State of the Science

Geriatric Syndromes in Older Adults With and Without Diabetes

A Systematic Review and Meta-Analysis
Khadija Elmotia, MPH; Oumaima Abouyaala, MSc; Soukaina Bougrine, MSc; and
Moulay Laarbi Ouahidi, PhD

ABSTRACT
PURPOSE: Diabetes prevalence is increasing among older adults globally. The current study aimed to
compare geriatric syndrome prevalence in older adults with and without diabetes.
METHOD: Primary research (2011 to 2024) in English, French, or Spanish was included. We used multiple
databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Pooled log odds ratios (ORs) and prevalence rates were calculated using random-effects models. Sensi-
tivity analysis explored heterogeneity, and publication bias was assessed.
RESULTS: Older adults with diabetes exhibited higher prevalence rates of cognitive impairment (9.13%
vs. 4.22%, log OR: 0.1884), depression (8.96% vs. 5.44%, log OR: 0.3543), falls (11.5% vs. 4.47%, log OR:
0.4237), functional impairment (14.2% vs. 10.6%, log OR: 1.02), urinary incontinence (9.72% vs. 4.35%, log
OR: 1.3668), frailty (22.8% vs. 12.1%, log OR: 1.3443), and polypharmacy (22.9% vs. 5.78%, log OR: 2.5420).
Diabetes was also associated with a higher comorbidity burden.
CONCLUSION: Multidisciplinary strategies addressing diabetes and associated conditions are crucial for
older adults with diabetes. Future research should delve into underlying mechanisms and optimize care
strategies. [Research in Gerontological Nursing, 18(2), 99-108.]

As the global population continues to age, the preva- riatric syndromes encompass a range of conditions, such
lence of chronic conditions among older adults has risen as falls, frailty, cognitive impairment, polypharmacy, and
significantly. Among these conditions, diabetes mellitus incontinence, among others. These syndromes are known
stands out as a major public health concern, with a sub- to be associated with adverse outcomes, including func-
stantial impact on the health and well-being of the older tional decline, hospitalizations, and reduced quality of life
population (International Diabetes Federation [IDF], (Doležalová et al., 2021). Diabetes, on the other hand, is
2017). Concurrently, geriatric syndromes, a collection of characterized by chronic hyperglycemia and systemic met-
multifactorial and interrelated conditions that commonly abolic derangements, leading to a heightened risk of car-
affect older adults, have gained increasing attention in diovascular complications, neuropathy, and microvascular
health care research and practice (Inouye et al., 2007). diseases (Kalra & Sharma, 2018).
The coexistence of diabetes and geriatric syndromes Geriatric syndromes are characterized by a complex in-
presents a complex and challenging clinical scenario. Ge- terplay of medical, psychological, and functional factors.

From Laboratory of Biology and Health, Department of Biology, Faculty of Science, Ibn Tofail University, Kenitra, Morocco.
Disclosure: The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Khadija Elmotia, MPH, Laboratory of Biology and Health, Department of Biology, Faculty of Science, Ibn Tofail Uni-
versity, BP 133, Kenitra 14000, Morocco; email: [Link]@[Link].
Submitted: May 16, 2024. Accepted: December 2, 2024. Published online: January 30, 2025.
doi: 10.3928/19404921-20250115-01

