Type 1 diabetes, ageing and frailty: an underexplored intersection

Over recent decades, the life expectancy of individuals with type 1 diabetes has steadily improved due to advances in therapies that enhance metabolic control alongside better prevention and management of complications. However, this extended survival brings new challenges. Type 1 diabetes, through sustained hyperglycaemia and recurrent hypoglycaemia, may act as an accelerator of ageing, predisposing individuals to the development of geriatric syndromes such as frailty. Frailty, defined as a state of reduced physiological reserve that heightens susceptibility to stressors and impairs the ability to restore homeostasis after acute events, has emerged as a recognised complication of diabetes and has been associated with several adverse outcomes including increased risks of hypoglycaemia, hospitalisation, disability, institutionalisation and death. The putative pathophysiology of frailty in type 1 diabetes is complex and multifactorial. It reflects the direct effects of chronic exposure to hyperglycaemia and consequent micro- and macrovascular complications, superimposed on age- and diabetes-related hormonal changes. Additional contributors include sarcopenia, cognitive decline and other comorbidities. Currently, most of the literature on diabetes and frailty focuses on type 2 diabetes, while the relationship with type 1 diabetes and the impact on outcomes remain to be fully elucidated. In this review we discuss the growing evidence on the link between frailty and type 1 diabetes, explore its underlying pathophysiological mechanisms, discuss assessment and treatment strategies, and highlight the key knowledge gaps and suggest future research directions in this evolving field.