# Frailty phenotype state transitions among older adults with a history of cancer and diabetes

## TL;DR

This study examines how cancer and diabetes affect frailty progression in older adults over nine years.

## Contribution

It reveals that diabetes alone or combined with cancer increases frailty incidence more than cancer alone.

## Key findings

- Older adults with diabetes or both diabetes and cancer had higher frailty incidence over nine years.
- Frailty prevalence was highest in those with diabetes or both diabetes and cancer.
- Mortality was highest in those with cancer or diabetes compared to those with neither condition.

## Abstract

Frailty is a multi-faceted, aging-related syndrome characterized by reduced physiologic reserve and increased vulnerability to adverse health outcomes. Frailty is dynamic and can improve or worsen over time. Cancer and diabetes are prevalent comorbid conditions in older adults that are independently associated with frailty. Little is known about how the co-occurrence of cancer and diabetes affects frailty in older adults. We investigated how co-occurring cancer and diabetes influence long-term frailty state transitions in older adults.

We conducted a longitudinal study using Rounds 1–9 of the National Health and Aging Trends Study (2011–2019), a nationally-representative prospective cohort of Medicare beneficiaries (65 + years). We described nine-year transitions across frailty phenotype states (robust, prefrail, frail) and death using a multi-state model, stratifying by cancer and diabetes history in Round 1: neither condition (N = 4,216), cancer only (N = 972), diabetes only (N = 1,434), and both conditions (N = 331). We compared the nine-year incidence of frailty across subgroups using Aalen-Johansen estimators, adjusting for age, race, and gender.

Older adults without a history of cancer or diabetes had the lowest nine-year mortality (57.5%) compared to those with cancer only (64.4%), diabetes only (65.1%), or both conditions (64.9%). The prevalence of frailty among those alive across time periods was highest in older adults with cancer and diabetes (Round 1 [R1]: 24.7%, R9: 22.3%) and those with diabetes only (R1: 24.0%, R9: 22.4%). The prevalence of frailty was lower in participants with cancer only (R1: 18.0%, R9: 16.3%) and those with neither condition (R1: 13.1%, R9: 15.1%). Among participants who were robust or prefrail at baseline, the nine-year cumulative incidence of frailty was higher among those with diabetes only (52.8%) or diabetes and cancer (54.6%) compared to those with cancer only (41.4%) or neither condition (47.3%).

Diabetes and cancer were both associated with an increased frailty prevalence; however, only older adults with diabetes or cooccurring diabetes and cancer had an increased 9-year incidence of frailty relative to older adults without a history of either condition. Future research should explore the underlying mechanisms driving frailty state transitions among chronic disease populations and evaluate targeted interventions to mitigate frailty progression.

The online version contains supplementary material available at 10.1186/s12877-025-06309-6.