Physical performance assessments should be implemented in clinical practice to optimize risk stratification for older patients with type 2 diabetes (T2D), according to the authors of a study published in Frontiers in Endocrinology.

Prognostic risk stratification plays a significant role in advance care planning for older adults with T2D, wrote Alberto Montesanto, PhD, and colleagues. Several clinical parameters are implicated in risk stratification for this patient population, including the following:

❯ Older patients are at high risk for adverse drug reactions due to kidney and liver function disorders.

❯ Impaired adrenergic alert symptoms increase the incidence of asymptomatic hypoglycemia more frequently in older patients.

❯ Older patients tend to have lower medication adherence rates compared with younger patients. “For these reasons, the promotion of healthy aging in patients with T2D requires a comprehensive age-related healthcare approach, as advocated by the latest ADA standard of care recommendations for this age group,” Dr. Montesanto and colleagues wrote. “The ADA recommendations are difficult to implement because modern T2D care systems require integrated care between general practitioners, diabetologists, geriatricians, and other members of the healthcare team. Often, older patients are excluded from the personalized treatment targets.”

To address this unmet need, the researchers conducted a retrospective, longitudinal study of real-world patients, examining correlations between risk factors, geriatric parameters, and mortality.

Clinical Assessments

The study included 977 patients with T2D who received outpatient care at the IRCCS INRCA Hospital of Ancona between January 2014 and October 2015.

The researchers gathered a wealth of baseline data, including patient demographics, medical history, anthropometric data, and laboratory parameters. The researchers also noted diabetes features such as duration of disease, complications, and medications.

In addition, the investigators gathered data on nutrition, QOL, mental status, and activities of daily living.

Of note, the researchers accounted for Short Physical Performance Battery (SPPB) scores (Table). The SPPB is a standardized, validated measure of global physical function, including a standing balance test, a walking speed test, and a strength test. The SPPB is scored from 0 to 12, with lower scores indicating worse physical dysfunction.

The cohort’s average age was 76.5 (SD, 4.5) years, and 46.5% were men. Patients had an average diabetes duration of 16.4 (SD, 11.1) years and an average A1C of 7.4% (SD, 1.2).

The mean follow-up was 53.3 (SD, 15.8) months. By the end of follow-up, 209 (20.9%) patients died, 778 (77.7%) were alive, and 14 (1.4%) had unknown vital status.

Frailty’s Impact

The researchers used a machine learning tool to conduct a multivariate data analysis. Out of 19 variables, the model identified 8 as the minimal set of predictors needed to accurately estimate mortality risk.

SPPB was the most significant predictor of mortality. Using a penalized Cox regression model, the researchers found that patients with an SPPB score lower than 5 had a 3.35-fold higher risk for death per unit of time compared with patients whose score was higher than 8 ( P<0.001). Similarly, intermediate SPPB scores were associated with a 2.39 higher risk (P<0.001).

“Patients in the lowest SPPB score group had more limitations in instrumental activities of daily living, higher prevalence of cognitive im – pairment and depression symptoms, and worse nutritional status and self-reported QOL,” the study authors added.

The next most important predictor of mortality was sex, followed by age, chronic kidney disease, neuropathy, peripheral artery disease, myocardial infarction, and myocardial ischemia.

The investigators noted that frailty is a known complication of diabetes, but outpatient clinics do not always perform frailty assessments due to practical issues such as limited time and staffing. The investigators wrote that physical performance assessments “need to be implemented in clinical practice.”

“Stratification is an important tool to optimize effectiveness and efficiency in T2D management in older patients. Targeting interventions to patients with the highest mortality risk may allow resources to be better used and reduce costs,” Dr. Montesanto and colleagues concluded.