[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.

[A framework for promoting and evaluating "Kayoi-no-ba" initiatives according to the Plan-Do-Check-Action cycle: The ACT-RECIPE framework].

Objective　In 2019, the Ministry of Health, Labour and Welfare emphasized the importance of promoting "Kayoi-no-ba" (or "places to go") initiatives according to the Plan-Do-Check-Action (PDCA) cycle. However, it proposed no specific promotion measures or standardized evaluation frameworks. This study is intended to propose a framework for local government officials to promote and evaluate "Kayoi-no-ba" initiatives according to the PDCA cycle.Methods　The working group (WG) conducted a narrative review of research and extracted evaluation models and indicators that could be used to create the framework. The co-researcher review committee discussed a draft framework prepared by the WG, and the WG revised it based on the discussion; this process was repeated four times. Using the completed framework, we calculated the score of the "Kayoi-no-ba" initiatives in 50 Tokyo municipalities and conducted regional correlation analyses on the relationship between the score of the "Kayoi-no-ba" initiatives in 50 Tokyo municipalities and the number of "Kayoi-no-ba" per 1,000 older persons.Results　The completed framework (named "ACT-RECIPE" by rearranging the underlined characters below) comprised the following six evaluation phases: (1) Comprehension: understanding the key lessons around disability and frailty prevention, and the necessity for "Kayoi-no-ba"; (2) Research and Planning: clarifying the current status of "Kayoi-no-ba," the strengths of the community, and the issues to be addressed through a community assessment, and developing a plan to resolve the issues; (3) Team Building and Collaboration: building a team by collaborating with organizations to solve problems; (4) Implementation: implementing the initiatives necessary to solve problems; (5) Evaluation: verifying changes in output and outcome indicators from the initiatives; and (6) Adjustment and Improvement: re-examining plans, teams, content, and goals based on the evaluation results. In these six phases, we designated 10 core items and accompanying subitems. The median score rate of the ACT-RECIPE framework in 50 municipalities was 75% for "Comprehension," 61% for "Research and Planning," 69% for "Team Building and Collaboration," 64% for "Implementation," 31% for "Evaluation," and 56% for "Adjustment and Improvement," and the mean ACT-RECIPE score rate was 57%. A significant positive correlation (rs=0.43, P=0.002) was observed between the ACT-RECIPE mean score rate and the number of "Kayoi-no-ba" per 1,000 older persons.Conclusion　We proposed the ACT-RECIPE as a framework for promoting and evaluating "Kayoi-no-ba" initiatives according to the PDCA cycle. We hope that this framework will lead to further progress in "Kayoi-no-ba" initiatives and facilitate evaluation of their effectiveness according to the PDCA cycle.

Accelerometer-measured sedentary behavior and risk of functional disability in older Japanese adults: a 9-year prospective cohort study.

BACKGROUND: The associations of sedentary time and patterns with functional disability among older adults remain unclear, and few studies have accounted for the co-dependency of sedentary behavior and physical activities when modeling sedentary behavior with risk of functional disability. We aimed to examine the associations between sedentary time and patterns and risk of incident functional disability, and assess whether replacing sedentary time with light physical activity (LPA) or moderate-to-vigorous intensity physical activity (MVPA) is associated with reduced risk of functional disability in community-dwelling older adults. METHODS: A total of 1,687 Japanese adults aged ≥ 65 years without functional disability at baseline were prospectively followed-up for 9 years (2011-2020). Functional disability was ascertained using the national database of Japan's Long-term Care Insurance System. Sedentary time and patterns, LPA, and MVPA were measured using a tri-axial accelerometer secured to participants' waists. RESULTS: During follow-up, 466 participants developed functional disability. Compared with the lowest quartile of total sedentary time, the multivariable-adjusted hazard ratios (95% confidence intervals) of functional disability for the second, third, and top quartiles were 1.21 (0.91‒1.62), 1.45 (1.10‒1.92), and 1.40 (1.05‒1.88) (p for trend = 0.01). After further adjusting for MVPA, total sedentary time was no longer significantly associated with the risk of functional disability (p for trend = 0.41). Replacing 10 min/day of sedentary time with the same amount of MVPA (but not LPA) was significantly associated with a 12% reduced risk of functional disability (hazard ratio [95% confidence interval]: 0.88 [0.84‒0.92]). No significant association was observed between sedentary bout length and functional disability. CONCLUSION: Higher levels of total sedentary time were associated with an increased risk of incident functional disability. However, this association was not independent of MVPA. Replacing sedentary time with MVPA, but not LPA, was associated with reduced risk of functional disability in older adults.

