scholar 

  28. Hirsch C, Anderson ML, Newman A, Kop W, Jackson S, Gottdiener J, et al. The association of race with frailty: the cardiovascular health study. Ann Epidemiol. 2006;16(7):545–53.

    Article  Google Scholar 

  29. Rubin DJ. Hospital readmission of patients with diabetes. Curr Diab Rep. 2015;15(4):17.

    Article  Google Scholar 

  30. Evans SJ, Sayers M, Mitnitski A, Rockwood K. The risk of adverse outcomes in hospitalized older patients in relation to a frailty index based on a comprehensive.

  31. Conway BN, May ME, Blot WJ. Mortality among low-income African Americans and whites with diabetes. Diabetes care. 2012;35(11):2293–9.

    Article  Google Scholar 

  32. Conway BN, May ME, Fischl A, Frisbee J, Han X, Blot WJ. Cause-specific mortality by race in low-income Black and White people with Type 2 diabetes. Diabet Med. 2015;32(1):33–41.

    Article  CAS  Google Scholar 

  33. Lynch CP, Gebregziabher M, Echols C, Gilbert GE, Zhao Y, Egede LE. Racial disparities in all-cause mortality among veterans with type 2 diabetes. J Gen Intern Med. 2010;25(10):1051–6.

    Article  Google Scholar 

  34. DeStefano F, Newman J. Comparison of coronary heart disease mortality risk between black and white people with diabetes. Ethn Dis. 1993;3(2):145–51.

    CAS  PubMed  Google Scholar 

Download references

Funding

Funding: This material is the result of work supported with resources and the use of facilities at the Miami VA Healthcare System GRECC.

Author information

Authors and Affiliations

  1. Miami VA Healthcare System Geriatric Research, Education and Clinical Center (GRECC), Miami, USA

    J. Ferri-Guerra, R. Aparicio-Ugarriza, D. Salguero, D. Baskaran, Y. N. Mohammed, H. Florez & Jorge G. Ruiz

  2. University of Miami Miller School of Medicine, Miami, USA

    J. Ferri-Guerra, R. Aparicio-Ugarriza, D. Salguero, Y. N. Mohammed, H. Florez & Jorge G. Ruiz

  3. VA GRECC Associate Director for Clinical Affairs, Bruce W. Carter Miami VAMC, GRECC (11GRC), 1201 NW 16th Street, Miami, Florida, 33125, USA

    Jorge G. Ruiz

Authors
  1. J. Ferri-Guerra
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. R. Aparicio-Ugarriza
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Salguero
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. D. Baskaran
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Y. N. Mohammed
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. H. Florez
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jorge G. Ruiz
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jorge G. Ruiz.

Ethics declarations

Ethical standards: A protocol of this study was submitted to and approved by the Institutional Review Board as a VA quality improvement project.

Additional information

Conflict of interest: The authors declare none.

Electronic supplementary material

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ferri-Guerra, J., Aparicio-Ugarriza, R., Salguero, D. et al. The Association of Frailty with Hospitalizations and Mortality Among Community Dwelling Older Adults with Diabetes. J Frailty Aging 9, 94–100 (2020). https://doi.org/10.14283/jfa.2019.31

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.14283/jfa.2019.31

Key words

Search

Navigation