Mexico-Japan Encounter on Active and Healthy Aging. Mexico City, February 10, 2015

Prevention of frailty and healthy aging: a 10-year community intervention in Japan.

Shoji Shinkai, MD, PhD, MPH

Research Team for Social Participation and Community Health,

Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan

What I talk about will be:

In Japan, the late onset disability becomes the major type of active life loss in old ages.

For further achieving healthy aging in Japan, it is important to focus on frailty, which precedes the late onset disability.

A comprehensive system incorporating primary to tertiary prevention of frailty is needed for tackling this issue.

Our ten-year community intervention showed that such

system was effective for assisting healthy aging in community-living older adults.

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63- 66- 69- 72- 75- 78- 81- 84- 87-

Independent in IADL&ADL

IADL disability

ADL disability

Males

Age (years)

Akiyama H et al. 『Kagaku』, Iwanami Publisher, 2010

Death

（10.9%）

（70.1%） （19.0%）

Patterns of Functional Decline in Later Life

20-year prospective study on Japanese elderly (N=5717)

late onset disability early onset disability

Successful aging

（87.9%）

（12.1%）

Patterns of Functional Decline in Later Life

20-year prospective study on Japanese elderly (N=5717)

Females

IADL disability

ADL disability

Death

Age (years)

Akiyama H et al. 『Kagaku』, Iwanami Publisher, 2010

63- 66- 69- 72- 75- 78- 81- 84- 87-

late onset disability

Independent in IADL&ADL

early onset disability

Molecular

& Genetic Physiology Frailty Disability

What is frailty? Frailty is an age-related syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems and causing vulnerability to adverse outcomes (Fried et al, 2001).

8 Can you see things clearly ? (visual impairment) 0. Yes 1. No (have problems) 9 Do you often slip or stumble at home ? 0. No 1. Yes 10 Do you ever refrain from going outdoors because of fear of falling ? 0. No 1. Yes 11 Have you been hospitalized in the last year ? 0. No 1. Yes 12 Do you have appetite these days? 0. Yes 1. No 13 Do you have any difficulty in chewing ? 0. have almost no difficulty 1. have difficulty 14 Did you lose weight of ≥ 3kg in the last 6 months ? 0. No 1. Yes 15 Do you feel that you have lost body muscle and/or fat during the last 6 months ? 0. No 1. Yes

1 Do you usually stay at home all day long? 0. No 1. Yes 2 How often do you usually go outdoors ? 0. more than once per 2-3 days 1. less than once a week 3 Do you have any hobby ? 0. Yes 1. No 4 Do you have neighbors who you can talk friendly ? 0. Yes 1. No 5 Do you have close friends, families, or relatives you go to meet ? 0. Yes 1. No 6 Do you have an experience of falling in the last year ? 0. No 1. Yes 7 Can you walk continuously over 1 km ? 0. Able to do without any difficulty 1. No, or able to do but with difficulty

A brief questionnaire for screening frailty - CL15

0 or 1 score for each item. 1 point is given to answer which indicates “having a risk ” e.g., have difficulty, low ability, have no friend. Each point of the 15 items is summed up to produce a composite score with a range of 0-15.

Homeboudness

Falling

Lower nutrition

(Shinkai S et al. Jpn J Public Health 2010; 57: 345-354)

Predictive validity of CL15

Table Relative risk of CL ≥4 compared with CL ≤3

Outcome Crude RR Adjusted RR*

ADL disability

2 years later 7.58 (4.20-13.7) 4.82 (2.54-9.15)

4 years later 4.97 (2.77-8.95) 3.07 (1.59-5.94)

LTCI service use 6.15 (4.39-8.63) 3.37 (2.31-4.91)

Death 3.73 (2.70-5.16) 2.40 (1.67-3.43)

*Adjusted for age, sex, and comorbidity

(Shinkai S et al. Jpn J Public Health 2013;60:262-274 )

Independent predictors for developing frailty

Muscle

Mass（less）, Strength（less)

Nutrition

Hb（low）, Alb（low）

Vascular health

ABI（low）, baPWV（high）, History of HT（+）

Sarcopenia

Lower nutrition

Subclinical vascular disease

(Yoshida H et al. Jpn J Geriatr 2012; 49: 442-448)

Background and Purpose

To date there has been no study on community-based intervention for healthy aging.

We have conducted a 10-year community intervention focusing on delaying the onset of frailty in later life, and examined its impact upon healthy aging.

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Geographical location of study site Kusatsu Town,

Gunma Prefecture Population, 7,200 (≥65 y, 29.4%) Main industry, hot spa & resort

Town view

Strategy for frailty prevention

１．A ｔight collaboration with public health sector at local government Public health sector at local government Senior clubs, NPO, Health volunteers, Other stake holders → formed a community forum to discuss how to tackle frailty issue in community

２．Primary prevention of frailty

Health promotion activities were focused on improvement of physical activity, nutrition and social participation of older residents.