Effects of community-based frailty-preventing intervention on all-cause and cause-specific functional disability in older adults living in rural Japan: A propensity score analysis.

Preventing frailty is crucial in aging societies. We examined the effectiveness of a community-based frailty-prevention program for delaying the onset of functional disability among community-dwelling older adults. From 2014 to 2019, 48 community-based frailty prevention classes (FPC, 60 min/session, once a week), comprising resistance exercise and nutritional or psychosocial programs, were established in Yabu City, Japan. We conducted a baseline survey in 2012 and followed up with participants for up to 6.8 years (4.8 years from establishing the first FPC). We analyzed data from 3350 older people. The primary and secondary outcomes were the onset of functional disability and cause-specific functional disability (including dementia and cardiovascular and orthopedic diseases), respectively. In addition to crude Cox proportional hazard regression, inverse probability of treatment weighting (IPTW) and propensity score matching (PSM; 918 nonparticipants and 459 participants) were used to adjust for confounders. Participants were more likely to be female and have a healthy lifestyle than nonparticipants. During the follow-up, 690 individuals developed a functional disability. The hazard ratio of incident functional disability in the participants was significantly lower than that in nonparticipants in the IPTW (hazard ratio 0.53, 95% confidential interval 0.38-0.75) and PSM (0.52, 0.37-0.71) analyses. In age-stratified analysis, significant associations were observed only in the ≥75-year-old subgroup. In a cause-specific analysis, participation significantly and consistently reduced incident functional disability caused by dementia (IPTW 0.47, 0.25-0.86; PSM 0.45, 0.25-0.83). Community-based FPC may be effective for preventing functional disability, especially caused by dementia, in this population.

Combined Impacts of Physical Activity, Dietary Variety, and Social Interaction on Incident Functional Disability in Older Japanese Adults.

BACKGROUND: This 3.6-year prospective study examined combined impacts of physical activity, dietary variety, and social interaction on incident disability and estimated population-attributable fraction for disability reduction in older adults. METHODS: Participants were 7,822 initially non-disabled residents (3,966 men and 3,856 women) aged 65-84 years of Ota City, Tokyo, Japan. Sufficiency of moderate-to-vigorous-intensity physical activity (MVPA) ≥150 min/week, dietary variety score (DVS) ≥3 (median), and social interaction (face-to-face and/or non-face-to-face) ≥1 time/week was assessed using self-administered questionnaires. Disability incidence was prospectively identified using the long-term care insurance system's nationally unified database. RESULTS: During a follow-up of 3.6 years, 1,046 (13.4%) individuals had disabilities. Independent multivariate-hazard ratios (HRs) and 95% confidence intervals (CIs) of MVPA, DVS, and social interaction sufficiency for incident disability were 0.68 (95% CI, 0.59-0.78), 0.87 (95% CI, 0.77-0.99), and 0.90 (95% CI, 0.79-1.03), respectively. Incident disability HRs gradually reduced with increased frequency of satisfying these behaviors (any one: HR 0.82; 95% CI, 0.65-1.03; any two: HR 0.65; 95% CI, 0.52-0.82; and all three behaviors: HR 0.54; 95% CI, 0.43-0.69), in an inverse dose-response manner (P < 0.001 for trend). Population-attributable fraction for disability reduction in satisfying any one, any two, and all three behaviors were 4.0% (95% CI, -0.2 to 7.9%), 9.6% (95% CI, 4.8-14.1%), and 16.0% (95% CI, 8.7-22.8%), respectively. CONCLUSION: Combining physical activity, dietary variety, and social interaction substantially enhances the impacts on preventing disability among older adults, with evidence of an inverse dose-response manner. Improving insufficient behavior elements through individual habits and preexisting social group activities may be effective in preventing disability in the community.

