Frailty status and risk of hypoglycemia-requiring hospital care among older adults with type 2 diabetes in Sulawesi, Indonesia: A retrospective cohort study

Abstract

Frailty is a state of increased vulnerability to adverse outcomes and is associated with poor health and increased mortality among older adults with type 2 diabetes mellitus (T2DM). The aim of this study was to assess the association between frailty status and hypoglycemia-related emergency department visits or hospitalizations among older adults with T2DM. A multicenter retrospective cohort study was performed using medical records from 10 hospitals in five provinces of Sulawesi, Indonesia (Gorontalo, South Sulawesi, North Sulawesi, Central Sulawesi, and Southeast Sulawesi), from January 2021 to December 2025. The study included 2,847 patients with T2DM aged ≥60 years. Frailty was evaluated using the fatigue, resistance, ambulation, illness, and weight loss (FRAIL) scale and categorized as robust, pre-frail, or frail. The primary outcome was time to a hypoglycemia-related emergency department visit or unplanned hospital admission. Multivariable Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs). The cohort had a mean age of 71.4±6.8 years and 58.3% were female; frailty was identified in 31.2% and pre-frailty in 34.6%. There were 387 hypoglycemia-related events during a median follow-up of 3.2 years. Compared with robust participants, frail participants had a higher hazard of the primary outcome (aHR: 2.74; 95% confidence interval (CI): 2.08–3.61; p<0.001), as did pre-frail participants (aHR: 1.58; 95%CI: 1.18–2.12; p=0.002). Frailty was independently associated with an increased risk of hypoglycemia requiring hospital care among older adults with T2DM. Frailty status may act as an important clinical indicator for identifying vulnerable patients, with a potential to optimize individualized diabetes management. Further multicenter research beyond Sulawesi is warranted to establish broader applicability across Indonesia.