Research in Gerontological Nursing • Vol. 18, No. 2, 2025 99

Common examples include frailty, which involves a decline electronic databases, including PubMed, Embase, and Sco-
in physiological reserves and increased vulnerability to ad- pus, from inception to January 30, 2024. MeSH (Medical
verse health outcomes (Inouye et al., 2007); falls, which Subject Headings) terms and keywords related to diabe-
are often linked to impaired balance and muscle strength; tes and each health outcome of interest were meticulously
and cognitive impairment, including conditions such as selected and combined using Boolean operators (AND,
dementia that affect memory and daily functioning. These OR) to construct search strings tailored to each database’s
syndromes frequently interact with diabetes in significant search syntax. For instance, MeSH terms such as “diabe-
ways. For instance, frailty in individuals with diabetes can tes mellitus” and keywords such as “type 2 diabetes” were
exacerbate their risk of severe complications and reduced combined with terms such as “cognitive dysfunction,”
mobility. Falls may be more common in those with diabe- “depression,” “accidental falls,” “frailty,” “polypharmacy,”
tes due to diabetic neuropathy and poor glycemic control, “comorbidity,” and “urinary incontinence.” These search
which can impair balance and coordination (Khan et al., strings were systematically applied to retrieve relevant
2015). In addition, cognitive decline in individuals with di- studies, ensuring inclusion of observational studies, cohort
abetes can complicate diabetes management, as cognitive studies, and randomized controlled trials. Furthermore,
impairments can hinder self-care practices and adherence we conducted manual searches of reference lists from rel-
to treatment regimens (Krogsboll et al., 2014). evant articles and reviews to identify any additional studies
Understanding the potential link between diabetes and missed during the electronic search process.
geriatric syndromes is crucial for several reasons. First, it The complete search strategy, including detailed search
may inform clinical decision-making, enabling health care terms and results for each database, is provided in Table B
providers to better anticipate and address the unique needs (available in the online version of this article).
of this population. Second, it has implications for health
care resource allocation, as the prevalence of diabetes con- Data Extraction
tinues to rise, and the burden of geriatric syndromes can A data extraction form was developed through discus-
strain health care systems (IDF, 2017). Finally, it can guide sions among members of the research team and underwent
preventive strategies and interventions aimed at reduc- piloting to ensure its effectiveness. This form encompassed
ing the burden of geriatric syndromes in older individuals various essential items, such as the first author’s name, pub-
with diabetes. lication year, study design, location, data collection method,
The current systematic review sought to synthesize the patient characteristics (including sample size and age), and
existing body of evidence on the association between dia- primary outcomes. The outcomes extracted included preva-
betes and geriatric syndromes and compare the prevalence lence rates of geriatric syndromes, mean values, standard
of geriatric syndromes in older adults with and without deviations, associations between diabetes and these syn-
diabetes. This meta-analysis endeavors to address a critical dromes, odds ratios (ORs), and confidence intervals (CIs)
question: Are geriatric syndromes more prevalent in older for each study. Data extraction was performed indepen-
individuals with diabetes compared to their non-diabetic dently and in duplicate to ensure reliability. Regular cross-
counterparts? validation sessions were held among reviewers to identify
and rectify any inconsistencies in the extracted data. In addi-
METHOD tion, periodic calibration exercises were conducted to main-
We conducted a systematic search for studies pertain- tain consistency throughout the process. EndNote X7 was
ing to diabetes and geriatric syndromes from April 1, 2023, used to identify and remove duplicate articles. Articles were
to January 30, 2024. Inclusion and exclusion criteria are evaluated for inclusion or exclusion based on predefined
detailed in Table 1. Our approach in preparing this review criteria (Table 1). The team independently reviewed titles
followed the Preferred Reporting Items for Systematic Re- and abstracts to choose potential studies. Next, a thorough
views and Meta-Analyses (PRISMA) guidelines (Table A, examination of the full texts was conducted to make the
available in the online version of this article). Furthermore, final inclusion of studies. Any disagreements among team
we established a methodological protocol for this study, members were resolved through discussion and consensus
registered under PROSPERO (CRD42023423018). during the meetings. All authors reached agreement on the
final studies included in the review.
Search Strategy Table 2 outlines the conceptual and operational defini-
We conducted a comprehensive search across multiple tions of the outcomes extracted from the included studies,

100 Copyright © SLACK Incorporated

 TABLE 1

Inclusion and Exclusion Criteria

Inclusion Criteria Exclusion Criteria
Studies published between 2010 and 2024 to focus on the Studies not meeting the quality criteria of the JBI critical
most current research to provide the best evidence-based appraisal tool
information
Primary research studying geriatric syndromes among Studies that do not clearly specify the age group or diabetes
older adults with and without diabetes diagnosis of participants
Studies using English, French, or Spanish language in the Studies including only older adults with diabetes and no control
abstract or full text group
Studies involving participants aged ≥60 years Studies lacking sufficient data or with a high risk of bias
Studies using valid and standardized screening tools to identify Case reports, editorials, conference abstracts, or reviews
cognitive impairment, falls, frailty, urinary incontinence, depres- without original data
sion, comorbidities, and polypharmacy
Note. JBI = Joanna Briggs Institute.

TABLE 2

Conceptual and Operational Definitions of Outcomes

Geriatric Syndrome Definition Screening Tools
Falls Any unintended event where an individual Timed Up and Go (TUG), self-reported history of
comes to rest on the ground or a lower level falls (at least one fall in the past 1 year), Perfor-
(World Health Organization, 2021) mance Oriented Mobility Assessment
Urinary incontinence The involuntary leakage of urine resulting from Self-reported diagnosis of incontinence for
impaired bladder control (Milsom et al., 2014) ≥3 months
Cognitive impairment A decline in memory, thinking, and decision- Mini-Mental State Examination, Abbreviated
making abilities beyond normal aging Mental Test Score, Short Blessed Test, Cogni-
(Petersen, 2011) tive Performance Scale, CERAD Word List, Digit
Symbol Substitution Test, Short Portable Mental
Status Questionnaire
Depression Persistent sadness, loss of interest, and symp- Geriatric Depression Scale (GDS), Patient Health
toms impairing daily functioning (American Questionnaire-9, Mini-GDS
Psychiatric Association, 2013)
Frailty A syndrome marked by reduced strength, Edmonton Frail Scale, Frailty Staging System,
endurance, and function (Fried et al., 2001) TUG, Frailty Risk Score, Clinical Frailty Scale,
grip strength
Polypharmacy Use of five or more medications simultaneously Medication review (>5 medications daily for
(Gnjidic et al., 2012) ≥3 months)
Comorbidity The coexistence of two or more chronic diseases Charlson Comorbidity Index
or conditions (Valderas et al., 2009)
Functional impairment Difficulty in performing tasks essential for Barthel Index for Activities of Daily Living, Katz
independent living Index of Instrumental Activities of Daily Living

along with the screening tools commonly used for their as- stitute (JBI) risk of bias assessment tool for cohort studies
sessment. and the JBI checklist for cross-sectional studies, chosen for
its relevance to the research objectives and robustness in
Risk of Bias Assessment evaluating study quality (Moola et al., 2020). Two separate
The quality appraisal process used the Joanna Briggs In- reviewers assessed the data independently using the JBI

Research in Gerontological Nursing • Vol. 18, No. 2, 2025 101

 stability and reliability of our findings by systematically ex-
ploring the impact of various methodological choices and
assumptions. This analysis entailed evaluating the influ-
ence of study quality through the exclusion of studies with
high risk of bias; assessing alternative statistical methods,
such as fixed-effects models; exploring potential publica-
tion bias using trim-and-fill analysis and funnel plot asym-
metry tests; and considering the influence of outliers by
excluding studies with extreme effect sizes.