Association of dietary variety with the risk for dementia: the Yabu cohort study.

OBJECTIVE: The consumption of various foods is internationally recommended in healthy diet although the association between dietary variety and incident dementia is unknown. We aimed to examine the association between dietary variety and the incidence of disabling dementia in older Japanese adults. DESIGN: We conducted a prospective cohort study. Dietary variety was assessed based on the Dietary Variety Score (DVS). DVS was assessed by counting the number of ten food components (meat, fish/shellfish, eggs, milk, soyabean products, green/yellow vegetables, potatoes, fruit, seaweed and fats/oils) that were consumed almost daily using a FFQ. Participants were categorised into low (0-2 points), middle (3-4 points) and high (5-10 points) groups based on the DVS. Data on newly diagnosed disabling dementia were retrieved from the public long-term care insurance database. Cox proportional hazards regression was used to estimate hazard ratios (HR) with 95 % CI. SETTING: Yabu cohort study, Japan. PARTICIPANTS: A total of 4972 community-dwelling adults aged 65 years or older. RESULTS: During the median follow-up of 6·8 years, 884 participants were newly diagnosed with disabling dementia. After adjusting for confounders, the multivariable-adjusted HR for incident disabling dementia was 0·82 (95 % CI, 0·69, 0·97) for participants in the highest DVS category compared with those in the lowest DVS category (Pfor trend = 0·019). CONCLUSIONS: A higher dietary variety is associated with a reduced risk of disabling dementia in older Japanese adults. These results have potential implications for the development of effective public nutritional approaches to prevent dementia in older adults.

The Kesennuma Study in Miyagi, Japan: Study Design and Baseline Profiles of Participants.

BACKGROUND: To clarify the association between psychosocial problems and frailty in the areas affected by the Great East Japan Earthquake, and to develop strategies for preventive long-term care in the community, we launched the Kesennuma Study in 2019. This report describes the study design and the participants' profiles at baseline. METHODS: The prospective study comprised 9,754 people (4,548 men and 5,206 women) randomly selected from community-dwelling independent adults aged 65 to 84 who were living in Kesennuma City, Miyagi. The baseline survey was conducted in October 2019. It included information on general health, socio-economic status, frailty, lifestyle, psychological factors (eg, personality, depressive moods), and social factors (eg, social isolation, social capital). A follow-up questionnaire survey is planned. Mortality, incident disability, and long-term care insurance certifications will also be collected. RESULTS: A total of 8,150 questionnaires were returned (83.6% response rate), and 7,845 were included in the analysis (80.4%; mean age 73.6 [standard deviation, 5.5] years; 44.7% male). About 23.5% were considered frail. Regarding psychological and social functions, 42.7% had depressive moods, 29.1% were socially isolated, and only 37.0% participated in social activities at least once a month. However, 82.5% trusted their neighbors. CONCLUSION: While local ties were strong, low social activity and poor mental health were revealed as issues in the affected area. Focusing on the association between psychological and social factors and frailty, we aim to delay the need for long-term care for as long as possible, through exercise, nutrition, social participation, and improvement of mental health.

Dose-Response Associations of Physical Activity and Sitting Time with All-Cause Mortality in Older Japanese Adults.