12

Group activities Health education

3. Secondary prevention of frailty

We introduced the comprehensive geriatric assessment to the routine health check-ups, through which high-risk persons were screened, and encouraged to participate in long-term care prevention class.

13

Vascular health (baPWV, ABI) measurement

Walking speed test

4. Tertiary prevention of frailty

Long-term care prevention classes

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Strength exercise Nutritional education Learn your community

Enjoy lunch! In memory of their participation,

Process evaluation.

For outcome evaluation,

we conducted biannual health monitoring surveys over the period, and analyzed the data which was recorded in the Long-Term Care Insurance System during 2001 through present.

15

10-year community-based intervention in Kusatsu

Result

Process evaluation

The municipal staffs shared the common goal with us and have performed routine works from the aspect of healthy aging.

16

Result

Process evaluation

Although the participation rate to annual health check-ups has remained at 30-40%, over 80% of the target population participated at least once during the 10 years.

The response rate to the biannual monitoring survey has been very high (over 90%) over the period.

17

Result Process evaluation

Many residents joined the surveys as interviewers, through which they recognized the issue of aged community.

Even after the end of long-term care prevention class, many participants continued such group activities by themselves.

18

Summary of process evaluation

The municipal staffs and we could share the strategy for frailty prevention.

Older residents became accustomed to the concept of healthy aging and improved their self-care ability.

19

Impact of geriatric health check-ups on subsequent mortality and disability

Impact of community intervention on functional health of older residents

Impact of community intervention on

Long-Term Care Insurance data

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Outcome evaluation

ADL / IADL

Nutritional Function

Psychological / Cognitive Function

Social Function

Physical Performance

Component of geriatric health check-ups

Comprehensive Geriatric Assessment (CGA)

Routine test items +

CGA

Distriction: ●● Name ●● Male ／ 85 years old

１．Indicatiors of Aging 判 定 総合

判定

①Nutritional Function (◎： High， 〇： Middle， △： Low)

BMI 25.2 kg/m2 ◎

Excell

ent

Total cholesterol 175 mg/dl ◎

●

●

Albumin 4.4 ｇ /dl 〇

Hemoglobin 13.8 ｇ /dl ◎

②Physical Performance (◎： 高い， 〇： 中程度， △： 低い)

Hand Grip Strength 26.0 ｋ g

△

Good Usual Walking Speed 83.0 m/min 〇

Standing Ballance 60.0 sec ◎

③Psychological / Cognitive Function (◎： 良い， 〇： やや心配， △： 心配)

Depressive Mode 2 /15point ◎

Forgetfullness 28 /30point ◎

④Social Function (◎： 高い，〇： 中程度， △： 低い)

Instrumental Self-maintenance ５ /5 point ◎

Excell

ent Intellectual Activity ４ /4 point ◎

Social Role ４ /4 point ◎ Homeboundness 〇

⑤Risk of Long-Term Care Need (◎： abcence， △： presence)

Frailty ５ /20point ◎

Motor Function ４ /5 point ◎

Nutritional Improvement ４ /2 point ◎

Oral Funtion ５ /3 point ◎

Number：1002

Kusatsu Smaile health

Check-ups in 2012

個人結果票

２．Factors that Affect Aging 判 定

①Blood Pressure・ Puls (◎： normal，〇： border，△： hypertension)

Blood Pressure 139／ 86 mmHg

△

Puls 75 beat/min

②Blood Test (◎： 良好， 〇： まあ良好， △： やや心配)

HbA1c（ glucose metabolism） 5.5 ％ ◎

Creatinine（ Kidney Function） 0.84 mg/dl 〇

estGFR（ Kidney Function） 70.0 ml/min/

③Body Composition (◎： 高い，〇： 中程度，△： 低い)

Muscle mass 23.1 kg △

Percentage of Skeletal Muscle Mass 39.3 ％

④Medical History (✓： presence)

Hypertension ✓

Strok

Heart Disease

Diabetes mellitus

Arthritic disorder ✓

⑤Arteriosclerosis (◎： 良好， 〇： ふつう ， △： 心配)

Ｐ ＷＶ （ blood vessel elasticity） right： 1721 left： 1835

△

Ａ Ｂ Ｉ （ 血管の詰まり ） right： 1.1 left： 1.1 ◎

⑥Oral Function (◎： 良好， 〇： ふつう ， △： 心配)

Swallowing

〇

Chewing 聞き取り （ 主観） 〇

Gum Chewing Test 3 /5point

Number：1002

Kusatsu geriatric health check-ups in 2012

A meeting to inform individuals of results

from geriatric health check-ups

Outcome evaluation

Impact of geriatric health check-ups on

Participants vs. Non-Participants

mortality ↓ (significant)

disability ↓ (marginally significant)