RESULTS
Figure 1 provides a visual summary of the study se-
lection process based on the PRISMA guidelines. We ini-
tially identified 720 studies through database and manual
searches. After removing duplicates and screening based
on inclusion and exclusion criteria, we included a total of
Figure 1. Flow chart of study selection. 28 studies for the final meta-analysis. Table D (available in
the online version of this article) presents detailed charac-
tool, focusing on various aspects of data quality, includ- teristics of the included studies, outlining the study design,
ing risk of bias, methodological rigor, and internal validity. sample sizes, gender distribution, mean ages, screening
Data analysis was performed with careful consideration tools used for geriatric syndromes, and quality scores.
given to the potential impact of bias on study findings. In our meta-analysis, we found a clear pattern of in-
Any discrepancies or disagreements between reviewers creased geriatric syndromes among older adults with dia-
were resolved through discussion and consensus-building betes compared to those without diabetes, highlighting the
during research team meetings. The detailed risk of bias additional health challenges this population faces (Table 3).
assessment for each included study is presented in Table C
(available in the online version of this article). Cognitive Impairment
Cognitive impairment was approximately twice as
Strategy for Data Synthesis common in individuals with diabetes, affecting 9% com-
For data synthesis, we used JAMOVI (version 2.3) pared to 4% of older adults without diabetes with a log OR
software to estimate the prevalence, standardized mean of 0.18 (Figure A, available in the online version of this
difference, and log ORs as the outcome measures, with a article). This finding underscores the cognitive decline that
random-effects model applied to the data. The restricted often accompanies diabetes.
maximum-likelihood estimator was used to estimate the
amount of heterogeneity (tau²). The presence of hetero- Depression
geneity was assessed using the Q-test for heterogeneity Similarly, the burden of depression was pronounced,
and the I² statistic. If any heterogeneity was detected (i.e., with 8.96% of older adults with diabetes experiencing de-
tau² > 0), a prediction interval for the true outcomes was pressive symptoms versus 5% in those without diabetes
provided. To identify potential outliers and influential (Figure B, available in the online version of this article).
studies, studentized residuals and Cook’s distances were This finding, indicated by an average log OR of 0.3543,
examined. Studies with Cook’s distances exceeding the highlights the heightened psychological challenges faced
median plus six times the interquartile range of the Cook’s by this population.
distances were considered influential. To assess funnel plot
asymmetry, the rank correlation test and regression test, Falls
using the standard error of the observed outcomes as a pre- The risk of falls also emerged as a critical concern, with
dictor, were conducted. a prevalence of 11% in older adults with diabetes compared
to 4% in their non-diabetic counterparts (Figure C, avail-
Sensitivity Analysis able in the online version of this article). Average log OR of
Sensitivity analysis was used to rigorously assess the 0.42 reinforces the link between diabetes and increased fall

102 Copyright © SLACK Incorporated

risk, signaling the need for preventive strate-
gies.

<0.0001

<0.0001
<0.0001

<0.0001
p Value
<0.001

<0.001
0.0112

0.0002
Urinary Incontinence
Urinary incontinence further exemplified
the impact of diabetes, affecting 10% of older
adults with the condition versus 4% without

I2 (%)

92.66
88.35

97.94

99.97
74.68
96.55
100

100
diabetes (Figure D, available in the online ver-
sion of this article). The log OR of 1.37 indi-

Prevalence of Geriatric Syndromes in Older Adults With and Without Diabetes

cates a significant association, emphasizing the
necessity for targeted interventions.

Average
Log OR

0.3543
0.18

0.42
1.37

1.02

1.34
2.54
Functional Impairment
Functional impairment was prevalent at
14% among those with diabetes, whereas it

p Value
stood at 11% in individuals without diabe-

Average SMD = 0.64 (95% CI [0.42, 0.86])

0.018

0.038
0.007
0.058

0.079

0.069
0.159
tes (Figure E, available in the online version
of this article). The log OR of 1.02 suggests a
positive correlation, calling for functional as-
(%) [95% CI]
Prevalence

12 [–1, 25]
sessments in diabetes management.

11 [1, 23]

6 [–2, 14]
Diabetes
Without

5 [0, 11]
4 [1, 8]

4 [1, 8]
4 [0, 9]
Frailty
Frailty was markedly higher in older
adults with diabetes, with a prevalence of 23%
TABLE 3

p Value
<0.001

<0.001
0.006
0.003
0.002

0.041

0.078
compared to 12% in those without diabetes
(Figure F, available in the online version of this
article). This substantial difference, reflected in
a log OR of 1.34, highlights the vulnerability
8.96 [2.6, 15.3]
With Diabetes
(%) [95% CI]
Prevalence

23 [11, 35]
23 [–3, 48]
11 [4, 19]
10 [4, 16]

14 [1, 28]

of this group and the need for comprehensive

9 [4, 15]

care approaches.