PURPOSE: Although examining the dose-response curves of physical activity (PA) and sitting time with health-related outcomes is an important research agenda, the results for older Japanese adults are extremely limited. We examined the dose-response associations of PA and sitting time with all-cause mortality among older Japanese. METHODS: Initially, 8,069 non-disabled residents (4,073 men; 3,996 women) aged 65-84 years of Ota City, Japan, were recruited. Moderate-to-vigorous PA (MVPA) and sitting time were evaluated using the International Physical Activity Questionnaire-Short Form. Multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of MVPA and sitting time for all-cause mortality were calculated, and the dose-response curves were examined using restricted cubic splines (RCS). RESULTS: During 4.1 years of follow-up, 458 participants (5.7%; 331 men and 127 women) died. Compared with the low MVPA (<600 metabolic equivalents [METs]·minutes/week) group, HR for mortality gradually reduced in moderate (600-3000 METs·minutes/week) and high (>3000 METs·minutes/week) MVPA groups (moderate: HR 0.66; 95% CI, 0.54-0.82; high: HR 0.58; 95% CI, 0.45-0.75; P <0.001 for trend). RCS showed that the HR for mortality reduced linearly up to approximately 2000 METs·minutes/week of MVPA, and maximal risk reduction was seen at approximately 3000-4500 METs·minutes/week of MVPA. No significant dose-response association of sitting time with mortality was observed. CONCLUSIONS: Higher MVPA levels reduced all-cause mortality risk, in a significant inverse non-linear dose-response manner. Sitting time was not significantly associated with all-cause mortality. It is important to disseminate the significance of even a slight increase in the MVPA.

[Diversity of participants and autonomy of community residents by types of "Kayoi-no-ba": findings from a survey of urban voluntary groups in which older adults participate].

Objectives　A recent long-term care insurance policy encourages the promotion of various types of "Kayoi-no-ba," or places to go, not limited to those focusing on functional training, as resident activities are expected to keep older adults from needing care. In this study, Kayoi-no-ba were voluntary groups in which older adults participated, and their attributes were examined in terms of "diversity of participants" and "autonomy of community residents," based on the type of group.Methods　The staff from the preventing long-term care division in each of the 38 municipalities in Tokyo selected 175 voluntary groups that met three criteria: (1) more than three community residents participate in activities at least once a month, (2) participants are primarily older adults or multi-generational residents including older adults, and (3) community residents participate in group management. Representatives from 165 groups responded to the questionnaire. For the group categorization, a latent class analysis was performed using the goals and activities of the group. Participants' age, gender, and health status were used to assess diversity. The number of residents who managed and/or supported group activities and the precise role the residents played in the activities were used to assess autonomy.Results　The groups were categorized into four types: "Physical Exercises," where the primary activity was physical exercise; "Multi-purpose," which included various purposes and activities; "Social Interaction Oriented," where interaction with others was the goal, but physical exercise was not; and "Non-Interaction," where social interaction was not the goal. Participants in the Multi-purpose group ranged in age and were more likely to have health problems, such as mobility limitations, dementia, and frailty, than those in the Physical Exercises and Social Interaction Oriented groups. Moreover, the Multi-purpose group had more resident managers and supporters involved in various roles.Conclusion　The Multi-purpose group had the most diverse participants and autonomy of residents. However, the type of Kayoi-no-ba should not be considered fixed. The support system should encourage flexible changes such as adding a new activity depending on the situation and the varying needs of the residents.

[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.

[Development and evaluation of a modified version of the dietary variety score for community-dwelling older adults].

