[Cut-off point of the risk assessment scale for the 9-year risk of functional disability].

Objectives　This study aimed to examine the cut-off point of the Risk Assessment Scale (RAS) for predicting the 9-year risk of functional disability among older Japanese adults.Methods　This prospective, 9-year follow-up study used data from the Sasaguri Genkimon Study in Fukuoka. Of the 2,629 older adults who did not have functional disabilities and participated in the baseline survey in 2011, 2,254 with complete data were included in the analysis. The RAS was assessed using a questionnaire that showed good predictive and external validity for the 3-year risk of functional disability. The outcome was the incidence of functional disability during follow-up, which was defined as a new certification for the need for support or care. The cut-off point of the RAS was estimated as the point indicating the maximum χ2 value of the log-rank test. The predictive validity of the RAS for functional disability was examined using C-statistics for the total score, and sensitivity and specificity for the cut-off point, respectively. Participants were then categorized into two groups according to the cut-off point (high-score and low-score groups). Hazard ratio (HR) and 95% confidence interval (95% CI) of the 9-year risk of functional disability for the high-score group compared with the low-score group were calculated using the Cox proportional hazard model. In the multivariate model, HR was adjusted for living alone, education, economic status, drinking, smoking, and multimorbidity.Results　New functional disability was certified in 647 participants (28.7%) during a median follow-up period of 8.75 years. The cut-off point for functional disability was 13/14. The C-statistic was 0.774, and the sensitivity and specificity were 0.726 and 0.712, respectively. Compared to the low-score group (0-13 points), the HR (95% CI) of the high-score group (≥ 14 points) for incident functional disability in 9 years was 5.50 (4.62-6.54) in the crude model, and 4.81 (4.00-5.78) in the multivariate model (P<.001).Conclusion　This study, with its long follow-up period of 9 years, demonstrated that the 13/14 cut-off point of the RAS is suitable for the long-term assessment of functional disability risk. Our results suggest the possibility of using the 13/14 cut-off point of the RAS as a promising tool to grasp the risk of functional disability over a longer time frame, highlighting the potential for early prevention and intervention.

Physical, social, and dietary behavioral changes during the COVID-19 crisis and their effects on functional capacity in older adults.

BACKGROUND: This two-year follow-up study aimed to identify factors associated with unhealthy behaviors during the COVID-19 pandemic and examine their impact on functional capacity in older adults. METHODS: Altogether, 536 adults aged ≥65 years participated in this study. The frequency of going out, exercise habits, face-to-face and non-face-to-face interactions, social participation, and eating habits were examined as behavioral factors before and after the first declaration of a state of emergency in Japan. Functional capacity was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence. RESULTS: Using latent class analysis considering changes in the six behaviors, the participants were divided into healthy (n = 289) and unhealthy (n = 247) behavior groups. The male sex was associated with 2.36 times higher odds, diabetes with 2.19 times higher odds, depressive mood with 1.83 times higher odds, poor subjective economic status with 2.62 times higher odds, and living alone with 44% lower odds of being unhealthy. The unhealthy behavior group showed significantly decreased functional capacity (B =-1.56 [-1.98, -1.14]) than the healthy behavior group. For each behavior, negative changes in going out (B =-0.99 [-1.60, -0.37]), face-to-face interaction (B =-0.65 [-1.16, -0.13]), and non-face-to-face interactions (B =-0.80 [-1.36, -0.25]) were associated with a decline in functional capacity. CONCLUSION: Our results showed four factors associated with engaging in unhealthy lifestyle behaviors and how behavioral changes affect functional capacity decline during the COVID-19 pandemic, which will help to develop public health approaches.

[Development of a risk prediction model and a sample risk chart for long-term care certification based on the functional health of older adults].