Polypharmacy
Diabetes (n)
Participants

In addition, polypharmacy was identified

Without

447,671

369,208
132,451

324,532
31,355

70,165

10,723

22,804
Note. CI = confidence interval; OR = odds ratio; SMD = standardized mean difference.

as a significant issue, with 23% of older adults

with diabetes affected, contrasted with only
6% of those without diabetes (Figure G, avail-
Participants With

able in the online version of this article). The

Diabetes (n)
110,784

log OR of 2.54 illustrates the strong associa-

93,612

14,195
29,497

40,520
9,921

1,901

7,211

tion between diabetes and the use of multiple

medications, raising concerns about effective
medication management.
Studies (n)

Comorbidity
16

12
15

7
6
6

Finally, comorbidity levels were significant-

ly higher in individuals with diabetes, with an
Polypharmacy

average standardized mean difference of 0.64

incontinence

Comorbidity
impairment

impairment
Depression

Functional

(Figure H, available in the online version of

Cognitive
Outcome

Urinary

Frailty

this article). This finding suggests that diabetes

Falls

is associated with a greater overall health bur-

Research in Gerontological Nursing • Vol. 18, No. 2, 2025 103

den, necessitating integrated care strategies that address falls prevention, including assessment, education, and tai-
physical and mental health challenges. lored interventions. Although physical therapy with balance
We observed substantial heterogeneity in the reported and gait training remains effective, community-based and
prevalence of geriatric syndromes among older adults with individual exercise options, such as tai chi or group fitness
diabetes. Despite this variability, the analysis was robust, classes, also play a vital role. Home modifications, such as
with no outliers or overly influential studies, confirmed installing grab bars and improving lighting, help minimize
by studentized residuals and Cook’s distances. Publication environmental hazards. In addition, regular medication re-
bias assessments, including rank correlation and regres- views to address polypharmacy and reduce the use of medi-
sion tests, found no significant funnel plot asymmetry. In cations affecting the central nervous system can significantly
addition, the Fail-Safe N analysis supported the credibility lower fall risk (Yang et al., 2016).
of the results, minimizing concerns about publication bias. Urinary incontinence is more common in individu-
als with diabetes due to factors such as neuropathy and
DISCUSSION polyuria secondary to hyperglycemia, which exacerbate
Our analysis highlights a significant association be- bladder control issues. Updated evidence emphasizes in-
tween cognitive impairment and diabetes, consistent with terventions, such as pelvic floor muscle training, bladder
previous research linking hyperglycemia and its vascu- training, and lifestyle modifications, including dietary ad-
lar complications to cognitive decline. However, in older justments and controlled fluid intake, particularly in frail
adults, especially those who are frail, tight glycemic con- older adults (Wagg, 2024; Wagg et al., 2023).
trol is not recommended due to the heightened risk of Our analysis indicates that functional impairment is
hypoglycemia and its associated complications (American significantly more prevalent among individuals with dia-
Diabetes Association, 2022). Instead, individualized glyce- betes. A meta-analysis corroborates this finding, highlight-
mic targets should be prioritized, balancing the benefits of ing that diabetes increases the risk of disability in activi-
glucose control with the risks. Early screening using tools, ties in daily living (ADL) and instrumental ADL (Wong
such as the Mini-Mental State Examination, combined et al., 2013). Functional impairment management involves
with cognitive rehabilitation and regular exercise, remains regular assessments using tools such as the Barthel Index
crucial, as early interventions can help slow cognitive de- and Katz Index. Although tailored rehabilitation programs
cline while maintaining overall safety and quality of life targeting strength, endurance, and flexibility can enhance
(Xue et al., 2019). functional outcomes, not all individuals may be eligible for
Our findings highlight a strong link between diabetes such programs. For these individuals, promoting regular
and depression, echoing Fiore et al. (2015), who observed physical activity, such as walking, chair exercises, or light
higher depression rates in older adults with diabetes. stretching, can offer meaningful benefits. Occupational
Chronic hyperglycemia affects mood and brain func- therapy can assist with ADLs and provide adaptive devices
tion. Health care providers should incorporate depression to support independence. In addition, the use of assistive
screening tools, such as the Geriatric Depression Scale devices, such as canes or walkers, can improve mobility
and Patient Health Questionnaire, as recommended by and help prevent further disability (Clegg et al., 2013).
the American Psychiatric Association (2010), particularly Our findings indicate a strong association between dia-
in clinical settings for older adults. Effective management betes and frailty. A meta-analysis confirms that frailty is
of depression in individuals with diabetes should involve more prevalent among older adults with diabetes. Frailty
a combination of cognitive-behavioral therapy; lifestyle often correlates with sarcopenia, where muscle mass and
changes, such as regular exercise and a balanced diet; and function decline due to factors such as hormonal changes,
maintaining good glycemic control (Fiore et al., 2015). inflammation, nerve health, nutrition, and reduced physi-
Older adults with diabetes face a higher risk of falls com- cal activity. Routine frailty assessments using validated
pared to those without diabetes. This finding aligns with a tools, such as the Frailty Index (Mitnitski et al., 2001) or
meta-analysis showing a risk ratio of 1.64 (95% CI [1.27, the Fried Frailty Phenotype (Fried et al., 2001), should be
2.11]) for falls in individuals with diabetes. To reduce fall integrated into diabetes management to enhance resil-
risk, a multifaceted approach is essential. The Centers for ience, reduce hospitalizations, and improve survival. Effec-
Disease Control and Prevention’s STEADI (Stopping Elderly tive management strategies include resistance and aerobic
Accidents, Deaths, and Injuries; [Link] training to improve muscle strength and nutritional sup-
[Link]) program offers a comprehensive framework for port to preserve muscle mass (Kong et al., 2021).