Objectives　The dietary variety score (DVS) was developed as an index to assess the variety of food intake among older Japanese adults and has been widely used in epidemiological studies and public health settings. However, this index has not been reviewed since its development in the 1990s and may not adequately reflect the current dietary habits of the older Japanese population. In this study, we developed a modified version of the DVS (MDVS) and examined its validity.Methods　We conducted a cross-sectional study of 357 community-dwelling adults aged ≥65 years (mean age: 76.2±4.6, men: 61.1%) who participated in the 2016 survey of the Hatoyama cohort study. The DVS and MDVS were assessed by the number of food groups eaten almost every day based on the weekly frequency of consumption. The DVS was calculated based on ten components: meat, fish/shellfish, eggs, milk, soybean products, green/yellow vegetables, potatoes, fruits, seaweed, and fats/oils. The components of the MDVS were determined by calculating the contribution of each food group to the total and nutrient intakes from the food groups comprising the main dish, side dish, and soup, based on the data from older adults aged ≥65 years who participated in the 2017 National Health and Nutrition Survey in Japan. Based on the contribution of each food group, we added "other vegetables" and "dairy products" in the MDVS. Dietary intake was assessed using a validated, self-administered diet history questionnaire. We calculated the probability of adequacy for each of the fourteen nutrients selected as per the estimated average requirement in the Dietary Reference Intake for Japanese 2020 and the mean probability of adequacy for all fourteen nutrients. In addition, we assessed the correlation between the DVS, MDVS, and each indicator and the significance of the difference between correlation coefficients.Results　The MDVS was significantly positively correlated with the energy ratios of protein and fat, dietary fiber, potassium, and the modified diet score based on the Japanese Food Guide Spinning Top (r=0.21-0.45) and negatively correlated with the carbohydrate energy ratio (r=-0.32). The MDVS was also correlated with the mean probability of nutrient adequacy (r=0.41). The correlation coefficients between the MDVS and each indicator were not significantly different from those of the DVS.Conclusions　Validity in terms of nutrient intake and diet quality was comparable between the DVS and MDVS. To revise the DVS, it is necessary to conduct nationwide studies based on highly accurate dietary surveys.

Development of risk prediction models for incident frailty and their performance evaluation.

There is currently no tool to predict incident frailty despite various frailty assessment tools. This study aimed to develop risk prediction models for incident frailty and evaluated their performance on discrimination, calibration, and internal validity. This 2-year follow-up study used data from 5076 non-frail older adults (51% women) living in Tokyo at baseline. We used the Kaigo-Yobo checklist, a standardised assessment instrument, to determine frailty. Twenty questionnaire-based variables that include sociodemographic, medical, behavioural, and subjective factors were entered into binary logistic regression analysis with stepwise backward elimination (p < 0.1 for retention in the model). Discrimination and calibration were assessed by area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow test, respectively. For the assessment of internal validity, we used a 5-fold cross-validation method and calculated the mean AUC. At the follow-up survey, 15.0% of men and 10.2% of women were frail. The frailty risk prediction model was composed of 10 variables for men and 11 for women. AUC of the model was 0.71 in men and 0.72 in women. The P-value for the Hosmer-Lemeshow test in both models was more than 0.05. For internal validity, the mean AUC was 0.71 in men and 0.72 in women. Probability of incident frailty rose with an increasing risk score that was calculated from the developed models. These results demonstrated that the developed models enable the identification of non-frail older adults at high risk of incident frailty, which could help to implement preventive approaches in community settings.

[Trajectories of Dietary Variety Score among community-dwelling older Japanese and their related factors].

AIM: To categorize the age-related trajectories of dietary variety score (DVS) in the community-dwelling elderly and to examine the associated factors. METHODS: The study population included 1,195 people who underwent a medical checkup for the elderly in Kusatsu-town, Gunma Prefecture in 2012 to 2017. A multinomial logistic regression analysis was performed to examine the factors associated with the age-related trajectories of DVS. The dependent variables were sex, age, family structure, years of education, BMI, subjective chewing ability, TMIG-IC, GDS-15, MMSE, smoking, alcohol consumption, and history of hypertension, dyslipidemia, diabetes mellitus, and stroke. RESULTS: The adjusted odds ratio (95% confidence intervals) of the low trajectory group in comparison to the medium trajectory group were 2.69 (1.02-7.08) for subjective chewing ability (no chewing), 1.11 (1.06-1.17) for GDS-15, 1.76 (1.14-2.73) for current smoking, and 1.70 (1.19-2.43) for past smoking. In contrast, the adjusted odds ratio of the high trajectory group in comparison to the medium trajectory group were 0.61 (0.37-1.00) for men, 1.04 (1.01-1.07) for age, 0.58 (0.38-0.89) for subjective masticatory ability (difficult to chew), 0.88 (0.82-0.96) for GDS-15, and 0.55 (0.37-0.83) for a history of hypertension. CONCLUSIONS: The age-related trajectory patterns of DVS in the community-dwelling elderly can be categorized into three types. In order to maintain a high quality of food intake, it was shown that, in addition to subjective masticatory ability and mental health factors, such as depression, we should pay attention to the control of hypertension, which is a risk factor for lifestyle diseases, and lifestyle habits such as smoking.

