Frailty and glycaemia in older adults with type 1 diabetes
Research type
Research Study
Full title
A cohort study to investigate frailty and glycaemic control in older adults with type 1 diabetes mellitus
IRAS ID
325332
Contact name
Jonathan Golding
Contact email
Sponsor organisation
University Hospitals Sussex
Duration of Study in the UK
3 years, 6 months, 1 days
Research summary
Research Summary:
This study will look at people over the age of 65 with Type 1 diabetes (T1DM).
People with T1DM require insulin injections to keep blood glucose levels as close to normal as possible. High or low blood glucose levels can cause unpleasant symptoms and longer term health problems. As people get older, changes in weight, appetite, physical activity and memory can affect the amount of insulin someone needs and/or their ability to look after their own T1DM. Collectively these changes are known as frailty. A particular problem is low blood glucose levels (hypoglycaemia). Hypoglycaemia is dangerous, increasing the risk of falls, hospital admissions and even death. Symptoms of hypoglycaemia will usually trigger the patient to take in sugar and modify their insulin. Older adults may lose these symptoms meaning these episodes may go unrecognised.We suspect that older people with more changes associated with frailty are likely to have more fluctuations in their glucose levels and be at greater risk of hypoglycaemia. This has not yet been proven in a trial.
In this study, a blood test will be used to assess insulin production. Frailty assessment will involve: quality of life and physical activity questionnaires; and physical tests such as grip strength and walking speed to assess for frailty. A continuous glucose monitor (a small device attached to the skin) will then be applied and worn by the participant for 10 days. During this time the participant will carry on monitoring their glucose levels as usual and adjusting their insulin doses. The participant will not see the data. Data will be analysed to see if frailty is associated with more episodes of hypoglycaemia. A second research visit will reassess frailty to see if glycaemia affects progression towards frailty in individuals with T1DM.
Lay summary of study results:
Who carried out the research?
The authors listed above carried out the research with the support of the sponsor, University Hospitals Sussex NHS Foundation Trust and with generous funding (equipment grant) from Dexcom. The lead researcher, Dr Jonathan Golding, is based at University Hospitals Sussex.Public and Participant Involvement (PPI) A PPI group of three older adults with type 1 diabetes (T1D) was involved in the research planning.
Introduction – why was the study needed?
T1D is a condition where the pancreas stops making insulin. This causes increased blood sugar levels that can be dangerous. People living with T1D must give insulin injections for life, to control their blood sugar levels, adjusting them daily according to how much they eat and what they do. High or low blood sugar levels can be dangerous and lead to long-term problems. In the UK around 46,000 people over the age of 65 live with T1D, and this number is growing.
Improved care is enabling people with T1D to live longer and more people living with T1D are expected to reach older ages in the coming years. Frailty describes the negative changes with ageing and include: weight loss, low walking speed, tiredness, and weak hand grip-strength. Most research into frailty and diabetes has taken place in people living with type 2 diabetes (T2D). In T2D, low blood sugar (hypoglycaemia) is a concern, leading to falls, fractures, and hospitalisations. Frailty in older people living with T2D, is known to be associated with more hypoglycaemia compared to those who are not living with frailty. This research asks whether older people living with T1D and frailty have more hypoglycaemia than those who do not live with frailty.What were the main questions of the study?
The aim was to find out if people living with frailty are having more hypoglycaemia than those who are not in older people living with T1D. Frailty, age, and cognition were also assessed to see if they were associated with changes to blood sugar measures, including hypoglycaemia.
The study
The study took place at between August 2023 and June 2025 at 6 participating UK research sites. Participants were recruited from diabetes clinics, and in Exeter from a research database of people interested in being involved in research. 86 adults over 65 years old with T1D were recruited. A test was done to measure the amount of insulin present for each participant, with a low level confirming a diagnosis of T1D. Those with a high level of insulin were excluded. Participants were asked about their diabetes and medical history. Tests were done to measure frailty level (categorised as robust, prefrail, or frail), and memory. A small device was placed on the skin called a continuous glucose monitor (CGM). This measures blood sugar levels regularly, and the information is transmitted to a handheld device, which the participant was asked to carry with them. The CGM was worn for 10 days. At the end of the 10 days, the devices were returned to the researcher, who was then able to compare blood sugar levels for participants with different frailty levels.Results
86 participants were recruited. Three were excluded because tests suggested there was still insulin present – this suggests that they may not have T1D.Description of the data
Average age was 75-years, with a median diabetes duration of 46 years. 43 (51.8%) participants were men with the rest women. Most (86.7%) were using CGM at the time of the study. 10 were using insulin pumps. Most people did not have a problem with the CGM device and no adverse reactions to the device were reported. The CGM active time – which is the amount of data recorded by the CGM was good at around 90%.
When assessed using a frailty test called the Fried Frailty Phenotype, 38 (45.8%) were assessed as robust, 29 (34.9%) prefrail and 16 (19.3%) frail.
Frailty
When participants with different frailty scores were compared, no differences were found in blood sugar levels. Importantly, there was no difference in the amount of hypoglycaemia.
Cognition
HbA1c, a blood test used to assess blood sugar levels over time, was higher in individuals who had lower cognitive scores. Higher blood sugar levels were also shown in data provided by the CGM. However, there was no difference in the amount of hypoglycaemia.How has the study helped?
It was thought that older adults living with T1D and frailty would have more hypoglycaemia than those without frailty. This is because living with T1D can be difficult, particularly with frailty. In people living with T2D, frailty has been associated with more hypoglycaemia. Although this study was small, there was no difference in the amount of hypoglycaemia found between the different frailty groups.
This research showed that memory seemed to have a bigger impact on blood sugar levels. This might have been due to missed doses of insulin, or more caution in insulin dosing. However, this also did not lead to more levels of hypoglycaemia.
The study was small, and it was challenging to recruit people living with T1D and frailty. Further research should look to confirm these findings. It would also be interesting to look for reasons why T2D and frailty leads to higher rates of hypoglycaemia, and T1D and frailty does not. A qualitative sub-study has also been completed and the qualitative results are presented within that study.
The results of this study have been shared at a professional diabetes conference, in a publication in a medical journal, and at a peer support group for people living with T1D.Conclusion
This study suggests that memory, may be more important for blood sugar control. Clinicians should consider memory support when treating older adults with T1D. As treatment for T1D has improved, people are able to live longer, and this will mean more people will be reaching older ages with T1D. Learning more about how ageing’s challenges affect people with T1D will be important in guiding their treatment.REC name
South West - Frenchay Research Ethics Committee
REC reference
23/SW/0057
Date of REC Opinion
20 Jun 2023
REC opinion
Further Information Favourable Opinion