104 Copyright © SLACK Incorporated

 In the current review, individuals with diabetes exhib- identification and management of geriatric syndromes
ited significantly higher comorbidity burdens compared affect long-term diabetes outcomes, including glycemic
to their non-diabetic counterparts. In addition, a cohort control and complication rates. In addition, there is a need
study found that diabetes was significantly linked to an el- to evaluate the feasibility and effectiveness of integrating
evated risk of multiple conditions. Poor diet and reduced standardized geriatric assessments into routine diabetes
physical activity often associated with diabetes further care, particularly in low-resource settings. Research on the
exacerbate the risk of other health conditions. Managing development of culturally and linguistically appropriate
comorbidities in individuals with diabetes requires a com- tools for assessing geriatric syndromes in diverse popula-
prehensive, interdisciplinary approach, involving coordi- tions is also critical. Finally, intervention trials targeting
nated care across specialties. This coordinated care could physical activity, cognitive health, and falls prevention
optimize treatment and reduce the cumulative burden of should explore their combined impact on functional inde-
disease (Iglay et al., 2016). pendence and quality of life in older adults with diabetes.
Polypharmacy was significantly more common in in- These research priorities could inform tailored care strate-
dividuals with diabetes. Formiga et al. (2016) found that gies and advance knowledge in this interdisciplinary field.
polypharmacy in individuals with diabetes can often re-
sult from the implementation of clinical practice guide- CONCLUSION
lines managing their comorbidities, which makes manag- The current review has provided valuable insights into
ing polypharmacy in these patients challenging. Effective the associations between diabetes and various geriat-
management of polypharmacy must include regular medi- ric syndromes among older individuals. Across multiple
cation reviews to identify and reduce non-essential medi- health outcomes, including cognitive impairment, depres-
cations using criteria such as the Beers Criteria® (Ameri- sion, falls, functional impairment, urinary incontinence,
can Geriatrics Society Beers Criteria® Update Expert Panel, frailty, polypharmacy, and comorbidity burden, the evi-
2019) and STOPP/START criteria (O’Mahony et al., 2015). dence underscores the need for a multifaceted approach to
Deprescribing practices focus on the gradual reduction or care. Health care providers must integrate targeted screen-
discontinuation of potentially harmful medications. En- ing, prevention, and management strategies into routine
gaging in patient education about the risks and benefits of care. Specifically, prevention measures should include
medications helps promote adherence and reduce confu- regular cognitive screenings to detect early signs of impair-
sion (Formiga et al., 2016). ment, mood evaluations to address depressive symptoms,
fall risk assessments, educational strategies including en-
LIMITATIONS vironmental modifications and strength training exercises
Despite the valuable insights gained from our system- to enhance balance and reduce fall risk, functional status
atic review and meta-analysis, it is important to acknowl- evaluations to identify mobility issues, and medication re-
edge several limitations that warrant consideration. First, views to manage polypharmacy risks.
the predominance of observational studies limits our abil- Interdisciplinary collaboration is crucial because it
ity to establish causality and introduces potential biases. brings together diverse expertise to address the complex
Second, significant heterogeneity exists across included and interrelated needs of older adults with diabetes. In pri-
studies in terms of populations, designs, and methodolo- mary care settings, a team comprising nurses, nurse prac-
gies, despite our efforts to address it. Third, publication titioners, primary care physicians, physician assistants,
bias may have influenced our findings, despite attempts to medical assistants, endocrinologists, geriatricians, dieti-
mitigate it through comprehensive searches. These limita- tians, and physical therapists can collaboratively develop
tions underscore the need for cautious interpretation of and implement individualized care plans. Nurses and nurse
our results and highlight avenues for future research to ad- practitioners can conduct routine screenings, provide pa-
dress these challenges. tient education, and manage chronic conditions. Primary
care physicians and physician assistants can oversee dia-
RESEARCH IMPLICATIONS betes management and coordinate care, while medical as-
Findings of the current study underscore the need for sistants support with administrative tasks and patient fol-
further research to explore the bidirectional relationship low ups. Together, these professionals can address diabetes
between diabetes and geriatric syndromes. Future research management and the prevention of associated syndromes,
should focus on longitudinal studies to assess how early ensuring a holistic approach to care. This approach ensures

Research in Gerontological Nursing • Vol. 18, No. 2, 2025 105

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 Table A. PRISMA 2020 Checklist

Location
Section and Item
Checklist item where item
Topic # is reported
TITLE
Title 1 Identify the report as a systematic review. 1
ABSTRACT
Abstract 2 See the PRISMA 2020 for Abstracts checklist. 1
INTRODUCTION
Rationale 3 Describe the rationale for the review in the context of existing knowledge. 2
Objectives 4 Provide an explicit statement of the objective(s) or question(s) the review addresses. 3
METHODS
Eligibility criteria 5 Specify the inclusion and exclusion criteria for the review and how studies were grouped for the syntheses. 5
Information 6 Specify all databases, registers, websites, organizations, reference lists and other sources searched or consulted to identify studies. Specify the date when 4
sources each source was last searched or consulted.
Search strategy 7 Present the full search strategies for all databases, registers and websites, including any filters and limits used. 4
8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each 4
Selection process
report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.
9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked 4
Data collection
process independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.