[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.

[Impact of lifestyle-related diseases and frailty on the incidence of loss of independence in Japanese community-dwelling older adults: A Longitudinal Study on Aging and Health in Kusatsu].

Objectives　This study aimed to determine risk factors for frailty and lifestyle-related diseases impacting the incidence of loss of independence among Japanese community-dwelling older adults, and to measure the magnitude of these associations.Methods　We conducted an 8.1-year prospective study involving 1,214 residents of the town of Kusatsu, aged 65 years and over, who were initially free of disability and underwent the comprehensive geriatric assessment between 2002 and 2011. Loss of independence was defined as the incidence of disability or having died before the occurrence of disability was certified by the Long-Term Care Insurance program in Japan. Risk factors for lifestyle-related diseases and health status comprised hypertension, diabetes mellitus, overweight, chronic kidney disease, current smoking, past history of stroke, heart disease and cancer, frailty, underweight, anemia, hypoalbuminemia, and cognitive decline. Frailty was defined as the presence of three or more of the following criteria: Weight loss, weakness, exhaustion, slowness, and low levels of physical activity. Prefrailty was defined as the presence of one or two of these same criteria. Cox proportional-hazard regression model was used to estimate hazard ratios (HR) and the population attributable fraction (PAF) of loss of independence.Results　During the follow-up, 475 cases, including 372 disabilities and 103 deaths, were identified as having experienced loss of independence. The multivariable HRs for the loss of independence were 1.3 to 2.2-fold higher for the presence of frailty, past history of stroke, cognitive decline, prefrailty, and smoking. The PAF of loss of independence was the greatest for prefrailty (19%), followed by frailty (12%). The PAF was relatively large for prefrailty (19%) and smoking (11%) in men, and frailty (18%), prefrailty (18%), and chronic kidney disease (11%) in women. Stratified by age category, participants aged 65-74 years having frailty and several lifestyle-related diseases showed significantly higher HRs for loss of independence and greater PAFs for prefrailty (18%), frailty (13%), and smoking (11%).Conclusions　Loss of independence among Japanese community-dwelling older adults who underwent screening examinations was largely attributed to frailty and prefrailty. Our findings suggest that the screening and the intervention for frailty and lifestyle-related diseases in the early stages of old age might be beneficial in prolonging healthy life expectancy of Japanese community-dwelling older adults.

[Awareness of the term "frailty" and its correlates among older adults living in a metropolitan area].