Objectives　The first aim of this study was to develop risk prediction models based on age, sex, and functional health to estimate the absolute risk of the 3-year incidence of long-term care certification and to evaluate its performance. The second aim was to produce risk charts showing the probability of the incident long-term care certification as a tool for prompting older adults to engage in healthy behaviors.Methods　This study's data was obtained from older adults, aged ≥65 years, without any disability (i.e., they did not certify≥care level 1) and residing in Yabu, Hyogo Prefecture, Japan (n=5,964). A risk prediction model was developed using a logistic regression model that incorporated age and the Kihon Checklist (KCL) score or the Kaigo-Yobo Checklist (KYCL) score for each sex. The 3-year absolute risk of incidence of the long-term care certification (here defined as≥care level 1) was then calculated. We evaluated the model's discrimination and calibration abilities using the area under the receiver operating characteristic curves (AUC) and the Hosmer-Lemeshow goodness-of-fit test, respectively. For internal validity, the mean AUC was calculated using a 5-fold cross-validation method.Results　After excluding participants with missing KCL (n=4) or KYCL (n=1,516) data, we included 5,960 for the KCL analysis and 4,448 for the KYCL analysis. We identified incident long-term care certification for men and women during the follow-up period: 207 (8.2%) and 390 (11.3%) for KCL analysis and 128 (6.6%) and 256 (10.2%) for KYCL analysis, respectively. For calibration, the χ2 statistic for the risk prediction model using KCL and KYCL was: P=0.26 and P=0.44 in men and P=0.75 and P=0.20 in women, respectively. The AUC (mean AUC) in the KCL model was 0.86 (0.86) in men and 0.83 (0.83) in women. In the KYCL model, the AUC was 0.86 (0.85) in men and 0.85 (0.85) in women. The risk charts had six different colors, suggesting the predicted probability of incident long-term care certification.Conclusions　The risk prediction model demonstrated good discrimination, calibration, and internal validity. The risk charts proposed in our study are easy to use and may help older adults in recognizing their disability risk. These charts may also support health promotion activities by facilitating the assessment and modification of the daily behaviors of older adults in community settings. Further studies with larger sample size and external validity verification are needed to promote the widespread use of risk charts.

[Effects of a multifactorial intervention for improving frailty on risk of long-term care insurance certification, death, and long-term care cost among community-dwelling older adults: A quasi-experimental study using propensity score matching].

Objectives　To examine the effects of a multifactorial intervention for improving frailty-comprising resistance exercise and nutritional and psychosocial programs-on the risk of long-term care insurance (LTCI) certification, death, and long-term care (LTC) cost among community-dwelling older adults.Methods　Seventy-seven individuals (47 in 2011 and 30 in 2013) from the Hatoyama Cohort Study (742 individuals) participated in a multifactorial intervention. Non-participants were from the same cohort (including people who were invited to participate in the multifactorial intervention but declined). We performed propensity score matching with a ratio of 1 : 2 (intervention group vs. non-participant group). Afterward, 70 individuals undergoing the multifactorial intervention and 140 non-participants were selected. The risk of LTCI certification and/or death and the mean LTC cost during the follow-up period (32 months) were compared using the Cox proportional hazards model and generalized linear model (gamma regression model).Results　The incidence of new LTCI certification (per 1,000 person-years) tended to be lower in the intervention group than in the non-participant group (1.8 vs. 3.6), but this was not statistically significant as per the Cox proportional hazards model (hazard ratio=0.51, 95% confidence interval [CI]=0.17-1.54). Although the incidence of LTC cost was not significant, the mean cumulative LTC cost during the 32 months and the mean LTC cost per unit during the follow-up period (1 month) were 375,308 JPY and 11,906 JPY/month, respectively, in the intervention group and 1,040,727 JPY and 33,460 JPY/month, respectively, in the non-participant group. Cost tended to be lower in the intervention group than in the non-participant group as per the gamma regression model (cumulative LTC cost: cost ratio=0.36, 95%CI=0.11-1.21, P=0.099; LTC cost per unit follow-up period: cost ratio=0.36, 95%CI=0.11-1.12, P=0.076).Conclusions　These results suggest that a multifactorial intervention comprising resistance exercise, nutritional, and psychosocial programs is effective in lowering the incidence of LTCI certification, consequently saving LTC cost, although the results were not statistically significant. Further research with a stricter study design is needed.

Associations of aging trajectories for an index of frailty score with mortality and medical and long-term care costs among older Japanese undergoing health checkups.

AIM: Using up to 13 years of repeated-measures data, we identified aging trajectories for an index in frailty score among older Japanese undergoing health checkups. In addition, we examined whether these trajectories were associated with all-cause and cause-specific mortality and healthcare costs. METHODS: In total, 1698 adults aged ≥65 years completed annual assessments during 2002-2014. During follow-up, the average number of follow-up assessments was 3.9, and the total number of observations was 6373. Frailty was defined by using the following criteria from Fried's phenotype: slowness, weakness, exhaustion, low physical activity and weight loss. RESULTS: We identified four aging trajectories for frailty. Specifically, 6.5%, 47.3%, 30.3% and 16.0% of participants were in the high, second, third and low trajectory groups, respectively. As compared with the low trajectory group, the high trajectory group had greater risks of cardiovascular disease (adjusted hazard ratios of 3.42) and other-cause death (adjusted hazard ratios of 3.04). The high trajectory group had the highest medical costs until late in the eighth decade of life, costs decreased after age 70 years and were lowest at age 90 years (estimated at $116.7); however, medical and long-term care costs greatly increased after age 80 years in the second and third trajectory groups. CONCLUSIONS: Higher aging trajectories in frailty score were associated with elevated risks for cardiovascular, other-cause and all-cause death among older Japanese receiving health checkups. Medical and care needs greatly increased for the second and third trajectory groups when their frailty level was progressed in later life. Geriatr Gerontol Int 2020; 20: 1072-1078..

