In this study in 384 older Malaysian admitted to hospital due to strokes, we found a high prevalence of diabetes (45.1%) among patients with strokes. Patients with diabetes had a higher burden of frailty, higher Charlson Comorbidity Index score, cardiovascular risk factors such as hypertension and CKD, and disease burden such as IHD and heart failure, and were at a younger age at the time of stroke. More than one-third (36%) of the patients had both diabetes and frailty.
The prevalence of diabetes in stroke inpatients in our study was higher compared to other countries in the Southeast Asian region. The mean age of our study participants is 81 years of age. As such, the results of our analysis provide an evidence base for the older old population with participants in similar studies having a mean age ranging from 57–68 years.4,28–32 Analysis from the National Neurology Registry for Acute Stroke in Malaysia showed estimates of diabetes prevalence ranged from 24.9–53.3% depending on first or recurrent stroke across ischemic and haemorrhagic stroke.33 Studies in neighbouring countries such as Thailand, Indonesia and Singapore have reported prevalence ranging from 17.1–38.5%.4,28,29 Similar studies in other countries such as Ethiopia, Pakistan and China have also reported a prevalence ranging from 8.1-35.46%.30–32 In a study of 208 stroke patients in a hospital in the city of Yogyakarta, Indonesia, the prevalence of diabetes was found to be 34.1% with common comorbidities including hypertension, dyslipidaemia and cardiac diseases like atrial fibrillation.4 In another analysis of 9766 patients across 3 hospitals in Singapore, the prevalence of diabetes in stroke inpatients was found to be 38.5%.28 With diabetes influencing stroke prevalence and outcomes, countries like Malaysia, Indonesia and Singapore face similar challenges in managing the growing impact of non-communicable diseases like diabetes.
Older people in Malaysia were more than 10 times more likely to have diabetes compared to younger people.18 There is growing evidence of the association of diabetes with frailty in the older population.34 In a study among community-dwelling older adults in Malaysia, the prevalence of frailty was found to be 18.3% and the top 2 comorbidities associated were diabetes and hypertension.35 With the growing population of older people in Malaysia, there is a need to have routine frailty assessments when providing care for older persons with diabetes. Evidence-based interventions can be tailored to the different frailty groups.
Research on the role of frailty in stroke outcomes is still growing. In a study of 433 individuals with ischaemic stroke, the 28-day mortality was noted to be higher in frail participants compared to non-frail participants.36 A separate study also reported higher one-year mortality in frail participants.22 In another study of 530 patients in China, it was found that frailty was an independent risk factor for one-year all-cause mortality among older stroke patients.37 A systematic review and meta-analysis described how the prevalence of frailty in acute stroke ranged from 2.2–54%, with outcomes inconsistently reported.38 Studies that met inclusion criteria appeared to be mainly from higher-income countries although the methodology was designed to be inclusive and global.38 Age being an irreversible risk factor for stroke highlights the need for studies in the older population, especially in low to middle-income countries such as Malaysia.
In patients with diabetes, frailty was found to be associated with an increased risk of all-cause mortality, cardiovascular-related mortality, major adverse cardiovascular events and hypoglycaemia.39 It does highlight the need for frailty assessment and management to be incorporated into routine diabetes care. The results of our analysis demonstrate a significant association between diabetes and increased frailty among older people with stroke. This aligns with previous studies that have further described the link between diabetes and frailty.40 The presence of diabetes appears to influence frailty potentially due to metabolic and inflammatory interactions which may exacerbate age-related decline in physiological reserves. The accelerated pace of muscle wastage, decreased physical function and heightened vulnerability to stressors in individuals with diabetes could contribute to the increased likelihood of a stroke attack.
Our findings highlight the compounded cardiovascular disease burden in older stroke survivors with diabetes and frailty. This is also similar to another study in an Egyptian population.41 The synergistic relationship between diabetes and cardiovascular disease burden has been extensively documented with diabetes serving as a significant risk factor for the development and progression of cardiovascular complications. In the context of stroke survivors, diabetes may also exacerbate underlying vascular damage, leading to greater impairment in vascular integrity and contributing to recurrent cardiovascular events. The increased prevalence of comorbidities such as hypertension, IHD, CCF, PVD, dyslipidaemia, cerebrovascular disease (including TIA) and chronic kidney disease observed in individuals with diabetes could further contribute to the amplified cardiovascular disease burden observed in our study population.
Clinical implications
Implications of our findings underscore the need for tailored interventions and management strategies for older stroke survivors with diabetes. Furthermore, goals of treatment differ in people with varying levels of frailty, with many not tolerating the usual targets of treatment at the higher frailty levels. The integration of multidisciplinary approaches, encompassing medical management, lifestyle modifications and rehabilitative interventions becomes imperative in addressing the intertwined challenges of frailty and cardiovascular disease burden. Optimizing appropriate glycaemic control and managing cardiovascular risk factors through appropriate pharmacological and lifestyle interventions could help reduce the adverse outcomes associated with diabetes in this population. This is more relevant as control rates for diabetes in the older population in Malaysia were reported to be low (21.8%)42 in comparison with neighbouring countries like Thailand reporting higher rates (26.4%).43
Moreover, the findings emphasize the importance of early identification and screening for diabetes and frailty in the older population. Timely diagnosis and management of diabetes could potentially mitigate the progression of frailty and help reduce the impact of stroke. Routine comprehensive geriatric assessment that incorporates frailty assessment and cardiovascular risk assessment should be further encouraged even in non-routine settings. This can aid in identifying high-risk individuals who may benefit from early targeted interventions.
Strengths and limitations
Our study findings provide insights into the complex interplay between diabetes, frailty, and comorbidities, particularly cardiovascular health, and further shed light on the multifaceted challenges in this vulnerable population. It also highlights the critical need for diabetes management particularly with the high prevalence of diabetes reported in Malaysia. Our study was conducted in a very old population in Malaysia and contributed to the evidence on the epidemiology of stroke, diabetes and comorbidities in low- and middle-income countries.
However, our study was a single-site study and results may not be generalisable to other health settings. The cross-sectional design prevents any establishment of a causal relationship between diabetes, frailty and cardiovascular disease burden. Future prospective studies with larger sample sizes and longitudinal follow-up can help to elucidate the temporal relationships and mechanisms underlying the observed associations. Although our study did not explore the influence of diabetes on the likelihood of stroke, it does describe the higher prevalence of frailty and cardiovascular comorbidities burden in those with diabetes. The results of our analysis do provide an opportunity for this area to be further explored and its influence on the management of post-stroke outcomes.