Objectives　This study aimed to examine the awareness of the term "frailty" and its correlates among older adults living in a Japanese metropolitan area.Methods　We used baseline and 2-year follow-up data from a community-wide intervention on preventing frailty in Ota City, Tokyo. In July 2016, we conducted a self-administered questionnaire survey via mail to investigate the lifestyle and health status of 15,500 non-disabled residents aged 65-84 years from all 18 districts. In July 2018, we investigated the awareness of the term "frailty" in the same sample using a different questionnaire, and 10,228 people (4,977 men and 5,251 women) were included in the analyses. In addition, 9,069 people (4,347 men and 4,722 women) who responded to both 2016 and 2018 surveys were analyzed for correlates of awareness of the term "frailty." We categorized the responses "I know the meaning" or "I have heard of it but do not know the meaning" as awareness of the term. Decision tree and multilevel Poisson regression analyses were performed to examine the association of the following with awareness of "frailty": age, marital status, living situation, education, equivalent income, body mass index, number of chronic diseases, alcohol consumption, smoking status, Dietary Variety Score (DVS), and presence or absence of lower back and knee pains, depressive mood, exercise habits, social activity, social isolation, and frailty.Results　Awareness of the term "frailty" was estimated as 20.1% in total (15.5% in men and 24.3% in women). The subgroup with the highest "frailty" awareness was women who exercised, were socially active, and had a DVS of 4 or more (awareness of 36.3%). Significant independent correlates of "frailty" awareness were age (as per year: multivariate-adjusted prevalence ratio=1.03, [95% confidence interval=1.02-1.04]), sex (women: 1.35 [1.21-1.51]), educational attainment (high school: 1.27 [1.11-1.45], higher than junior college/vocational schools: 1.47 [1.28-1.70]), equivalent income (more than 2.5 million yen/year: 1.12 [1.01-1.25]), exercise habits (presence: 1.26 [1.11-1.43]), DVS (6 points or more: 1.37 [1.21-1.55]), social activity (presence: 1.33 [1.20-1.49]), social isolation (presence: 0.75 [0.67-0.85]), and frailty (presence: 0.72 [0.62-0.84]).Conclusions　Although many policies refer to "frailty," the level of awareness of the term among older adults was low. Older adults, especially women, who had higher socioeconomic status, better exercise and dietary habits, and stronger social connections, were significantly more aware of the term. In contrast, individuals who were socially isolated and/or frail did not know the term. Thus, it is crucial to develop specific measures to promote frailty prevention among high-risk individuals.

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).

[Process and outcome evaluation of community-based strategies for frailty prevention in the elderly with the help of the senior workforce at Silver Human Resources Centers in Yabu City, Japan].

Objectives　Preventing frailty is a crucial issue in aging societies such as Japan. In 2011, we launched an action research project in Yabu City, Hyogo Prefecture, to develop effective community-based strategies to prevent frailty in the elderly. We attempted to introduce community-based frailty prevention classes in every administrative district with the help of the senior workforce at Silver Human Resources Centers. This study aimed to evaluate the effectiveness and the applicability to different communities of this strategy, which will be called the "Yabu model."Methods　Using PAIREM (Plan, Adoption, Implementation, Reach, Effectiveness, Maintenance) framework, we evaluated the effectiveness and the applicability to different communities of the Yabu model. To evaluate its effectiveness, we conducted a baseline and follow-up survey of residents aged 65 years or older in 2012 (n=7,287, 90.7% response rate) and 2017 (n=8,157, 85.7%), using a mailed self-administered questionnaire.Results　(1) Plan: The idea was to establish a frailty prevention class (60 min/session, once a week) consisting of resistance exercises and nutritional or psychosocial programs (standard course, six months, 20 sessions/course; short course, one and a half months, 6 sessions/course; after the course, residents continued with the activities themselves). We planned to launch three classes in the first year (2014) and then to increase the number of classes by ten each year after the second year. (2) Adoption: Out of 154 administrative districts, 36 (23.4%) held frailty prevention classes between 2014 and 2017. (3) Implementation: The median attendance rate for the standard or short course (number of times each participant attended/number of frailty prevention class sessions held) was 75.0%. (4) Reach: A total of 719 older people participated in the standard or short course. The participation rate in the administrative districts, where each frailty prevention class was held, was 32.8%, while at the city level it was 8.1%. (5) Effectiveness: Propensity score matching after multiple imputations were performed. While the prevalence of frailty in non-participants increased by 13.7% in the five years from 2012 to 2017, it only increased by 6.8% in participants. Compared to non-participants, program participants had a significantly lower prevalence odds ratio of frailty at the time of the follow-up survey (OR=0.65, 95% confidence interval 0.46-0.93). (6) Maintenance: After the standard or short course, 25 out of 26 communities (96.2%) continued the frailty prevention activities once a week.Conclusion　The frailty prevention classes were adopted across many districts and lowered the participants' risk of frailty. Moreover, participants continued to engage in frailty prevention activities even after the course. These results indicate the Yabu model's effectiveness and its applicability for a different community.