Healthy lifestyle behaviors and transitions in frailty status among independent community-dwelling older adults: The Yabu cohort study.

Frailty is a dynamic condition that can worsen or improve. Although previous studies have identified demographic and intrinsic factors associated with transitions in frailty status, less evidence is available regarding associations with daily activities. This longitudinal study examined associations of behavioral factors with incident frailty, adverse events (e.g. residence in a nursing home, hospitalization, and death), and frailty improvement among older adults. The analysis included data from 3,769 independent older adults aged 65 years or more (mean age, 76.3 ± 7.2years; proportion of frail participants, 30.1%) from the Yabu cohort study (baseline, 2012; follow-up, 2017). The Kaigo-Yobo Checklist, a standardized questionnaire, was used to assess frailty status (non-frail or frail) and seven behavioral factors: farming, shopping, exercise, eating habit, intellectual activity, social participation, and smoking. At the 5-year follow-up survey, the proportions of participants transitioning from non-frail to frail, from non-frail to incident adverse events, from frail to non-frail, and from frail to incident adverse events were 16.8%, 13.9%, 15.2%, and 50.1%, respectively. In the analysis of non-frail participants, farming, exercise, intellectual activity, and social participation were associated with lower odds of becoming frail and experiencing adverse events. In the analysis for frail participants, farming, intellectual activity, and social participation were significantly associated with improvement in frailty status, and farming, shopping, and social participation were associated with lower odds of incident adverse events. These findings suggest that farming, healthy daily activities, and social participation help improve and prevent frailty/adverse events.

Association of Trajectories of Higher-Level Functional Capacity with Mortality and Medical and Long-Term Care Costs Among Community-Dwelling Older Japanese.

Background: Higher-level functional capacity is crucial component for independent living in later life. We used repeated-measures analysis to identify aging trajectories in higher-level functional capacity. We then determined whether these trajectories were associated with all-cause mortality and examined differences in medical and long-term care costs between trajectories among community-dwelling older Japanese. Methods: 2,675 adults aged 65-90 years participated in annual geriatric health assessments and biennial health monitoring surveys during the period from October 2001 through August 2011. The average number of follow-up assessments was 4.0, and the total number of observations was 10,609. Higher-level functional capacity, which correspond to the fourth and fifth sublevels of Lawton's hierarchical model, was assessed with the Tokyo Metropolitan Institute of Gerontology-Index of Competence (TMIG-IC). Results: We identified four distinct trajectory patterns (high-stable, late-onset decreasing, early-onset decreasing, and low-decreasing) on the TMIG-IC through age 65-90 years. As compared with the high-stable trajectory group, participants in the late-onset decreasing, early-onset decreasing, and low-decreasing TMIG-IC trajectory groups had adjusted hazard ratios for mortality of 1.22 (95% confidence interval: 1.01-1.47), 1.90 (1.53-2.36), and 2.87 (2.14-3.84), respectively. Participants with high-stable and late-onset decreasing higher-level functional capacity trajectories had lower mean monthly medical costs and long-term care costs. In contrast, mean total costs were higher for those with low-decreasing trajectories, after excluding the large increase in such costs at the end of life. Conclusions: People with a low-decreasing aging trajectory in higher-level functional capacity had higher risks of death and had high monthly total costs.

A Community-Wide Intervention Trial for Preventing and Reducing Frailty Among Older Adults Living in Metropolitan Areas: Design and Baseline Survey for a Study Integrating Participatory Action Research With a Cluster Trial.

BACKGROUND: Preventing and reducing frailty is an important challenge for Japan in the next decade, especially in metropolitan areas. We launched a community-wide intervention trial (the Ota Genki Senior Project) in 2016 to develop effective community-based strategies for frailty prevention in metropolitan areas. This report describes the study design and baseline survey. METHODS: This study is a community-wide intervention trial that integrates participatory action research into a cluster non-randomized controlled trial for adults aged 65 years or older living in Ota City, Tokyo. We allocated 3 of 18 districts to an intervention group and the other 15 to a control group. Using a mailed self-administered questionnaire, we conducted a baseline survey of 15,500 residents (8,000 and 7,500 in the intervention and control groups, respectively) from July through August 2016. In addition to socioeconomic status and lifestyle variables, we assessed frailty status (primary outcome) and physical, nutritional, and psychosocial variables (secondary outcomes). Based on the baseline findings, an intervention to improve outcomes will be implemented as participatory action research. Follow-up surveys will be conducted in the same manner as the baseline survey. RESULTS: A total of 11,925 questionnaires were returned (76.9% response rate; 6,105 [76.3%] and 5,820 [77.6%] in the intervention and control groups, respectively), and 11,701 were included in the analysis (mean age, 74.3 [standard deviation, 5.5] years; 48.5% were men). CONCLUSIONS: This study is expected to contribute to development of a prototype of a community-wide frailty prevention strategy, especially in metropolitan areas in Japan. TRIAL REGISTRATION: UMIN Clinical Trials Registry (UMIN000026515).