10a List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study 5-7
were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.
Data items 6
10b List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any
assumptions made about any missing or unclear information.
Study risk of bias 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and 8
assessment whether they worked independently, and if applicable, details of automation tools used in the process.
Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results. 4
13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing 5-6
against the planned groups for each synthesis (item #5)).
13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data 8
conversions.
Synthesis 13c Describe any methods used to tabulate or visually display results of individual studies and syntheses. 8
methods
13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta‐analysis was performed, describe the model(s), 8
method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.
13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta‐regression). 8
13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results. 8
Reporting bias 14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases). 8
assessment
Certainty 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. 8
assessment
 Location
Section and Item
Checklist item where item
Topic # is reported
RESULTS
Study selection 16a Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, 9
ideally using a flow diagram.
16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded. 9
Study 17 Cite each included study and present its characteristics. 10-13
characteristics
Risk of bias in 18 Present assessments of risk of bias for each included study. 10-13
studies
Results of 19 For all outcomes, present, for each study: (a) summary statistics for each group (where appropriate) and (b) an effect estimates and its precision 10-13
individual studies ([Link]/credible interval), ideally using structured tables or plots.
Results of 20a For each synthesis, briefly summarize the characteristics and risk of bias among contributing studies. 10-13
syntheses 20b Present results of all statistical syntheses conducted. If meta‐analysis was done, present for each the summary estimate and its precision (e.g. 14-18
confidence/credible interval) and measures of statistical heterogeneity. If comparing groups, describe the direction of the effect.
20c Present results of all investigations of possible causes of heterogeneity among study results. 14-18
20d Present results of all sensitivity analyses conducted to assess the robustness of the synthesized results. 14-18
Reporting biases 21 Present assessments of risk of bias due to missing results (arising from reporting biases) for each synthesis assessed. 14-18
Certainty of 22 Present assessments of certainty (or confidence) in the body of evidence for each outcome assessed. 14-18
evidence
DISCUSSION
Discussion 23a Provide a general interpretation of the results in the context of other evidence. 19-20
23b Discuss any limitations of the evidence included in the review. 21
23c Discuss any limitations of the review processes used. 21
23d Discuss implications of the results for practice, policy, and future research. 19-20
OTHER INFORMATION
Registration and 24a Provide registration information for the review, including register name and registration number, or state that the review was not registered. 4
protocol 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared. 4
24c Describe and explain any amendments to information provided at registration or in the protocol. 4
Support 25 Describe sources of financial or non‐financial support for the review, and the role of the funders or sponsors in the review. 22
Competing 26 Declare any competing interests of review authors. 22
interests
Availability of 27 Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; _
data, code and data used for all analyses; analytic code; any other materials used in the review.
other materials
 Table B. Complete Search Strategy

Database Search Terms Search Date of Number

Filters Search of
Results
PubMed ("Diabetes Mellitus"[MeSH] OR "Type 2 No filters, From April 1, 300
Diabetes"[Title/Abstract]) AND ("Cognitive Humans, 2023, to
Dysfunction"[MeSH] OR "Depression"[MeSH] OR Adults aged January 30,
"Accidental Falls"[MeSH] OR "Frailty"[MeSH] OR 65+ 2024
"Polypharmacy"[MeSH] OR "Comorbidity"[MeSH] OR
"Urinary Incontinence"[MeSH])

Embase ('diabetes mellitus'/exp OR 'type 2 diabetes'/exp) AND No filters, From April 1, 250
('cognitive dysfunction'/exp OR 'depression'/exp OR Humans, 2023, to
'falls'/exp OR 'frailty'/exp OR 'polypharmacy'/exp OR Adults aged January 30,
'comorbidity'/exp OR 'urinary incontinence'/exp) 65+ 2024

Scopus TITLE‐ABS‐KEY("diabetes mellitus" OR "type 2 diabetes") No filters, From April 1, 170

AND TITLE‐ABS‐KEY("cognitive dysfunction" OR Humans, 2023, to
"depression" OR "accidental falls" OR "frailty" OR Adults aged January 30,
"polypharmacy" OR "comorbidity" OR "urinary 65+ 2024
incontinence")

Manual Reference lists from key articles and review papers N/A From April 1, 50
Search 2023, to
January 30,
2024
 Table C. JBI Critical Appraisal Score

Were the Were the Was the Were Were Were Were the Was Quality
criteria for study exposure objective, confou strategies to outcomes appropri score
ate
inclusion in the subjects and measured in standard nding deal with measured in statistica
sample clearly the setting a valid and criteria used factors confounding a valid and l analysis
Study (cross-sectional) used?
defined? described in reliable for identifi factors reliable way?
detail? way? measurement ed? stated?
of the
condition?
Abodo et al., (2017) Yes Yes Yes Yes Yes Yes Yes Yes 8