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Result

Impact of geriatric health check-ups on mortality and disability

Impact of community intervention on functional health of older adults

Impact of community intervention on

Long-Term Care Insurance data

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Outcome evaluation

-1.0

-0.8

-0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Hand-gripstrength

Maximumgait speed

Albmin

Hemoglobin

GDS

MMSE

(Year of survey)

(Seino S et al. Jpn J Public Health 2014;61:286-298)

Changes in standardized score of physical, nutritional, psychological functions over time among participants to health check-ups

Males

Stan

dar

diz

ed s

core

(Year of survey)

(Seino S et al. Jpn J Public Health 2014;61:286-298)

Stan

dar

diz

ed s

core

Females

-1.2

-1.0

-0.8

-0.6

-0.4

-0.2

0.0

0.2

0.4

0.6

0.8

1.0

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Hand-gripstrength

Maximumgait speed

Albmin

Hemoglobin

GDS

MMSE

Females

Changes in standardized score of physical, nutritional, psychological functions over time among participants to health check-ups

80.8 82.7

85.7 86.0 86.1 86.9

63.7

68.7 69.4 69.7

76.4 74.3

60

70

80

90

H13年 H15年 H17年 H19年 H21年 H23年

“Can you go outside of town by yourself using public transportation or car?”

Males

Females

Changes in life space over time among all older residents

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2001 2003 2005 2007 2009 2011

Year of survey

Pro

po

rtio

n o

f ‘y

es’ (

%)

90 80 70 60

Impact of geriatric health check-ups on mortality and disability

Impact of community intervention on functional health of older residents

Impact of community intervention on

Long-Term Care Insurance data

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Outcome evaluation

Changes in incidence rate of disability over time certified under the LTCI program among older adults

2 1.81.1

1.61.1 1 1.4

2.3

1.1

8.8

12.2

9.3

7.5

6.4 6.5 6.45.4

6

0

2

4

6

8

10

12

14

2001 2002 2003 2004 2005 2006 2007 2008 2009 (Year)

≥ 75 years

65-74 years

Inci

den

ce p

er

per

son

-yea

rs

(Shinkai S et al. Jpn J Public Health 2013;60:596-605)

10

0

Intervention period

Whole nation

Kusatsu town

24.2

26.6

28.4 29.1

29.7 29.3 29.1 29.2 29.4

21.5

23.6

25.3 26.2

27.2 26.9 27.1

27.4 28.0

21.4

25.2

26.6 26.5

24.4 24.5 24.6 24.8

23.6

19

21

23

25

27

29

31

3.9

4.4

4.8 4.9 4.8 4.6 4.4

4.3 4.2

3.3

3.7

4.0

4.1 4.1 3.9 3.8

3.8

3.8

4.5

4.3 4.0

4.4 4.3 4.1

4.3

4.6 4.5

2

3

4

5

6

0 0 0 0 0 0 0 0 0

Pro

po

rtio

n o

f se

rvic

e u

ser

(%)

2001 2002 2003 2004 2005 2006 2007 2008 2009

Gunma prefecture

Whole nation Kusatsu town

Gunma prefecture

≥ 75 years

65-74 years

(Shinkai S et al. Jpn J Public Health 2013;60:596-605)

Changes in the proportions of service users over time under the LTCI program in older populations

Changes in active life expectancy at 70 years of age over time in Kusatsu

Females

Males

15.1715.41

15.6516.02

16.36

12.7312.91

13.0913.27 13.19

11

12

13

14

15

16

17

2003 2005 2007 2009 2011 (Year of survey)

Act

ive

life

exp

ecta

ncy

(ye

ars)

(Shinkai S et al. Jpn J Public Health 2013;60:596-605)

Summary of outcome evaluation

The 10-year community intervention in Kusatsu successfully improved the functional health of older adults.

Annual incidence rate of disability certified under the LTCI program significantly decreased over time in old-old population.

Active life expectancy at the age of 70 was extended greatly, especially in women.

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Implication of this intervention

Public health approach is effective for preventing frailty in a community.

Both high-risk and population approaches should be respected.

Health professionals in local government should play a key role in frailty prevention in a community.

“Think globally, act locally.”

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Direction of Health Promotion for the Elderly in “Healthy Japan 21 (secondary), 2013”

Longer healthy life expectancy / Closing the health gap

・ Good food and nutrition ・ Physical activity and strength ・ Social participation and network

・ Maintaining physical, mental and social functions ・ Preventing geriatric syndromes

Preventing long-term care or delaying it Social participation and contribution

・ More opportunities for social participation ・ Improving access to support for health ・ Health promotion based on community network

Improving QOL of individuals Improving social environment