[Prospective study of cognitive decline assessed using the mini-mental state examination and the risk of incident long-term care insurance among community-dwelling older Japanese].

AIM: We examined the longitudinal association between the change in the Mini-Mental State Examination (MMSE) score per year and the incidence of a certified need for care in the long-term care insurance system among community-dwelling older Japanese subjects. METHODS: A total of 773 adults 65 years of age or older who participated in a baseline survey (2002 to 2007) underwent MMSE reevaluation at least once until Wave-1 (2003 to 2008). The incidence of a certified need for care in the long-term care insurance system until Wave-2 (Wave-1 to 2013) was examined in all subjects. RESULTS: During an average follow-up of 1,195 days (baseline survey to Wave-1), the change in the MMSE score per year was greater than 0 in 511 (66.1%) participants, 0 to -0.5 in 94 (12.2%) participants, -0.5 to -1 in 66 (8.5%) participants, -1 to -2 in 56 (7.2%) participants, and less than -2 in 46 (6.0%) participants. During an average follow-up of 1,802 days (Wave-1 to Wave-2), 104 participants (13.5%) were newly certified with a need for care in the long-term care insurance system. After controlling for important confounders, elders with a change in the MMSE score of 0 to -0.5, -0.5 to -1, -1 to -2 and less than -2 per year were 1.73 (95% confidence interval, 0.93-3.23), 1.94 (1.01-3.45), 1.95 (1.02-3.76) and 3.16 (1.68-5.98) times as likely to be newly certified with a need for care in the long-term care insurance system, respectively, compared those with a change in the score greater than 0. CONCLUSIONS: The extent of change in the MMSE score per year independently predicted the incident certified need for care in the long-term care insurance system in a general population of older Japanese subjects. A decrease of greater than 0.5 points per year may be a useful cutoff value for clinically evaluating elders.

The Yabu cohort study: design and profile of participants at baseline.

BACKGROUND: Further evidence into the effects of social relationships on health (including those at both the individual and community levels) is needed in Japan. The Yabu Cohort Study was launched in 2012 to identify the associations between social relationships and health among community-dwelling older Japanese people and to evaluate population approaches for preventive long-term care in the community. This report describes the study design and the profile of the participants at baseline. METHODS: The Yabu Cohort Study is a prospective study of community-dwelling individuals aged 65 years and older in Yabu, Hyogo Prefecture, Japan. The baseline survey, using a mailed self-administered questionnaire, was conducted from July through August 2012. It included information on socioeconomic status, general and psychological health, and social relationships (social network, social support, and social capital). Survival time, long-term care insurance certification, and medical and long-term care costs after the baseline survey will be followed. RESULTS: Of 7271 questionnaires distributed, a total of 6652 were returned (91.5% response rate), and 6241 were included in the analysis. Mean age was 71.9 ± 5.2 years, 43.2% were men, and 83.8% had lived in their neighborhood for more than 40 years. Approximately 45.2% expressed general trust. About 82.4%, 49.9%, and 55.5% have participated in neighborhood association activities, municipal seminars for preventive long-term care, and salon activities in the community, respectively. CONCLUSIONS: The study is expected to provide valuable evidence on the effects of social relationships on health and to suggest the usefulness of population approaches for preventive long-term care in Japanese communities.

Normative data for the montreal cognitive assessment in a Japanese community-dwelling older population.

BACKGROUND: Although the Montreal Cognitive Assessment (MoCA) is acknowledged as a promising neuropsychological tool, its normative data for older populations have not been established yet. The purpose of this study was to provide normative data for the MoCA in Japanese community-dwelling older people. METHODS: In a Japanese town, 1,977 participants aged 65 years or older (mean age 73.6 years; male 41.3%) completed MoCA tests. After descriptive and regression analyses, normative data were developed for MoCA scores in the population. RESULTS: The mean MoCA score observed (21.8 points) was lower than that for normal controls (27.4 points) in the original validation study of the MoCA. Additionally, 82.6% of MoCA scores fell below the standard cutoff of 26 points for detecting mild cognitive impairment (MCI). The regression analysis showed that higher age and fewer years of formal education were associated with lower MoCA scores (p < 0.001). Normative data for MoCA scores were presented with respect to age and education. CONCLUSION: This study provided normative data for the MoCA in a Japanese community-dwelling older population. This research also suggests that conventional use of the MoCA as a screening tool for MCI might be problematic in cultures different from that in which the cutoff was developed.