A study in Taiwan of individuals with diabetic kidney disease (DKD) found a relationship between frailty and subsequent risk of delirium and cognitive impairment, prompting the authors to recommend regular use of frailty screening to reduce risk of such episodes.
Patients with DKD and 1, 2, or more than 2 items on the authors’ “FRAIL” scale had a progressively higher risk of developing delirium/cognitive impairment than those who did not have DKD. In addition, for each increase in the number of items on the FRAIL scale, the associated risk rose by 9%. For those with 1, 2, and more than 2 FRAIL items, the HRs were 1.18 (95% CI, 1.08-1.28), 1.26 (95% CI, 1.14-1.39), and 1.30 (95% CI, 1.10-1.55), respectively.
“Based on findings from the existing literature and ours, we believe that frailty screening may be a missing piece within our strategies of promoting brain health, regardless of patients’ age,” the authors wrote in Diabetic Medicine.
Delirium, which involves disturbance of cognition and attention over a limited timeframe, is common in older patients and often occurs during hospitalizations or after surgery. The need to reduce episodes during hospitalization or intensive care unit (ICU) admission is critical because they increase the risk of longer stays and higher mortality among older adults, the authors said.
Diabetes is a known risk factor for delirium in medical and surgical patients, and clinicians have long inferred that chronic kidney disease entails such risk. But the risk to patients in the DKD subgroup has been poorly defined, the authors said.
They used a FRAIL scale consisting of 5 items: Fatigue, Resistance (difficulty walking up 10 steps alone without rest), Ambulation (walking several hundred yards without aid), Illness (entailing 5 of 11 chronic illnesses), and Loss of body weight.
The study consisted of 149,145 patients with DKD from across Taiwan. Those without frailty represented 31.0% of patients. The rest were as follows: 1 item on the FRAIL list (51.7%), 2 items (16.0%), and more than 2 items (1.3%). Illness was the most prevalent item (89.2%), followed by fatigue (9.7%).
After an average of 3.68 years of follow-up, results showed 6613 (4.4%) of patients with DKD developed delirium/cognitive impairment. HRs for each subgroup were progressively higher, independent of demographic features, lifestyle factors, comorbidities, medications, and major procedures, according to the study findings. The associated risk rose if centering solely on in-hospital episodes, the authors said.
However, despite pointing to increases of all delirium/cognitive impairment events and in-hospital events, the pattern did not hold true for in-ICU delirium events, according to the study. The researchers suggested the anomaly might be related to the relatively low incidence density of in-ICU delirium, requiring further study with a larger cohort.
The study also found that patients with DKD and obesity were more likely not to be frail than those without obesity, running counter to expectations. It is possible, the authors said, that obesity alone may not increase the risk of frailty, while abdominal obesity or sarcopenia obesity might. They also speculated there might have been overlap in diagnosis codes between those who were obese and those who were considered overweight. Obesity is known to increase the risk of subsequent cognitive decline in general.
Severely frail patients were also less likely to receive antidiabetic medications, because physicians may avoid prescribing them due to possible adverse influences.
Lee S‐Y, Wang J, Chao C‐T, Chien K-L, Huan J-W. Frailty is associated with a higher risk of developing delirium and cognitive impairment among patients with diabetic kidney disease: A longitudinal population‐based cohort study. Diabet Med e14566. Published online March 27, 2021. doi:10.1111/dme.14566