Aguayo et al., 2019 Yes Yes Yes Yes Yes Yes Yes Yes 8

Argano et al., 2022 Yes yes Yes Yes Yes Yes Yes Yes 8
Yes Yes Yes Yes Yes Yes Yes Yes 8
Cacciatore, et al. 2013
Carmienke et al., 2020 Yes Yes Yes Yes Yes Yes Yes Yes 8
Yes Yes Yes Yes Yes Yes Yes Yes 8
Casagrande et al., 2021
Chau et al., 2011 Yes Yes Yes Yes Yes Yes Yes Yes 8

Cigolle et al., 2011 Yes Yes Yes Yes Yes Yes Yes Yes 8

Dybicz et al., 2011 Yes Yes Yes Yes Yes Yes Yes Yes 8

Forbes et al., 2017 Yes No Yes Yes Yes Yes Yes Yes 8

Huang et al., 2021 Yes Yes Yes Yes Yes Yes Yes Yes 8

Karjalainen, 2021 Yes Yes Yes Yes Yes Yes Yes Yes 8

Karjalainen et al., 2018 Yes Yes Yes Yes Yes Yes Yes Yes 8

Karsli et al., 2022 Yes Yes Yes Yes Yes Yes Yes Yes 8

Kera et al., 2018 Yes Yes Yes Yes Yes Yes Yes Yes 7

Kitamura et al., 2019 Yes Yes Yes Yes Yes Yes Yes Yes 8
Kotsani et al., 2018 Yes Yes Yes Yes Yes Yes Yes Yes 8

Yes Yes Yes Yes Yes Yes Yes Yes 8

Lekan & McCoy, 2018

Li et al., 2013 Yes Yes Yes Yes Yes Yes Yes Yes 8

Yes Yes Yes Yes Yes Yes Yes Yes 8

Moon et al., 2019
Nezu et al., 2014 Yes Yes Yes Yes Yes Yes Yes Yes 8
Yes Yes Yes Yes Yes Yes Yes Yes 8
Panahi et al., 2024
Taha, 2021 Yes Yes Yes Yes Yes Yes Yes Yes 8

Thein et al., 2018 Yes Yes Yes Yes Yes Yes Yes Yes 8

Varghese et al., 2017 Yes Yes Yes Yes Yes Yes Yes Yes 8

Wallander et al., 2017 Yes Yes Yes Yes Yes Yes Yes Yes 8
Wojszel & Magnuszewski, 2020 Yes Yes Yes Yes Yes Yes Yes Yes 8
Yes Yes Yes Yes Yes Yes Yes Yes 8
Zghebi et al., 2020
 Table C. JBI Critical Appraisal Score (continued)

Study Groups Exposures Exposure Confounding Strategies to Participants Outcome Follow-up Complete Strategies Appropriate Score
(Cohort) Similar & Measured Measurement Factors Deal with Free of Measurement Time Follow-up for Statistical
Recruited Similarly? Valid & Identified? Confounding? Outcome at Valid & Reported or Reasons Incomplete Analysis?
from Same Reliable? Start? Reliable? & Explained? Follow-
Population? Sufficient? up?
Aguayo Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
et al.,
2019
Forbes et Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
al., 2017
Kitamura Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
et al.,
2019
Lekan & Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
McCoy,
2018
Panahi et Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
al., 2024
Zghebi et Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11
al., 2020
 Table D. Study Characteristics

Study Country Study Design Sample Size Female Male Mean Age Screening Tools Quality
With Without With Without With Without With Without Score
Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes Diabetes
Abodo et al., Ivory Cross- 145 150 NG NG NG NG 79.6 81.2  Mini-GDS 8
2017 Coast sectional  MMSE
 ADL

Aguayo et Denmark Cohort 635 4,742 46% 57% 54% 43% 72 70  EFS 11
al., 2019

Argano et al., Italy Cross- 1378 3330 NG NG 56.2% 43.8 % 78.45 79.68  GDS 8
2022 sectional  Barthel Scale
 Short Blessed
Test score

Cacciatore et 188 1,100 67.0% 55.3% 33.0% 44.7 72.8 74.3  FSS 8
Cross-
al., 2013 Italy  GDS
sectional
 MMSE
Carmienke et Germany Cross- 248 692 58.5% 59.7% 41.5 40.3 73.4 72.7  Coop-Wonca – 8
al., 2020 sectional Charts
 STEP
Questionnaire
208 999 49.5 % 58.9% 50.5% 41.1% NG NG  CERAD W-L 8
Casagrande
Cross-  DSST
et al., 2021 USA
sectional  PHQ-9

Chau et al., China Cross- 9,222 57,591 6,130 38,007 3,092 19,584  Abbreviated 8
2011 sectional (86.1%) (86.4%) Mental Test—
Hong Kong
 GDS
  IADL
 ADL

Cigolle, et USA longitudinal 3,506 15,402 52.1% 57.7% 47.9 42.3 NG NG  MMSE 8
al., 2011 health  ADL
interview  IADL
survey data
Dybicz et al., USA Retrospective 761 1556 30.8% 69.2% 38.2% 61.8% NG NG  CPS 8
2011 observational  Activities of
Daily Living
Domain Scale
(ADL DS)

