Dear Editor, With the narrowing gap in life expectancy between individuals with and without diabetes,1 focusing on diabetes care that improves healthy life expectancy and quality of life has become increasingly important. Managing frailty, sarcopenia, and cognitive impairment, which are the three major comorbidities of diabetes in the older adults, has become an urgent priority with the prolonged longevity of older adults with diabetes. Among these, frailty and sarcopenia are well-known in terms of their prevention and progression; however, both screening and intervention in clinical settings remain inadequate. As diabetes management becomes more complex with age, visible health issues predominantly dominate clinical resources, leaving latent problems, such as risk assessment for frailty and sarcopenia and the implementation of early interventions largely unaddressed. Based on their characteristics and health status, Japan’s Clinical Practice Guideline for the Treatment of Diabetes in the Elderly classifies patients into three categories: I (independent group), II (intermediate group), and III (dependent group),2,3 each with tailored glycemic targets. Although correcting hyperglycemia can increase the risk of hypoglycemia, this categorization emphasizes individualized, safe, and effective glucose management. In addition, several simple questionnaires for evaluating functional ability have been established, making the categorization more accessible in general practice.3,4 This study investigated the association of musculoskeletal indicators, which are closely related to frailty and sarcopenia, with the categorization. We aimed to identify the function of this classification, which is conventionally utilized to guide glycemic management, as a framework for comprehensive geriatric assessment (CGA) in older adults. This study analyzed 91 patients with diabetes aged ≥65 years who underwent dual-energy X-ray absorptiometry to measure skeletal muscle mass and bone density. The categorization was based on the daily function score-8, which is an eight-item questionnaire that assesses both basic and instrumental activities of daily living.4,5 The participants (mean age: 79.0 ± 6.3 years), consisting of 59 men (category I, 28; II, 23; III, 8) and 32 women (category I, 17; II, 10; III, 5), were classified into categories I (n = 45), II (n = 33), and III (n = 13). The skeletal muscle mass index (SMI) and femoral percentage of the young adult mean (%YAM) were as follows: Category I, SMI 6.3 ± 0.87 kg/m2, %YAM 85% ± 11%; category II, SMI 5.9 ± 0.98 kg/m2, %YAM 80% ± 18%; and category III, SMI 6.1 ± 0.98 kg/m2, %YAM 79% ± 17%. For analysis, participants were grouped into “healthy” (category I) and “impaired” (categories II and III). Multiple regression analysis, adjusted for age and sex, was conducted to investigate the association between the categorization and SMI or %YAM. A higher categorization was negatively associated with SMI (β = −0.183, P = 0.049). No significant interaction between sex and the categorization was observed for SMI (P > 0.05), whereas a significant interaction was found for %YAM (P = 0.011). In women, a higher categorization was negatively associated with %YAM (β = −0.474, P = 0.003), whereas no such association was found in men (β = 0.064, P = 0.633). As the category worsens, screening for frailty and sarcopenia becomes increasingly important Figure 1. Because the specific components and domains of functional decline can vary among individuals, a CGA is essential for older adults classified in the impaired category. CGA is particularly beneficial for patients exhibiting functional decline, and tailoring the assessment to the domains highlighted by the category classification may facilitate its implementation, even in outpatient settings. This targeted, stepwise approach enhances the feasibility and effectiveness of incorporating CGA into routine practice. Although the inclusion of body mass index as a covariate did not affect the results, the pathophysiology of frailty, sarcopenia, and osteoporosis is closely linked to diet and nutritional status. A key future challenge is the generation of evidence supporting personalized dietary interventions.Figure 1: “Category-Based Classification” as an Efficient Screening Tool for Identifying Geriatric Syndromes. aThe glycemic targets for individuals utilizing insulin formulations, sulfonylureas, glinides, etc., as delineated in the “Glycemic Targets for Elderly Patients with Diabetes,” are as follows. Various methods have been developed for efficient categorization. ADL: Activities of daily livingThese preliminary results support and emphasize the importance of “individualized diabetes care,” as outlined by the categorization. Further studies should aim to demonstrate the benefits of early intervention for high-risk patients, both at the individual and societal levels, to prevent geriatric syndromes. Ethics statement The study protocol was approved by the Institutional Review Board of the National Center for Geriatrics and Gerontology, Japan (IRB No. 1724; approval date: July 7, 2023). The informed consent was waived by the IRB. Data availability statement Anonymized data will be available on request to any qualified investigator after approval by the ethics committee. Financial support and sponsorship This study was supported by JSPS MEXT KAKENHI (JP23K16812) from the Japan Society for the Promotion of Science and by Research Funding for Longevity Science (24-1) from the National Center for Geriatrics and Gerontology. The funding agencies had no involvement in the preparation of this manuscript. Conflicts of interest There are no conflicts of interest.
Omura et al. (Mon,) studied this question.