De-escalation, palliation and end of life care in frail older people with diabetes-a critical review

Frail older people with diabetes will need regular medications review and individualized care, especially at the final phase of life. Although guidelines are detailed on escalation of medications, there is little detail on how to de-escalate therapy when need arises. In addition, there is no description of patients' criteria in whom de-escalation should be considered. In the guidelines, frailty is referred to as one homogeneous group. However, frailty is a metabolically heterogeneous condition with a span of variability in insulin resistance depending on proportional ratios of visceral body fat mass, muscle mass, and total body weight. Therefore, cardiovascular risk and the need for tight targets are variable depending on frailty metabolic phenotype. Taking this into consideration, the phenotype of frailty should be taken into account when considering de-escalation of therapy. Furthermore, de-escalation of cardiovascular therapy will differ by frailty phenotype and underlying cardiovascular risk. This manuscript addresses the issue of metabolic variability of frailty and suggests three chronological stages, from de-escalation, palliation to end-of-life care in a patient-centered perspective. Future research is required to develop de-escalation pathways and strategies, which will impact on health care costs, patients' safety, and quality of life.