Forbes et al., UK Cohort 35,717 307,918 52.3% 60.7% 47.7% 39.3 78.13 78.98  Comorbidity 11
2017 index
 Polypharmacy
> 5 drugs per
day
Huang et al., UK Cross- 1100 6629 49.3% 56.4% 50.7% 43.6% 70.0 67.2  Polypharmacy 8
2021 sectional >5 drugs
long term
medication per
day
Karjalainen, Finland Cross- 389 604 50.8% 54.4% 49.2% 45.6% 75 77  GDS 8
2021 sectional

Karjalainen Finland Cross- 389 604 50.8% 54.4% 49.2% 45.6% 75 74  GDS 8
et al., 2018 sectional

Karsli et al., Turkey Cross- 149 149 67.1% 59.7% 32.9% 40.3% 70.38 70.97  EFS 8
2022 sectional
  At least one
fall in the last
year

Kera et al., Japan Cross- 705 984 56.1% 59.2% 43.9 40.8 72.1 71.3  Grip strength 8
2018 sectional  TUG
 MMSE

Kitamura et Japan Cohort 181 1090 47% 63% 53% 37% 71.0 72.1  MMSE 11
al., 2019  GDS
 Grip strength
 TUG

Kotsani et al., Greece Cross- 198 205 55.1% 54.6% 44.9% 45.4% 72.9 74.0  TUG 8
2018 sectional  GDS
 MMSE
 Global
Disability
Scale (GloDiS)

136 142 48% 57% 52% 43% 69.4 70.8  FRS 11

Lekan &
 ADL
McCoy, 2018 USA Cohort

Li et al., Taiwan Cross- 473 2251 56.4% 48.2% 43.6% 51.8% NG NG  ADL, IADL 8
2013 sectional  GDS
 MMSE
 Cross- 2,395 7,904 61.0% 59.5% 39.0% 40.5% 74.6 74.6  MMSE 8
sectional  Polypharmacy:
≥5 drugs for 3
months
 Falls: one or
Moon et al., more falls over
2019 Korea 1 year
 GDS
 Urinary
incontinence:
diagnosed
incontinence
for ≥3 months
Nezu et al., Japan Cross- 572 3374 36.0% 52.0% 64.0% 48% 72.0 72.0 Japanese version of 8
2014 sectional the Medical Outcomes
Study 36-Item Short-
Form General Health
Survey Version 2.0
(SF-36 v2)

466 1556 54.6% 49.5% 45.4% 50.5% 68.30 69.72 Self-reported 11

information acquired
Panahi et al.,
through multiple
2024 Iran Cohort
validated
questionnaires
administered
Taha, 2021 Egypt Cross- 82 162 57.3% 56.8% 42.7% 43.2% 68.91 68.26  Katz ADL 8
sectional  IADL
 At least one
fall in the last
year
  Polypharmacy:
≥5 drugs

Thein et al., Singapore Cross- 486 2210 59.5% 63.5% 40.5% 36.5% 67.3 65.6  MMSE 8
2018 sectional  POMA
 ADL
 IADL

Varghese et India Cross- 406 744 36.7% 34.1% 63.3% 65.9% 68.2 68.5  GDS 8
al., 2017 sectional  SPMSQ
 At least one
fall in the last
year
Wallander et Sweden Cohort 84,702 343,603 50% 59% 50% 41% 79.3 81.1  Charlson 11
al., 2017 Comorbidity
Index
 Self-reported
fall injury

Wojszel & Poland Cross- 126 290 73.8% 79% 26.2% 21.0% 81 82.5  AMTS 8
Magnuszews sectional  GDS
ki, 2020  Barthel Index
 Clinical Frailty
Scale
10,202 49,589 NG NG NG NG NG NG  Read/ICD-10 11
Zghebi et al., diagnostic
UK Cohort
2020 code
Figure A1. Prevalence of cognitive impairment in older adults without diabetes.
Figure A2. Prevalence of cognitive impairment in older adults with diabetes.
Figure A3. Pooled log odds ratio for cognitive impairment.
Figure B1. Prevalence of depression in older aduls without diabetes.
Figure B2. Prevalence of depression in older aduls with diabetes.
Figure B3. Pooled log odds ratio for depression.
 Figure C1. Prevalence of falls in older adults with diabetes.

Figure C2. Prevalence of falls in older adults without diabetes.

Figure C3. Pooled log odds ratio for falls.
 Figure D1. Prevalence of urinary incontinence in older adults with diabetes.

Figure D2. Prevalence of urinary incontinence in older adults without diabetes.

Figure D3. Pooled log odds ratio for urinary incontinence.
 Figure E1. Prevalence of functional impairment in older adults with diabetes.

Figure E2. Prevalence of functional impairment in older adults without diabetes.

Figure E3. Pooled log odds ratio for functional impairment.
Figure F1. Prevalence of frailty in older adults without diabetes.

Figure F2. Prevalence of frailty in older adults with diabetes.

Figure F3. Pooled log odds ratio for frailty.
 Figure G1. Prevalence of polypharmacy in older adults with diabetes.

Figure G2. Prevalence of polypharmacy in older adults without diabetes.

 Figure G3. Pooled log odds ratio for polypharmacy.

Figure H. Average standardized mean difference of comorbidity.

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prohibited without permission.